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Rigon L, Genovese D, Piano C, Brunetti V, Guglielmi V, Cimmino AT, Scala I, Citro S, Bentivoglio AR, Rollo E, Di Iorio R, Broccolini A, Morosetti R, Monforte M, Frisullo G, Caliandro P, Pedicelli A, Caricato A, Masone G, Calabresi P, Marca GD. Movement disorders following mechanical thrombectomy resulting in ischemic lesions of the basal ganglia: An emerging clinical entity. Eur J Neurol 2024; 31:e16219. [PMID: 38299441 DOI: 10.1111/ene.16219] [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: 11/15/2023] [Revised: 12/20/2023] [Accepted: 01/04/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND AND PURPOSE Post-stroke movement disorders (PMDs) following ischemic lesions of the basal ganglia (BG) are a known entity, but data regarding their incidence are lacking. Ischemic strokes secondary to proximal middle cerebral artery (MCA) occlusion treated with thrombectomy represent a model of selective damage to the BG. The aim of this study was to assess the prevalence and features of movement disorders after selective BG ischemia in patients with successfully reperfused acute ischemic stroke (AIS). METHODS We enrolled 64 consecutive subjects with AIS due to proximal MCA occlusion treated with thrombectomy. Patients were clinically evaluated by a movement disorders specialist for PMDs onset at baseline, and after 6 and 12 months. RESULTS None of the patients showed an identifiable movement disorder in the subacute phase of the stroke. At 6 and 12 months, respectively, 7/25 (28%) and 7/13 (53.8%) evaluated patients developed PMDs. The clinical spectrum of PMDs encompassed parkinsonism, dystonia and chorea, either isolated or combined. In most patients, symptoms were contralateral to the lesion, although a subset of patients presented with bilateral involvement and prominent axial signs. CONCLUSION Post-stroke movement disorders are not uncommon in long-term follow-up of successfully reperfused AIS. Follow-up conducted by a multidisciplinary team is strongly advisable in patients with selective lesions of the BG after AIS, even if asymptomatic at discharge.
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Affiliation(s)
- Leonardo Rigon
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Danilo Genovese
- Dipartimento di neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS - UOC Neurologia, Rome, Italy
- The Marlene and Paolo Fresco Institute for Parkinson's Disease and Movement Disorders, New York University Langone Health, New York, New York, USA
| | - Carla Piano
- Dipartimento di neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS - UOC Neurologia, Rome, Italy
| | - Valerio Brunetti
- Dipartimento di neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS - UOC Neurologia, Rome, Italy
| | - Valeria Guglielmi
- Dipartimento di neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS - UOC Neurologia, Rome, Italy
| | | | - Irene Scala
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Salvatore Citro
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Rita Bentivoglio
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS - UOC Neurologia, Rome, Italy
| | - Eleonora Rollo
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Riccardo Di Iorio
- Dipartimento di neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS - UOC Neurologia, Rome, Italy
| | - Aldobrando Broccolini
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS - UOC Neurologia, Rome, Italy
| | - Roberta Morosetti
- Dipartimento di neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS - UOC Neurologia, Rome, Italy
| | - Mauro Monforte
- Dipartimento di neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS - UOC Neurologia, Rome, Italy
| | - Giovanni Frisullo
- Dipartimento di neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS - UOC Neurologia, Rome, Italy
| | - Pietro Caliandro
- Dipartimento di neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS - UOC Neurologia, Rome, Italy
| | - Alessandro Pedicelli
- UOC Radiologia e Neuroradiologia, Dipartimento di diagnostica per immagini, radioterapia oncologica ed ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Anselmo Caricato
- Neuro Intensive Care Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanna Masone
- Dipartimento di neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS - UOC Neurologia, Rome, Italy
| | - Paolo Calabresi
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS - UOC Neurologia, Rome, Italy
| | - Giacomo Della Marca
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS - UOC Neurologia, Rome, Italy
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2
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Zhao Z, Zhang Y, Su J, Yang L, Pang L, Gao Y, Wang H. A comprehensive review for artificial intelligence on neuroimaging in rehabilitation of ischemic stroke. Front Neurol 2024; 15:1367854. [PMID: 38606275 PMCID: PMC11007047 DOI: 10.3389/fneur.2024.1367854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/08/2024] [Indexed: 04/13/2024] Open
Abstract
Stroke is the second leading cause of death worldwide, with ischemic stroke accounting for a significant proportion of morbidity and mortality among stroke patients. Ischemic stroke often causes disability and cognitive impairment in patients, which seriously affects the quality of life of patients. Therefore, how to predict the recovery of patients can provide support for clinical intervention in advance and improve the enthusiasm of patients for rehabilitation treatment. With the popularization of imaging technology, the diagnosis and treatment of ischemic stroke patients are often accompanied by a large number of imaging data. Through machine learning and Deep Learning, information from imaging data can be used more effectively. In this review, we discuss recent advances in neuroimaging, machine learning, and Deep Learning in the rehabilitation of ischemic stroke.
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Affiliation(s)
- Zijian Zhao
- Rehabilitation Center, ShengJing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yuanyuan Zhang
- Rehabilitation Center, ShengJing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Jiuhui Su
- Department of Orthopedics, Haicheng Bonesetting Hospital, Haicheng, Liaoning Province, China
| | - Lianbo Yang
- Department of Reparative and Reconstructive Surgery, The Second Hospital of Dalian Medical University, Dalian Liaoning Province, China
| | - Luhang Pang
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yingshan Gao
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Hongbo Wang
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
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3
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Chen M, Joshi KC, Kolb B, Sitton CW, Pujara DK, Abraham MG, Ortega-Gutierrez S, Kasner SE, Hussain SM, Churilov L, Blackburn S, Sundararajan S, Hu YC, Herial N, Arenillas JF, Tsai JP, Budzik RF, Hicks W, Kozak O, Yan B, Cordato D, Manning NW, Parsons M, Hanel RA, Aghaebrahim A, Wu T, Cardona Portela P, Gandhi CD, Al-Mufti F, Perez de la Ossa N, Schaafsma J, Blasco J, Sangha N, Warach S, Kleinig TJ, Johns H, Shaker F, Abdulrazzak MA, Ray A, Sunshine J, Opaskar A, Duncan KR, Xiong W, Al-Shaibi FK, Samaniego EA, Nguyen TN, Fifi JT, Tjoumakaris SI, Jabbour P, Mendes Pereira V, Lansberg MG, Sila C, Bambakidis NC, Davis S, Wechsler L, Albers GW, Grotta JC, Ribo M, Hassan AE, Campbell B, Hill MD, Sarraj A. Clinical relevance of intracranial hemorrhage after thrombectomy versus medical management for large core infarct: a secondary analysis of the SELECT2 randomized trial. J Neurointerv Surg 2024:jnis-2023-021219. [PMID: 38471760 DOI: 10.1136/jnis-2023-021219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 02/18/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND The incidence of intracerebral hemorrhage (ICH) and its effect on the outcomes after endovascular thrombectomy (EVT) for patients with large core infarcts have not been well-characterized. METHODS SELECT2 trial follow-up imaging was evaluated using the Heidelberg Bleeding Classification (HBC) to define hemorrhage grade. The association of ICH with clinical outcomes and treatment effect was examined. RESULTS Of 351 included patients, 194 (55%) and 189 (54%) demonstrated intracranial and intracerebral hemorrhage, respectively, with a higher incidence in EVT (134 (75%) and 130 (73%)) versus medical management (MM) (60 (35%) and 59 (34%), both P<0.001). Hemorrhagic infarction type 1 (HBC=1a) and type 2 (HBC=1b) accounted for 93% of all hemorrhages. Parenchymal hematoma (PH) type 1 (HBC=1c) and type 2 (HBC=2) were observed in 1 (0.6%) EVT-treated and 4 (2.2%) MM patients. Symptomatic ICH (sICH) (SITS-MOST definition) was seen in 0.6% EVT patients and 1.2% MM patients. No trend for ICH with core volumes (P=0.10) or Alberta Stroke Program Early CT Score (ASPECTS) (P=0.74) was observed. Among EVT patients, the presence of any ICH did not worsen clinical outcome (modified Rankin Scale (mRS) at 90 days: 4 (3-6) vs 4 (3-6); adjusted generalized OR 1.00, 95% CI 0.68 to 1.47, P>0.99) or modify EVT treatment effect (Pinteraction=0.77). CONCLUSIONS ICH was present in 75% of the EVT population, but PH or sICH were infrequent. The presence of any ICH did not worsen functional outcomes or modify EVT treatment effect at 90-day follow-up. The high rate of hemorrhages overall still represents an opportunity for adjunctive therapies in EVT patients with a large ischemic core.
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Affiliation(s)
- Michael Chen
- Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Krishna C Joshi
- Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Bradley Kolb
- Rush University Medical Center, Chicago, Illinois, USA
| | - Clark W Sitton
- Diagnostic & Interventional Imaging, UT Houston, Houston, Texas, USA
| | | | - Michael G Abraham
- Neurology and Radiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Santiago Ortega-Gutierrez
- Neuroloy, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Scott E Kasner
- Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shazam M Hussain
- Cleveland Clinic Stroke Program, Cleveland Clinic, Cleveland Heights, Ohio, USA
| | | | - Spiros Blackburn
- Neurosurgery, University of Texas Medical School at Houston Vivian L Smith Department of Neurosurgery, Houston, Texas, USA
| | | | - Yin C Hu
- Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Nabeel Herial
- Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Juan F Arenillas
- Stroke Unit, Neurology Department, Stroke Unit. Neurology Department. Universitary Hospital, Valladolid (Spain), Valladolid, Spain
| | - Jenny P Tsai
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - William Hicks
- OhioHealth Neurological Physicians, Riverside Methodist Hospital, Columbus, Ohio, USA
| | - Osman Kozak
- Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Abington Memorial Hospital, Abington, Pennsylvania, USA
| | - Bernard Yan
- The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Dennis Cordato
- Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, New South Wales, Australia
- Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia
| | - Nathan W Manning
- Institute of Neurosciences, UNSW Prince of Wales Clinical School, Sydney, New South Wales, Australia
- Advanced Endovascular Therapy, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
| | - Mark Parsons
- Liverpool Hospital, Liverpool, New South Wales, Australia
| | | | - Amin Aghaebrahim
- Neurological Institute, Lyerley Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Teddy Wu
- Neurology, Christchurch Hospital, Christchurch, Canterbury, New Zealand
| | | | - Chirag D Gandhi
- Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Fawaz Al-Mufti
- Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | | | - Joanna Schaafsma
- Medicine - Div. Neurology, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Jordi Blasco
- Neurointerventional Department C.D.I, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Navdeep Sangha
- Kaiser Permanente Southern California, Los Angeles, California, USA
| | - Steven Warach
- University of Texas at Austin Dell Seton Medical Center, Austin, Texas, USA
| | - Timothy J Kleinig
- Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Hannah Johns
- University of Melbourne, Parkville, Victoria, Australia
| | - Faris Shaker
- Neurology, University of Texas McGovern Medical School, Houston, Texas, USA
| | | | - Abhishek Ray
- Neurological Surgery, University Hospitals, Cleveland, Ohio, USA
| | - Jeffery Sunshine
- Radiology, University Hospitals-Case Medical Center, Cleveland, Ohio, USA
| | - Amanda Opaskar
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Kelsey R Duncan
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Wei Xiong
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | | | - Edgar A Samaniego
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Thanh N Nguyen
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Johanna T Fifi
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Pascal Jabbour
- Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Vitor Mendes Pereira
- Division of Neuroradiology, Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada
| | - Maarten G Lansberg
- Department of Neurology, Stanford Stroke Center, Stanford University, Stanford, California, USA
| | - Cathy Sila
- Neurological Institute, University Hospitals- Case Medical Center, Cleveland, Ohio, USA
- Neurology, Case Western Reserve University School of Medicine
| | - Nicholas C Bambakidis
- Neurological Surgery, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Stephen Davis
- The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Lawrence Wechsler
- University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Gregory W Albers
- Neurology & Neurological Sciences, Stanford University, Stanford, California, USA
| | - James C Grotta
- Neurology, Memorial Hermann Hospital/UT Houston, Houston, Texas, USA
| | - Marc Ribo
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain
- Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Bruce Campbell
- The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Michael D Hill
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Clinical Neurosciences, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Amrou Sarraj
- Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Hua X, Liu M, Wu S. Definition, prediction, prevention and management of patients with severe ischemic stroke and large infarction. Chin Med J (Engl) 2023; 136:2912-2922. [PMID: 38030579 PMCID: PMC10752492 DOI: 10.1097/cm9.0000000000002885] [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: 07/17/2023] [Indexed: 12/01/2023] Open
Abstract
ABSTRACT Severe ischemic stroke carries a high rate of disability and death. The severity of stroke is often assessed by the degree of neurological deficits or the extent of brain infarct, defined as severe stroke and large infarction, respectively. Critically severe stroke is a life-threatening condition that requires neurocritical care or neurosurgical intervention, which includes stroke with malignant brain edema, a leading cause of death during the acute phase, and stroke with severe complications of other vital systems. Early prediction of high-risk patients with critically severe stroke would inform early prevention and treatment to interrupt the malignant course to fatal status. Selected patients with severe stroke could benefit from intravenous thrombolysis and endovascular treatment in improving functional outcome. There is insufficient evidence to inform dual antiplatelet therapy and the timing of anticoagulation initiation after severe stroke. Decompressive hemicraniectomy (DHC) <48 h improves survival in patients aged <60 years with large hemispheric infarction. Studies are ongoing to provide evidence to inform more precise prediction of malignant brain edema, optimal indications for acute reperfusion therapies and neurosurgery, and the individualized management of complications and secondary prevention. We present an evidence-based review for severe ischemic stroke, with the aims of proposing operational definitions, emphasizing the importance of early prediction and prevention of the evolution to critically severe status, summarizing specialized treatment for severe stroke, and proposing directions for future research.
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Affiliation(s)
- Xing Hua
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ming Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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5
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Broocks G, McDonough R, Bechstein M, Hanning U, Brekenfeld C, Flottmann F, Kniep H, Nawka MT, Deb-Chatterji M, Thomalla G, Sporns P, Yeo LL, Tan BY, Gopinathan A, Kastrup A, Politi M, Papanagiotou P, Kemmling A, Fiehler J, Meyer L. Benefit and risk of intravenous alteplase in patients with acute large vessel occlusion stroke and low ASPECTS. J Neurointerv Surg 2023; 15:8-13. [PMID: 35078927 DOI: 10.1136/neurintsurg-2021-017986] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/10/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The benefit of best medical treatment including intravenous alteplase (IVT) before mechanical thrombectomy (MT) in patients with acute ischemic stroke and extensive early ischemic changes on baseline CT remains uncertain. The purpose of this study was to evaluate the benefit of IVT for patients with low ASPECTS (Alberta Stroke Programme Early CT Score) compared with patients with or without MT. METHODS This multicenter study pooled consecutive patients with anterior circulation acute stroke and ASPECTS≤5 to analyze the impact of IVT on functional outcome, and to compare bridging IVT with direct MT. Functional endpoints were the rates of good (modified Rankin Scale (mRS) score ≤2) and very poor (mRS ≥5) outcome at day 90. Safety endpoint was the occurrence of symptomatic intracranial hemorrhage (sICH). RESULTS 429 patients were included. 290 (68%) received IVT and 168 (39%) underwent MT. The rate of good functional outcome was 14.4% (95% CI 7.1% to 21.8%) for patients who received bridging IVT and 24.4% (95% CI 16.5% to 32.2%) for those who underwent direct MT. The rate of sICH was significantly higher in patients with bridging IVT compared with direct MT (17.8% vs 6.4%, p=0.004). In multivariable logistic regression analysis, IVT was significantly associated with very poor outcome (OR 2.22, 95% CI 1.05 to 4.73, p=0.04) and sICH (OR 3.44, 95% CI 1.18 to 10.07, p=0.02). Successful recanalization, age, and ASPECTS were associated with good functional outcome. CONCLUSIONS Bridging IVT in patients with low ASPECTS was associated with very poor functional outcome and an increased risk of sICH. The benefit of this treatment should therefore be carefully weighed in such scenarios. Further randomized controlled trials are required to validate our findings.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marie Teresa Nawka
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Leonard Ll Yeo
- National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Benjamin Yq Tan
- National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Anil Gopinathan
- National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andreas Kastrup
- Department of Neurology, Klinikum Bremen-Mitte gGmbH, Bremen, Germany
| | - Maria Politi
- Department of Neuroradiology, Klinikum Bremen-Mitte GmbH, Bremen, Germany
| | - Panagiotis Papanagiotou
- Department of Neuroradiology, Klinikum Bremen-Mitte GmbH, Bremen, Germany.,National and Kapodistrian University of Athens, Aretaiio Hospital, Athens, Greece
| | | | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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6
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Multi-Energy CT Applications. Radiol Clin North Am 2023; 61:1-21. [DOI: 10.1016/j.rcl.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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7
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Chen W, Wu J, Wei R, Wu S, Xia C, Wang D, Liu D, Zheng L, Zou T, Li R, Qi X, Zhang X. Improving the diagnosis of acute ischemic stroke on non-contrast CT using deep learning: a multicenter study. Insights Imaging 2022; 13:184. [PMID: 36471022 PMCID: PMC9723089 DOI: 10.1186/s13244-022-01331-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE This study aimed to develop a deep learning (DL) model to improve the diagnostic performance of EIC and ASPECTS in acute ischemic stroke (AIS). METHODS Acute ischemic stroke patients were retrospectively enrolled from 5 hospitals. We proposed a deep learning model to simultaneously segment the infarct and estimate ASPECTS automatically using baseline CT. The model performance of segmentation and ASPECTS scoring was evaluated using dice similarity coefficient (DSC) and ROC, respectively. Four raters participated in the multi-reader and multicenter (MRMC) experiment to fulfill the region-based ASPECTS reading under the assistance of the model or not. At last, sensitivity, specificity, interpretation time and interrater agreement were used to evaluate the raters' reading performance. RESULTS In total, 1391 patients were enrolled for model development and 85 patients for external validation with onset to CT scanning time of 176.4 ± 93.6 min and NIHSS of 5 (IQR 2-10). The model achieved a DSC of 0.600 and 0.762 and an AUC of 0.876 (CI 0.846-0.907) and 0.729 (CI 0.679-0.779), in the internal and external validation set, respectively. The assistance of the DL model improved the raters' average sensitivities and specificities from 0.254 (CI 0.22-0.26) and 0.896 (CI 0.884-0.907), to 0.333 (CI 0.301-0.345) and 0.915 (CI 0.904-0.926), respectively. The average interpretation time of the raters was reduced from 219.0 to 175.7 s (p = 0.035). Meanwhile, the interrater agreement increased from 0.741 to 0.980. CONCLUSIONS With the assistance of our proposed DL model, radiologists got better performance in the detection of AIS lesions on NCCT.
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Affiliation(s)
- Weidao Chen
- grid.13402.340000 0004 1759 700XInterdisciplinary Institute of Neuroscience and Technology, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, 310027 Zhejiang China ,Infervision Institute of Research, Beijing, 100025 China
| | - Jiangfen Wu
- grid.11135.370000 0001 2256 9319Academy for Advanced Interdisciplinary Studies, Peking University, Beijing, China ,Infervision Institute of Research, Beijing, 100025 China
| | - Ren Wei
- Infervision Institute of Research, Beijing, 100025 China
| | - Shuang Wu
- Infervision Institute of Research, Beijing, 100025 China
| | - Chen Xia
- Infervision Institute of Research, Beijing, 100025 China
| | - Dawei Wang
- Infervision Institute of Research, Beijing, 100025 China
| | - Daliang Liu
- grid.415912.a0000 0004 4903 149XLiaocheng People’s Hospital, Liaocheng, 252000 Shandong China
| | - Longmei Zheng
- Medical Imaging Center, Ankang Central Hospital, Ankang, 725000 Shanxi China
| | - Tianyu Zou
- grid.478119.20000 0004 1757 8159Weihai Municipal Hospital, Weihai, 264200 Shandong China
| | - Ruijiang Li
- grid.168010.e0000000419368956Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94304 USA
| | - Xianrong Qi
- grid.11135.370000 0001 2256 9319School of Pharmaceutical Sciences, Peking University, Beijing, 100191 China ,grid.11135.370000 0001 2256 9319Beijing Key Laboratory of Molecular Pharmaceutics and New Drug Delivery System, School of Pharmaceutical Sciences, Peking University, Beijing, 100191 China
| | - Xiaotong Zhang
- grid.13402.340000 0004 1759 700XInterdisciplinary Institute of Neuroscience and Technology, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, 310027 Zhejiang China ,grid.13402.340000 0004 1759 700XCollege of Electrical Engineering, Zhejiang University, Hangzhou, 310000 Zhejiang China ,grid.13402.340000 0004 1759 700XMOE Frontier Science Center for Brain Science & Brain-machine Integration, Zhejiang University, Hangzhou, 310000 Zhejiang China
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8
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Safouris A, Palaiodimou L, Szikora I, Kargiotis O, Magoufis G, Psychogios K, Paraskevas G, Spiliopoulos S, Brountzos E, Nardai S, Goyal N, De Sousa DA, Strbian D, Caso V, Alexandrov A, Tsivgoulis G. Endovascular treatment for anterior circulation large-vessel occlusion ischemic stroke with low ASPECTS: a systematic review and meta-analysis. Ther Adv Neurol Disord 2022; 15:17562864221139632. [PMID: 36467113 PMCID: PMC9716457 DOI: 10.1177/17562864221139632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 10/31/2022] [Indexed: 08/30/2023] Open
Abstract
BACKGROUND Endovascular treatment (EVT) for acute ischemic stroke (AIS) patients presenting with Alberta Stroke Program Early CT Score (ASPECTS) 0-5 has not yet proven safe and effective by clinical trials. OBJECTIVES The aim of the study was to assess whether EVT in AIS patients presenting with low ASPECTS is beneficial. DESIGN Systematic review and meta-analysis of available studies in accordance with the PRISMA statement. DATA SOURCES AND METHODS We have searched MEDLINE, the Cochrane Central Register of Controlled Trials, and reference lists of articles published until 28 May 2022 with the aim to calculate (1) modified Rankin scale (mRS) score 0-3 at 3 months, (2) mRS score 0-2 at 3 months, (3) symptomatic intracranial hemorrhage (sICH), and (3) mortality at 3 months. RESULTS Overall, 24 eligible studies were included in the meta-analysis, comprising a total of 2539 AIS patients with ASPECTS 0-5 treated with EVT. The pooled proportion of EVT-treated patients achieving mRS 0-3 at 3 months was calculated at 38.4%. The pooled proportion of EVT-treated patients achieving mRS 0-2 at 3 months was 25.7%. Regarding safety outcomes, sICH occurred in 12.8% of patients. The 3-month pooled mortality was 30%. In pairwise meta-analysis, patients treated with EVT had a higher likelihood of achieving mRS 0-3 at 3 months compared with patients treated with best medical therapy (BMT, OR: 2.41). sICH occurred more frequently in EVT-treated patients compared with the BMT-treated patients (OR: 2.30). Mortality at 3 months was not different between the two treatment groups (OR: 0.71). CONCLUSION EVT may be beneficial for AIS patients with low baseline ASPECTS despite an increased risk for sICH. Further data from randomized-controlled clinical trials are needed to elucidate the role of EVT in this subgroup of AIS patients. REGISTRATION The protocol has been registered in the International Prospective Register of Ongoing Systematic Reviews PROSPERO; Registration Number: CRD42022334417.
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Affiliation(s)
- Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus,
Greece
- Second Department of Neurology, Attikon
University Hospital, Athens, Greece
- School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Aktios Rehabilitation Center, Athens,
Greece
- Department of Neurointerventions, National
Institute of Mental Health, Neurology and Neurosurgery, Section of
Neurointervention, Department of Neurosurgery, Semmelweis University,
Budapest, Hungary
| | - Lina Palaiodimou
- Second Department of Neurology, Attikon
University Hospital, Athens, Greece
- School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - István Szikora
- Department of Neurointerventions, National
Institute of Mental Health, Neurology and Neurosurgery, Section of
Neurointervention, Department of Neurosurgery, Semmelweis University,
Budapest, Hungary
| | | | - George Magoufis
- Neuroradiology Department, Metropolitan
Hospital, Piraeus, Greece
| | | | - Georgios Paraskevas
- Second Department of Neurology, Attikon
University Hospital, Athens, Greece
- School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - Stavros Spiliopoulos
- Interventional Radiology Department, Attikon
University Hospital, Athens, Greece
| | - Elias Brountzos
- Interventional Radiology Department, Attikon
University Hospital, Athens, Greece
| | - Sándor Nardai
- Department of Neurointerventions, National
Institute of Mental Health, Neurology and Neurosurgery, Section of
Neurointervention, Department of Neurosurgery, Semmelweis University,
Budapest, Hungary
| | - Nitin Goyal
- Department of Neurology, The University of
Tennessee Health Science Center, Memphis, TN, USA
- Department of Neurosurgery, The University of
Tennessee Health Science Center and Semmes Murphey Neurologic and Spine
Clinic. Memphis, TN, USA
| | - Diana Aguiar De Sousa
- Stroke Center, Lisbon Central University
Hospital and Faculty of Medicine, University of Lisbon, Lisbon,
Portugal
| | - Daniel Strbian
- Neurological Research Unit, University Medical
Center Hamburg-Eppendorf, Hamburg, Germany
| | - Valeria Caso
- Neurology Unit, ‘M. Bufalini’ Hospital-AUSL
Romagna, Cesena, Italy
| | - Andrei Alexandrov
- Department of Neurology, The University of
Tennessee Health Science Center, Memphis, TN, USA
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon
University Hospital, Rimini 1, Chaidari, 124 62 Athens, Greece
- School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Department of Neurology, The University of
Tennessee Health Science Center, Memphis, TN, USA
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9
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Yu M, Miao X, Huang Y, Ma L, Yin L, Ren H, Wang Z. A clinical application study of a stent placement assessment. Medicine (Baltimore) 2022; 101:e31882. [PMID: 36451472 PMCID: PMC9704916 DOI: 10.1097/md.0000000000031882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Atherosclerotic acute carotid occlusion is a specific type of stroke, and controversy exists regarding the surgical strategy, that is, whether an internal carotid artery stent should be placed immediately after opening the occluded vessel. There is no objective evaluation system for this procedure. In a previous study, we summarized an evaluation decision system Emergent Carotid Artery Stent placement decision Evaluation System (ECASES) for emergency stent placement. STUDY DESIGN This is a prospective, single-center, randomized controlled trial. Patients with acute ischemic stroke caused by atherosclerotic carotid artery occlusion confirmed by imaging (computed tomography/magnetic resonance angiography/digital subtraction angiography) will be randomly divided into the study and control groups, with 101 patients in each group. The study group will undergo surgery according to the ECASES system and the control group will undergo surgery according to the operator's experience. The postoperative outcomes of the 2 groups will be compared. STUDY OUTCOMES Primary outcome: Neurological functional status (modified Rankin Scale and National Institutes of Health Stroke Scale scores) of patients 90 days postoperatively. Secondary outcomes: neurological function changes, hemorrhage events, cerebral edema, postoperative modified treatment in cerebral infarction grade, new cerebral infarction, and reocclusion of responsible vessels. DISCUSSION Currently, no prospective controlled data exist regarding the efficacy and safety of carotid stenting in the acute phase. Previously, we had developed an ECASES stent placement system for acute carotid artery occlusion. The present study will evaluate the efficacy and safety of ECASES in a randomized, double-blind prospective study and clarify its guiding significance in acute atherosclerotic carotid artery occlusion surgery.
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Affiliation(s)
- Mingsheng Yu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Xinglu Miao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Department of Neurosurgery, Jining No.1 People’s Hospital, Jining, Shandong Province, China
| | - Ying Huang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Lin Ma
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Long Yin
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Hecheng Ren
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
- * Correspondence: Hecheng Ren, Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin 300350, China (e-mail: ); Zengguang Wang, Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China (e-mail: )
| | - Zengguang Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- * Correspondence: Hecheng Ren, Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin 300350, China (e-mail: ); Zengguang Wang, Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China (e-mail: )
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10
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Broocks G, Hanning U, Bechstein M, Elsayed S, Faizy TD, Brekenfeld C, Flottmann F, Kniep H, Deb-Chatterji M, Schön G, Thomalla G, Kemmling A, Fiehler J, Meyer L. Association of Thrombectomy With Functional Outcome for Patients With Ischemic Stroke Who Presented in the Extended Time Window With Extensive Signs of Infarction. JAMA Netw Open 2022; 5:e2235733. [PMID: 36239941 PMCID: PMC9568804 DOI: 10.1001/jamanetworkopen.2022.35733] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
IMPORTANCE Only limited data are available about a potential benefit associated with endovascular treatment (EVT) for patients with ischemic stroke presenting in the extended time window who also show signs of extensive infarction. OBJECTIVE To assess the association of recanalization after EVT with functional outcomes for patients with ischemic stroke presenting in the extended time window who also show signs of extensive infarction. DESIGN, SETTING, AND PARTICIPANTS This retrospective, multicenter cohort study included patients enrolled in the German Stroke Registry-Endovascular Treatment with an Alberta Stroke Program Early CT Score (ASPECTS) of 5 or less who presented between 6 and 24 hours after stroke onset and underwent computed tomography and subsequent EVT between July 1, 2015, and December 31, 2019. MAIN OUTCOMES AND MEASURES The primary end point was a modified Rankin Scale (mRS) score of 3 or less at day 90. The association between recanalization (defined as the occurrence of a modified Thrombolysis in Cerebral Infarction Scale score of 2b or 3) and outcome was assessed using logistic regression and inverse probability weighting analysis. INTERVENTION Endovascular treatment. RESULTS Of 5853 patients, 285 (5%; 146 men [51%]; median age, 73 years [IQR, 62-81 years]) met the inclusion criteria and were analyzed. Of these 285 patients, 79 (27.7%) had an mRS score of 3 or less at day 90. The rate of successful recanalization was 75% (215 of 285) and was independently associated with a higher probability of reaching an mRS score of 3 or less (adjusted odds ratio, 4.39; 95% CI, 1.79-10.72; P < .001). In inverse probability weighting analysis, a modified Thrombolysis in Cerebral Infarction Scale score of 2b or 3 was associated with a 19% increase (95% CI, 9%-29%; P < .001) in the probability for an mRS score of 3 or more. Multivariable logistic regression analysis suggested a significant treatment benefit associated with vessel recanalization in a time window of up to 17.6 hours and ASPECTS of 3 to 5. The rate of secondary symptomatic intracerebral hemorrhage was 6.3% (18 of 285). CONCLUSIONS AND RELEVANCE In this cohort study reflecting daily clinical practice, vessel recanalization for patients with a low ASPECTS and extended time window was associated with better functional outcomes in a time window up to 17.6 hours and ASPECTS of 3 to 5. The results of this study encourage current randomized clinical trials to enroll patients with a low ASPECTS, even within the extended time window.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D. Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - André Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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11
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When Can an Emergency CTA Be Dispensed with for TIA Patients? J Clin Med 2022; 11:jcm11195686. [PMID: 36233554 PMCID: PMC9573404 DOI: 10.3390/jcm11195686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 08/31/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Transient ischemic attacks (TIAs) and minor strokes are often precursors of a major stroke. Therefore, diagnostic work-up of the TIA is essential to reduce the patient’s risk of further ischemic events. Purpose: With the help of this retrospective study, we aim to determine for which TIA patients a CT angiography (CTA) is not immediately necessary in order to reduce radiation exposure and nephrotoxicity. Material and Methods: Clinical and imaging data from patients who presented as an emergency case with a suspected diagnosis of TIA at a teaching hospital between January 2016 and December 2021 were evaluated. The included 1526 patients were divided into two groups—group 1, with major pathologic vascular findings in the CTA, and group 2, with minor vascular pathologies. Results: Out of 1821 patients with suspected TIA on admission, 1526 met the inclusion criteria. In total, 336 (22%) had major vascular pathologies on CTA, and 1190 (78%) were unremarkable. The majority of patients with major vascular pathologies were male and had a history of arterial hypertension, coronary heart disease, myocardial infarction, ischemic stroke, TIA, atherosclerotic peripheral vascular disease, smoking, antiplatelet medication, had a lower duration of TIA symptoms, and had lower ABCD2 scores. Conclusions: We were able to demonstrate a direct correlation between major CTA pathologies and a history of smoking, age, hyperlipidemia, history of peripheral arterial disease, and a history of stroke and TIA. We were able to prove that the ABCD2 score is even reciprocal to CTA pathology. This means that TIA patients without described risk factors do not immediately require a CTA and could be clarified in the course of treatment with ultrasound or MRI.
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12
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Broocks G, Heit JJ, Kuraitis GM, Meyer L, van Horn N, Bechstein M, Thaler C, Christensen S, Mlynash M, Lansberg MG, Kemmling A, Schön G, Albers G, Fiehler J, Wintermark M, Faizy TD. Benefit of Intravenous Alteplase Before Thrombectomy Depends on ASPECTS. Ann Neurol 2022; 92:588-595. [PMID: 35801346 DOI: 10.1002/ana.26451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE Baseline variables could be used to guide the administration of additional intravenous alteplase (IVT) before mechanical thrombectomy (MT). The aim of this study was to determine how baseline imaging and demographic parameters modify the effect of IVT on clinical outcomes in patients with ischemic stroke due to large vessel occlusion. METHODS Multicenter retrospective cohort study of ischemic stroke patients triaged by multimodal-CT undergoing MT treatment after direct admission to an MT-eligible center. Inverse-probability weighting analysis (IPW) was used to assess the treatment effect of IVT adjusted for baseline variables. Multivariable logistic regression analysis with IPW-weighting and interaction terms for IVT was performed to predict functional independence (mRS 0-2 at 90-days). RESULTS 720 patients were included, of which 366 (51%) received IVT. In IPW, the treatment effect of IVT on outcome (mRS 0-2) distinctively varied according to the ASPECTS subgroup (ASPECTS 9-10: +15%, ASPECTS 6-8: +7%, ASPECTS <6: -11%). In multivariable logistic regression analysis, IVT was independently associated with functional independence (aOR: 1.57, 95%CI: 1.16-2.14, p=0.003) and the interaction term was significant for ASPECTS and IVT revealing that IVT was only significantly associated with better outcomes in patients with higher ASPECTS. No other significant baseline variable interaction terms were identified. INTERPRETATION ASPECTS was the only baseline variable that showed a significant interaction with IVT for outcome prediction. The application of IVT in patients with an ASPECTS of <6 might have detrimental effects on outcome and may only be considered carefully. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, CA
| | | | - Lukas Meyer
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf
| | - Noel van Horn
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf
| | - Matthias Bechstein
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf
| | - Christian Thaler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf
| | - Soren Christensen
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA
| | - Andre Kemmling
- Department of Neuroradiology, University Marburg.,Department of Neuroradiology, University Schleswig Holstein, Campus Lübeck
| | - Gerhard Schön
- Institute of Epidemiology and Medical Biometry, University Medical Center Hamburg-Eppendorf
| | - Gregory Albers
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf
| | - Max Wintermark
- Department of Radiology, Stanford University School of Medicine, CA
| | - Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf
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13
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van Poppel LM, B.L.M. Majoie C, Marquering HA, Emmer BJ. Associations between Early Ischemic Signs on Non-Contrast CT and Time since Acute Ischemic Stroke Onset: A Scoping Review. Eur J Radiol 2022; 155:110455. [DOI: 10.1016/j.ejrad.2022.110455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 07/15/2022] [Accepted: 07/25/2022] [Indexed: 11/03/2022]
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14
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Lin SF, Chen CF, Hu HH, Ho BL, Chen CH, Chan L, Lin HJ, Sun Y, Lin YY, Chen PL, Lin SK, Wei CY, Lin YT, Lee JT, Chao AC. Comparison of Different Dosages of Alteplase in Atrial Fibrillation-Related Acute Ischemic Stroke After Intravenous Thrombolysis: A Nationwide, Multicenter, Prospective Cohort Study in Taiwan. J Am Heart Assoc 2022; 11:e023032. [PMID: 35048714 PMCID: PMC9238492 DOI: 10.1161/jaha.121.023032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Insufficient evidence is available for patients with acute ischemic stroke with atrial fibrillation (AF) to determine the efficacy and safety of different dosages of intravenous thrombolysis treatment. This study examined clinical outcomes in Chinese patients with stroke with and without AF after intravenous thrombolysis treatment with different intravenous thrombolysis doses. Methods and Results This multicenter, prospective cohort study recruited 2351 patients with acute ischemic stroke (1371 with AF and 980 without AF) treated with intravenous thrombolysis using alteplase. The Totaled Health Risks in Vascular Events score is a validated risk‐scoring tool used for assessing patients with acute ischemic stroke with and without AF. We evaluated favorable functional outcome at day 90 and symptomatic intracranial hemorrhage within 24 to 36 hours and outcomes of the patients receiving different doses of alteplase. Compared with the non‐AF group, the AF group exhibited a 2‐ to 3‐fold increased risk of symptomatic intracranial hemorrhage according to the National Institute of Neurological Disorders and Stroke standard (relative risk [RR], 2.10 [95% CI, 1.35–3.26]). Favorable functional outcome at 90 days and symptomatic intracranial hemorrhage rates according to the European Cooperative Acute Stroke Study II and the Safe Implementation of Thrombolysis in Stroke‐Monitoring Study standards did not significantly differ between the AF and non‐AF groups. In addition, the low‐dose alteplase subgroup exhibited an increased risk of symptomatic intracranial hemorrhage according to the National Institute of Neurological Disorders and Stroke standard (RR, 2.84 [95% CI, 1.63–4.96]). A validation study confirmed these findings after adjustment for scores determined using different stroke risk‐scoring tools. Conclusions Different alteplase dosages did not affect functional status at 90 days in the AF and non‐AF groups. Thus, the adoption of low‐dose alteplase simply because of AF is not recommended.
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Affiliation(s)
- Sheng-Feng Lin
- Department of Public Health, School of Medicine, College of Medicine Taipei Medical University Taipei Taiwan.,School of Public Health, College of Public Health Taipei Medical University Taipei Taiwan.,Department of Critical Care Medicine Taipei Medical University Hospital Taipei Taiwan.,Department of Emergency Medicine Taipei Medical University Hospital Taipei Taiwan
| | - Chien-Fu Chen
- Department of Neurology, College of Medicine Kaohsiung Medical University Kaohsiung Taiwan.,Department of Neurology Kaohsiung Medical University Hospital Kaohsiung Taiwan
| | - Han-Hwa Hu
- Beijing Tiantan Hospital, Capital Medical University Beijing China.,Advanced Innovation Center for Human Brain Protection Capital Medical University Beijing China.,Department of Neurology Taipei Medical University-Shuang Ho Hospital Taipei Taiwan
| | - Bo-Lin Ho
- Department of Neurology, College of Medicine Kaohsiung Medical University Kaohsiung Taiwan.,Department of Neurology Kaohsiung Medical University Hospital Kaohsiung Taiwan
| | - Chih-Hung Chen
- Department of Neurology National Cheng Kung University Hospital Tainan Taiwan.,Department of Neurology National Cheng Kung University Tainan Taiwan
| | - Lung Chan
- Department of Neurology Taipei Medical University-Shuang Ho Hospital Taipei Taiwan
| | - Huey-Juan Lin
- Department of Neurology Chi Mei Medical Center Tainan Taiwan
| | - Yu Sun
- Department of Neurology En Chu Kong Hospital New Taipei City Taiwan
| | - Yung-Yang Lin
- Department of Neurology Taipei Veterans General Hospital Taipei Taiwan
| | - Po-Lin Chen
- Department of Neurology Taichung Veterans General Hospital Taichung Taiwan
| | - Shinn-Kuang Lin
- Stroke Center and Department of Neurology Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation Taipei Taiwan
| | - Cheng-Yu Wei
- Department of Neurology Show Chuan Memorial Hospital Changhua Taiwan
| | - Yu-Te Lin
- Division of Neurology Department of Medicine Kaohsiung Veterans General Hospital Kaohsiung Taiwan
| | - Jiunn-Tay Lee
- Department of Neurology National Defense Medical Center, Tri-Service General Hospital Taipei Taiwan
| | - A-Ching Chao
- Department of Neurology, College of Medicine Kaohsiung Medical University Kaohsiung Taiwan.,Department of Neurology Kaohsiung Medical University Hospital Kaohsiung Taiwan
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15
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Padrick MM, Brown W, Lyden PD. Intravenous Thrombolysis. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00053-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Dzialowski I, Puetz V, Parsons M, Bivard A, von Kummer R. Computed Tomography-Based Evaluation of Cerebrovascular Disease. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00047-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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17
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Katyal A, Bhaskar SMM. Value of pre-intervention CT perfusion imaging in acute ischemic stroke prognosis. DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY (ANKARA, TURKEY) 2021; 27:774-785. [PMID: 34792033 DOI: 10.5152/dir.2021.20805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Noninvasive imaging plays an important role in acute stroke towards diagnosis and ongoing management of patients. Systemic thrombolysis and endovascular thrombectomy (EVT) are proven treatments currently used in standards of care in acute stroke settings. The role of computed tomography angiography (CTA) in selecting patients with large vessel occlusion for EVT is well established. However, the value of CT perfusion (CTP) imaging in predicting outcomes after stroke remains ambiguous. This article critically evaluates the value of multimodal CT imaging in early diagnosis and prognosis of acute ischemic stroke with a focus on the role of CTP in delineating tissue characteristics, patient selection, and outcomes after reperfusion therapy. Insights on various technical and clinical considerations relevant to CTP applications in acute ischemic stroke, recommendations for existing workflow, and future areas of research are discussed.
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Affiliation(s)
- Anubhav Katyal
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, Australia; University of New South Wales (UNSW), South Western Sydney Clinical School, NSW, Australia
| | - Sonu Menachem Maimonides Bhaskar
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, Australia; Department of Neurology - Neurophysiology, Liverpool Hospital - South West Sydney Local Health District (SWSLHD), Sydney, Australia;University of New South Wales (UNSW), South Western Sydney Clinical School, NSW, Australia; Ingham Institute for Applied Medical Research, Stroke - Neurology Research Group, Sydney, Australia; NSW Brain Clot Bank, NSW Health Statewide Biobank and NSW Health Pathology, Sydney, NSW, Australia;Thrombolysis and Endovascular WorkFLOw Network (TEFLON), Sydney, Australia
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18
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Bing F, Berger I, Fabry A, Moroni AL, Casile C, Morel N, M'Biene S, Guellerin J, Pignal-Jacquard C, Vadot W, Rodier G, Delory T, Jund J. Intra- and inter-rater consistency of dual assessment by radiologist and neurologist for evaluating DWI-ASPECTS in ischemic stroke. Rev Neurol (Paris) 2021; 178:219-225. [PMID: 34785042 DOI: 10.1016/j.neurol.2021.08.007] [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: 02/12/2021] [Revised: 08/04/2021] [Accepted: 08/11/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To estimate the intra -and inter-rater consistency of radiologist and neurologist working in pairs attributing DWI-ASPECTS (Diffusion Alberta Stroke Program Early CT Score) in patients with acute middle cerebral artery ischemic stroke referred for mechanical thrombectomy, intravenous thrombolysis or bridging therapy. METHODS Five neurologists and 5 radiologists working in pairs and in hour period scored independently and in two reading sessions anonymized DWI-ASPECTS of 80 patients presenting with acute anterior ischaemic stroke in our center. We measured agreement between pairs using intraclass correlation coefficients (ICCs). A Fleiss kappa was used for dichotomized (0-6;7-10) and trichotomized (0-3;4-6;7-10) ASPECTS. The interrater distribution of the score in the trichotomized (0-3;4-6;7-10) ASPECTS was calculated. We determined the interrater (Cohen kappa) and intrarater (Fleiss kappa) agreement on the ASPECTS regions. RESULTS The average DWI-ASPECTS was 6.35 (SD±2.44) for the first reading, and 6.47 (SD±2.44) for the second one. The ICC was 0.853 (95%CI, 0.798-0.896) for the interrater, and 0.862 (95%CI, 0.834-0.885) for the intrarater evaluation. Kappa coefficients were high for dichotomized (k=0.75) and trichotomized (k=0.64) ASPECTS. Evaluators agreement on the ASPECTS category (0-3), (4-6) and (7-10) was 88, 76 and 93% respectively. The anatomic region infarcted was well identified (k=0.70-0.77), except for the internal capsula (k=0.57). Interrater agreement was fair for M5 (k=0.37), moderate for internal capsula (0.52) and substantial for the other regions (0.60-0.79). CONCLUSIONS Reliability of DWI-ASPECTS is good when determined by radiologist and neurologist working in pairs, which corresponds to our current clinical practice. However, discrepancies are possible for cut-off determination, which may impact the indication of thrombectomy, and for the determination of the exact infarcted region. Agreement to propose category (4-6) is lower than for (0-3) and (8-10) ASPECTS categories.
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Affiliation(s)
- F Bing
- Radiology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France.
| | - I Berger
- Neurology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - A Fabry
- Radiology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - A-L Moroni
- Radiology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - C Casile
- Radiology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - N Morel
- Neurology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - S M'Biene
- Radiology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - J Guellerin
- Neurology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - C Pignal-Jacquard
- Radiology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - W Vadot
- Neurology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - G Rodier
- Neurology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - T Delory
- Clinical Research Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - J Jund
- Medical Information and Evaluation Unit (SIEM), CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
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Controversies in Imaging of Patients with Acute Ischemic Stroke: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2021; 217:1027-1037. [PMID: 34106758 DOI: 10.2214/ajr.21.25846] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The development of reperfusion therapies has profoundly impacted stroke care, initially with the advent of IV thrombolytic (IVT) treatment and, more recently, with the development and refinement of endovascular treatment (EVT). Progress in neuroimaging has supported the paradigm shift of stroke care, and advanced neuroimaging now has a fundamental role in triaging patients for both IVT and EVT. As the standard of care for acute ischemic stroke (AIS) evolves, controversies remain in certain clinical scenarios. This article explores the use of multimodality imaging for treatment selection of AIS in the context of recent guidelines, highlighting controversial topics and providing guidance for clinical practice. Results of major randomized trials supporting EVT are reviewed. Advantages and disadvantages of CT, CTA, MRI, and MRA in stroke diagnosis are summarized, with attention to level 1 evidence supporting the role of vascular imaging and perfusion imaging. Patient selection is compared between approaches based on time thresholds and physiologic approaches based on infarct core measurement using imaging. Moreover, various imaging approaches to core measurement are described. As ongoing studies push treatment boundaries, advanced imaging is expected to help identify a widening range of patients who may benefit from therapy.
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20
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Evaluation of analytic and clinical performance of thrombin-antithrombin complex and D-dimer assay in prognosis of acute ischemic stroke. Blood Coagul Fibrinolysis 2021; 31:303-309. [PMID: 32371663 DOI: 10.1097/mbc.0000000000000915] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: To evaluate analytic and clinical performance of plasma thrombin-antithrombin complex (TAT) and D-dimer assay in assessing the severity and outcome of acute ischemic stroke. The prospective study was conducted and extended from January 2018 to December 2018. A total of 236 patients admitted within 24 h after neurologic symptoms onset were recruited. The median TAT and D-dimer levels were significantly higher in the acute ischemic stroke patients than in the controls. The average TAT levels in patients with mild, moderately severe and severe stroke were 1.75 [interquartile ranges (IQR), 1.1-2.6], 3.3 (IQR, 1.8-4.5) and 13.5 (IQR, 7.2-15.3) ng/ml. The D-dimer levels of respective patient groups were 0.39 (IQR, 0.22-0.73), 0.58 (IQR, 0.39-1.25) and 3.59 (IQR, 1.73-4.74) mg/l. With the optimal cut-off TAT level (1.75 ng/ml) determined from receiver operating characteristic analysis, the Area under the curve (AUC), the sensitivity and specificity of TAT for stroke diagnosis were 0.763, 58.1 and 87.8%. The cut-off D-dimer level was 0.38 mg/l and the AUC, the sensitivity and specificity were 0.772, 60.2 and 88.9%. The Area under the receiver operating characteristic curves (AUROCs) and sensitivity in the moderate to severe stroke increased to 0.903 and 86.9% for TAT, and 0.880 and 80.3% for D-dimer, respectively. Age and high TAT level were significant independent risk factors for stroke severity. Age, high initial National Institutes of Health Stroke Scale score and high TAT level were significant independent poor prognostic factors on multivariate analysis. TAT and D-dimer were superior in separating the moderate-to-severe stroke than mild stroke. A high TAT plasma level is an independent predictor for stroke severity and poor prognosis during 1-month follow-up.
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21
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Mendelson SJ, Prabhakaran S. Diagnosis and Management of Transient Ischemic Attack and Acute Ischemic Stroke: A Review. JAMA 2021; 325:1088-1098. [PMID: 33724327 DOI: 10.1001/jama.2020.26867] [Citation(s) in RCA: 258] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE Stroke is the fifth leading cause of death and a leading cause of disability in the United States, affecting nearly 800 000 individuals annually. OBSERVATIONS Sudden neurologic dysfunction caused by focal brain ischemia with imaging evidence of acute infarction defines acute ischemic stroke (AIS), while an ischemic episode with neurologic deficits but without acute infarction defines transient ischemic attack (TIA). An estimated 7.5% to 17.4% of patients with TIA will have a stroke in the next 3 months. Patients presenting with nondisabling AIS or high-risk TIA (defined as a score ≥4 on the age, blood pressure, clinical symptoms, duration, diabetes [ABCD2] instrument; range, 0-7 [7 indicating worst stroke risk]), who do not have severe carotid stenosis or atrial fibrillation, should receive dual antiplatelet therapy with aspirin and clopidigrel within 24 hours of presentation. Subsequently, combined aspirin and clopidigrel for 3 weeks followed by single antiplatelet therapy reduces stroke risk from 7.8% to 5.2% (hazard ratio, 0.66 [95% CI, 0.56-0.77]). Patients with symptomatic carotid stenosis should receive carotid revascularization and single antiplatelet therapy, and those with atrial fibrillation should receive anticoagulation. In patients presenting with AIS and disabling deficits interfering with activities of daily living, intravenous alteplase improves the likelihood of minimal or no disability by 39% with intravenous recombinant tissue plasminogen activator (IV rtPA) vs 26% with placebo (odds ratio [OR], 1.6 [95% CI, 1.1-2.6]) when administered within 3 hours of presentation and by 35.3% with IV rtPA vs 30.1% with placebo (OR, 1.3 [95% CI, 1.1-1.5]) when administered within 3 to 4.5 hours of presentation. Patients with disabling AIS due to anterior circulation large-vessel occlusions are more likely to be functionally independent when treated with mechanical thrombectomy within 6 hours of presentation vs medical therapy alone (46.0% vs 26.5%; OR, 2.49 [95% CI, 1.76-3.53]) or when treated within 6 to 24 hours after symptom onset if they have a large ratio of ischemic to infarcted tissue on brain magnetic resonance diffusion or computed tomography perfusion imaging (modified Rankin Scale score 0-2: 53% vs 18%; OR, 4.92 [95% CI, 2.87-8.44]). CONCLUSIONS AND RELEVANCE Dual antiplatelet therapy initiated within 24 hours of symptom onset and continued for 3 weeks reduces stroke risk in select patients with high-risk TIA and minor stroke. For select patients with disabling AIS, thrombolysis within 4.5 hours and mechanical thrombectomy within 24 hours after symptom onset improves functional outcomes.
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Affiliation(s)
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, Illinois
- Pritzker School of Medicine, Department of Neurology, University of Chicago, Chicago, Illinois
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22
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Berge E, Whiteley W, Audebert H, De Marchis GM, Fonseca AC, Padiglioni C, de la Ossa NP, Strbian D, Tsivgoulis G, Turc G. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J 2021; 6:I-LXII. [PMID: 33817340 DOI: 10.1177/2396987321989865] [Citation(s) in RCA: 434] [Impact Index Per Article: 144.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/27/2020] [Indexed: 02/06/2023] Open
Abstract
Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.
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Affiliation(s)
- Eivind Berge
- Department of Internal Medicine and Cardiology, Oslo University Hospital, Oslo, Norway
| | - William Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Heinrich Audebert
- Klinik und Hochschulambulanz für Neurologie, Charité Universitätsmedizin Berlin & Center for Stroke Research Berlin, Berlin, Germany
| | - Gian Marco De Marchis
- University Hospital of Basel & University of Basel, Department for Neurology & Stroke Center, Basel, Switzerland
| | - Ana Catarina Fonseca
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Chiara Padiglioni
- Neurology Unit-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hopital Sainte-Anne, Université de Paris, Paris, France.,INSERM U1266.,FHU NeuroVasc
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23
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Rao MR, Norquay G, Stewart NJ, Wild JM. Measuring 129 Xe transfer across the blood-brain barrier using MR spectroscopy. Magn Reson Med 2021; 85:2939-2949. [PMID: 33458859 PMCID: PMC7986241 DOI: 10.1002/mrm.28646] [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: 07/27/2020] [Revised: 11/04/2020] [Accepted: 11/24/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE This study develops a tracer kinetic model of xenon uptake in the human brain to determine the transfer rate of inhaled hyperpolarized 129 Xe from cerebral blood to gray matter that accounts for the effects of cerebral physiology, perfusion and magnetization dynamics. The 129 Xe transfer rate is expressed using a tracer transfer coefficient, which estimates the quantity of hyperpolarized 129 Xe dissolved in cerebral blood under exchange with depolarized 129 Xe dissolved in gray matter under equilibrium of concentration. THEORY AND METHODS Time-resolved MR spectra of hyperpolarized 129 Xe dissolved in the human brain were acquired from three healthy volunteers. Acquired spectra were numerically fitted with five Lorentzian peaks in accordance with known 129 Xe brain spectral peaks. The signal dynamics of spectral peaks for gray matter and red blood cells were quantified, and correction for the 129 Xe T1 dependence upon blood oxygenation was applied. 129 Xe transfer dynamics determined from the ratio of the peaks for gray matter and red blood cells was numerically fitted with the developed tracer kinetic model. RESULTS For all the acquired NMR spectra, the developed tracer kinetic model fitted the data with tracer transfer coefficients between 0.1 and 0.14. CONCLUSION In this study, a tracer kinetic model was developed and validated that estimates the transfer rate of HP 129 Xe from cerebral blood to gray matter in the human brain.
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Affiliation(s)
- Madhwesha R Rao
- POLARIS, Department of Infection, Immunity and Cardiovascular Disease and Insigneo Institute of In-silico Medicine, University of Sheffield, Sheffield, UK
| | - Graham Norquay
- POLARIS, Department of Infection, Immunity and Cardiovascular Disease and Insigneo Institute of In-silico Medicine, University of Sheffield, Sheffield, UK
| | - Neil J Stewart
- POLARIS, Department of Infection, Immunity and Cardiovascular Disease and Insigneo Institute of In-silico Medicine, University of Sheffield, Sheffield, UK
| | - Jim M Wild
- POLARIS, Department of Infection, Immunity and Cardiovascular Disease and Insigneo Institute of In-silico Medicine, University of Sheffield, Sheffield, UK
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24
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Pektezel MY, Arsava EM, Gocmen R, Topcuoglu MA. Isolated Sulcal Effacement and Response to Intravenous Thrombolysis in Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2020; 29:105168. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 10/23/2022] Open
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25
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Mansour OY, Ramadan I, Abdo A, Hamdi M, Eldeeb H, Marouf H, Elsalamawy D, Elfatatry A, Elnekidy A, Reda MI. Deciding Thrombolysis in AIS Based on Automated versus on WhatsApp Interpreted ASPECTS, a Reliability and Cost-Effectiveness Analysis in Developing System of Care. Front Neurol 2020; 11:333. [PMID: 32508730 PMCID: PMC7248253 DOI: 10.3389/fneur.2020.00333] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 04/07/2020] [Indexed: 01/01/2023] Open
Abstract
Background: Automated ASPECTS has the potential of reducing interobserver variability in the determination of early ischemic changes. We aimed to assess the performance of an automated ASPECTS vs. ASPECTS interpreted for sent CT images on WhatsApp and to correlate these results with the outcome. Materials and Methods: Patients with anterior circulation stroke who had baseline NCCT and underwent successful IV-thrombolysis were included. NCCT-ASPECTS was assessed by two neuroradiologists, and discrepancies were resolved by agreement. Two groups of patients were included; group 1, where treatment was decided after an automated ASPECTS interpretation that was provided by RAPID software, and group 2, where patients received IV-tPA after an assessment of CT images sent on WhatsApp. Results: A total of 122 patients were included: 36 in group 1 and 86 in group 2. In group 2, the interobserver agreement for NCCT ASPECTS was moderate (κ = 0.36), as was the dichotomized data (κ = 0.44). IOA, however, improved (to κ = 0.57 and κ = 0.64) when the same CT images were interpreted on a workstation. In group 1, Automated ASPECTS showed excellent agreement (κ = 0.80) with agreement reads for workstation images. There were significantly (P < 0.001) increased odds of functional independence and fewer hemorrhagic complications with thrombolyzed patients in group 1. Conclusions: Automated ASPECTS provided by the RAPID@IschemaView ASPECTS performs at a level equal to the agreement read of expert neuroradiologists, and this performance was severely degraded when WhatsApp captured CT images used for ASPECTS assessment. In our study, we found that automated ASPECTS might predict outcomes after IV thrombolysis.
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Affiliation(s)
- Ossama Yassin Mansour
- Alexandria Stroke and Neurointerventional Services, Alexandria University, Alexandria, Egypt.,Neurology Department, Alexandria University, Alexandria, Egypt
| | - Ismail Ramadan
- Neurology Department, Alexandria University, Alexandria, Egypt
| | - Ashraf Abdo
- Neurology Department, Alexandria University, Alexandria, Egypt
| | - Mohamed Hamdi
- Neurology Department, Alexandria University, Alexandria, Egypt
| | - Hany Eldeeb
- Neurology Department, Alexandria University, Alexandria, Egypt
| | - Hazem Marouf
- Neurology Department, Alexandria University, Alexandria, Egypt
| | - Doaa Elsalamawy
- Neurology Department, Alexandria University, Alexandria, Egypt
| | - Amr Elfatatry
- Neurology Department, Alexandria University, Alexandria, Egypt
| | | | - M Ihab Reda
- Neuroradiology Department, Alexandria University, Alexandria, Egypt
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26
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Sarraj A, Hassan AE, Grotta J, Sitton C, Cutter G, Cai C, Chen PR, Imam B, Pujara D, Arora A, Reddy S, Parsha K, Riascos RF, Vora N, Abraham M, Edgell R, Hellinger F, Haussen DC, Blackburn S, Kamal H, Barreto AD, Martin-Schild S, Lansberg M, Gupta R, Savitz S, Albers GW. Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT): A Prospective, Multicenter Cohort Study of Imaging Selection. Ann Neurol 2020; 87:419-433. [PMID: 31916270 DOI: 10.1002/ana.25669] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 01/03/2020] [Accepted: 01/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The primary imaging modalities used to select patients for endovascular thrombectomy (EVT) are noncontrast computed tomography (CT) and CT perfusion (CTP). However, their relative utility is uncertain. We prospectively assessed CT and CTP concordance/discordance and correlated the imaging profiles on both with EVT treatment decisions and clinical outcomes. METHODS A phase 2, multicenter, prospective cohort study of large-vessel occlusions presented up to 24 hours from last known well was conducted. Patients received a unified prespecified imaging evaluation (CT, CT angiography, and CTP with Rapid Processing of Perfusion and Diffusion software mismatch determination). The treatment decision, EVT versus medical management, was nonrandomized and at the treating physicians' discretion. An independent, blinded, neuroimaging core laboratory adjudicated favorable profiles based on predefined criteria (CT:Alberta Stroke Program Early CT Score ≥ 6, CTP:regional cerebral blood flow (<30%) < 70ml with mismatch ratio ≥ 1.2 and mismatch volume ≥ 10ml). RESULTS Of 4,722 patients screened from January 2016 to February 2018, 361 patients were included. Two hundred eighty-five (79%) received EVT, of whom 87.0% had favorable CTs, 91% favorable CTPs, 81% both favorable profiles, 16% discordant, and 3% both unfavorable. Favorable profiles on the 2 modalities correlated similarly with 90-day functional independence rates (favorable CT = 56% vs favorable CTP = 57%, adjusted odds ratio [aOR] = 1.91, 95% confidence interval [CI] = 0.40-9.01, p = 0.41). Having a favorable profile on both modalities significantly increased the odds of receiving thrombectomy as compared to discordant profiles (aOR = 3.97, 95% CI = 1.97-8.01, p < 0.001). Fifty-eight percent of the patients with favorable profiles on both modalities achieved functional independence as compared to 38% in discordant profiles and 0% when both were unfavorable (p < 0.001 for trend). In favorable CT/unfavorable CTP profiles, EVT was associated with high symptomatic intracranial hemorrhage (sICH) (24%) and mortality (53%) rates. INTERPRETATION Patients with favorable imaging profiles on both modalities had higher odds of receiving EVT and high functional independence rates. Patients with discordant profiles achieved reasonable functional independence rates, but those with an unfavorable CTP had higher adverse outcomes. Ann Neurol 2020;87:419-433.
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Affiliation(s)
- Amrou Sarraj
- Department of Neurology, University of Texas at Houston, Houston, TX
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX
| | - James Grotta
- Department of Neurology, University of Texas at Houston, Houston, TX
| | - Clark Sitton
- Department of Radiology, University of Texas at Houston, Houston, TX
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham School of Public Health, Birmingham, AL
| | - Chunyan Cai
- Department of Clinical and Translational Science, University of Texas at Houston, Houston, TX
| | - Peng R Chen
- Department of Neurosurgery, University of Texas at Houston, Houston, TX
| | - Bita Imam
- Department of Neurology, University of Texas at Houston, Houston, TX
| | - Deep Pujara
- Department of Neurology, University of Texas at Houston, Houston, TX
| | | | - Sujan Reddy
- Department of Neurology, University of Texas at Houston, Houston, TX
| | - Kaushik Parsha
- Department of Neurology, University of Texas at Houston, Houston, TX
| | - Roy F Riascos
- Department of Radiology, University of Texas at Houston, Houston, TX
| | - Nirav Vora
- Department of Neurology, OhioHealth-Riverside Methodist Hospital, Columbus, OH
| | - Michael Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS
| | - Randall Edgell
- Department of Neurology, Saint Louis University, St. Louis, MO
| | | | | | - Spiros Blackburn
- Department of Neurosurgery, University of Texas at Houston, Houston, TX
| | - Haris Kamal
- Department of Neurology, University of Texas at Houston, Houston, TX
| | - Andrew D Barreto
- Department of Neurology, University of Texas at Houston, Houston, TX
| | - Sheryl Martin-Schild
- Department of Neurology, Touro Infirmary and New Orleans East Hospital, New Orleans, LA
| | | | - Rishi Gupta
- Department of Neurology, WellStar Health System, Atlanta, GA
| | - Sean Savitz
- Department of Neurology, University of Texas at Houston, Houston, TX
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27
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Thorén M, Dixit A, Escudero-Martínez I, Gdovinová Z, Klecka L, Rand VM, Toni D, Vilionskis A, Wahlgren N, Ahmed N. Effect of Recanalization on Cerebral Edema in Ischemic Stroke Treated With Thrombolysis and/or Endovascular Therapy. Stroke 2019; 51:216-223. [PMID: 31818228 DOI: 10.1161/strokeaha.119.026692] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background and Purpose- A large infarct and expanding cerebral edema (CED) due to a middle cerebral artery occlusion confers a 70% mortality unless treated surgically. Reperfusion may cause blood-brain barrier disruption and a risk for cerebral edema and secondary parenchymal hemorrhage (PH). We aimed to investigate the effect of recanalization on development of early CED and PH after recanalization therapy. Methods- From the SITS-International Stroke Treatment Registry, we selected patients with signs of artery occlusion at baseline (either Hyperdense Artery Sign or computed tomography/magnetic resonance imaging angiographic occlusion). We defined recanalization as the disappearance of radiological signs of occlusion at 22 to 36 hours. Primary outcome was moderate to severe CED and secondary outcome was PH on 22- to 36-hour imaging scans. We used logistic regression with adjustment for baseline variables and PH. Results- Twenty two thousand one hundred eighty-four patients fulfilled the inclusion criteria (n=18 318 received intravenous thrombolysis, n=3071 received intravenous thrombolysis+thrombectomy, n=795 received thrombectomy). Recanalization occurred in 64.1%. Median age was 71 versus 71 years and National Institutes of Health Stroke Scale score 15 versus 16 in the recanalized versus nonrecanalized patients respectively. Recanalized patients had a lower risk for CED (13.0% versus 23.6%), adjusted odds ratio (aOR), 0.52 (95% CI, 0.46-0.59), and a higher risk for PH (8.9% versus 6.5%), adjusted odds ratio, 1.37 (95% CI, 1.22-1.55), than nonrecanalized patients. Conclusions- In patients with acute ischemic stroke, recanalization was associated with a lower risk for early CED even after adjustment for higher rate for PH in recanalized patients.
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Affiliation(s)
- Magnus Thorén
- From the Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden (M.T., N.A.)
| | - Anand Dixit
- Newcastle upon Tyne NHS Foundation Trust, University of Newcastle upon Tyne, United Kingdom (A.D.)
| | - Irene Escudero-Martínez
- Department of Neurology, University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain (I.E.-M.)
| | - Zuzana Gdovinová
- Department of Neurology, Faculty of Medicine, P.J. Safarik University Košice, Slovak republic (Z.G.)
| | - Lukas Klecka
- Departement of Neurology, Municipal hospital of Ostrava, Czech Republic (L.K.)
| | - Viiu-Marika Rand
- Department of Neurology, North Estonia Medical Centre, Tallinn (V.-M.R.)
| | - Danilo Toni
- Unità di Trattamento Neurovascolare, University La Sapienza Rome, Italy (D.T.)
| | - Aleksandras Vilionskis
- Department of Neurology, Institute of Clinical Medicine, Vilnius University, Republican Vilnius University hospital, Lithuania (A.V.)
| | - Nils Wahlgren
- Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.)
| | - Niaz Ahmed
- From the Department of Neurology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden (M.T., N.A.)
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Yu W, Jiang WJ. A Simple Imaging Guide for Endovascular Thrombectomy in Acute Ischemic Stroke: From Time Window to Perfusion Mismatch and Beyond. Front Neurol 2019; 10:502. [PMID: 31178813 PMCID: PMC6543836 DOI: 10.3389/fneur.2019.00502] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/25/2019] [Indexed: 01/01/2023] Open
Affiliation(s)
- Wengui Yu
- Department of Neurology, University of California Irvine, Irvine, CA, United States
| | - Wei-Jian Jiang
- New Era Stroke Care and Research Institute, The Rocket Force General Hospital, Beijing, China
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Abstract
Acute ischemic stroke (AIS) is a medical emergency that requires prompt recognition and streamlined work-up to ensure that time-dependent therapies are initiated to achieve the best outcomes. This article discusses frequently missed AIS in the emergency department, the role of various imagining modalities in the work-up of AIS, updates on the use of intravenous thrombolytics and endovascular therapy for AIS, pearls on supportive care management of AIS, and prehospital and hospital process improvements to shorten door-to-needle time.
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Affiliation(s)
- Alfredo E Urdaneta
- Department of Emergency Medicine, Stanford University, 900 Welch Road, Suite 350, Palo Alto, CA 94305, USA.
| | - Paulomi Bhalla
- Department of Neurology, Stanford Health Care - Valley Care, Stanford University, 300 Pasteur Drive, Palo Alto, CA 94304, USA
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Maegerlein C, Fischer J, Mönch S, Berndt M, Wunderlich S, Seifert CL, Lehm M, Boeckh-Behrens T, Zimmer C, Friedrich B. Automated Calculation of the Alberta Stroke Program Early CT Score: Feasibility and Reliability. Radiology 2019; 291:141-148. [DOI: 10.1148/radiol.2019181228] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Christian Maegerlein
- From the Department of Diagnostic and Interventional Neuroradiology (C.M., J.F., S.M., M.B., M.L., T.B.B., C.Z., B.F.) and Department of Neurology (S.W., C.L.S.), Klinikum rechts der Isar, Technical University Munich, Ismaninger Str 22, 81675 Munich, Germany
| | - Johanna Fischer
- From the Department of Diagnostic and Interventional Neuroradiology (C.M., J.F., S.M., M.B., M.L., T.B.B., C.Z., B.F.) and Department of Neurology (S.W., C.L.S.), Klinikum rechts der Isar, Technical University Munich, Ismaninger Str 22, 81675 Munich, Germany
| | - Sebastian Mönch
- From the Department of Diagnostic and Interventional Neuroradiology (C.M., J.F., S.M., M.B., M.L., T.B.B., C.Z., B.F.) and Department of Neurology (S.W., C.L.S.), Klinikum rechts der Isar, Technical University Munich, Ismaninger Str 22, 81675 Munich, Germany
| | - Maria Berndt
- From the Department of Diagnostic and Interventional Neuroradiology (C.M., J.F., S.M., M.B., M.L., T.B.B., C.Z., B.F.) and Department of Neurology (S.W., C.L.S.), Klinikum rechts der Isar, Technical University Munich, Ismaninger Str 22, 81675 Munich, Germany
| | - Silke Wunderlich
- From the Department of Diagnostic and Interventional Neuroradiology (C.M., J.F., S.M., M.B., M.L., T.B.B., C.Z., B.F.) and Department of Neurology (S.W., C.L.S.), Klinikum rechts der Isar, Technical University Munich, Ismaninger Str 22, 81675 Munich, Germany
| | - Christian L. Seifert
- From the Department of Diagnostic and Interventional Neuroradiology (C.M., J.F., S.M., M.B., M.L., T.B.B., C.Z., B.F.) and Department of Neurology (S.W., C.L.S.), Klinikum rechts der Isar, Technical University Munich, Ismaninger Str 22, 81675 Munich, Germany
| | - Manuel Lehm
- From the Department of Diagnostic and Interventional Neuroradiology (C.M., J.F., S.M., M.B., M.L., T.B.B., C.Z., B.F.) and Department of Neurology (S.W., C.L.S.), Klinikum rechts der Isar, Technical University Munich, Ismaninger Str 22, 81675 Munich, Germany
| | - Tobias Boeckh-Behrens
- From the Department of Diagnostic and Interventional Neuroradiology (C.M., J.F., S.M., M.B., M.L., T.B.B., C.Z., B.F.) and Department of Neurology (S.W., C.L.S.), Klinikum rechts der Isar, Technical University Munich, Ismaninger Str 22, 81675 Munich, Germany
| | - Claus Zimmer
- From the Department of Diagnostic and Interventional Neuroradiology (C.M., J.F., S.M., M.B., M.L., T.B.B., C.Z., B.F.) and Department of Neurology (S.W., C.L.S.), Klinikum rechts der Isar, Technical University Munich, Ismaninger Str 22, 81675 Munich, Germany
| | - Benjamin Friedrich
- From the Department of Diagnostic and Interventional Neuroradiology (C.M., J.F., S.M., M.B., M.L., T.B.B., C.Z., B.F.) and Department of Neurology (S.W., C.L.S.), Klinikum rechts der Isar, Technical University Munich, Ismaninger Str 22, 81675 Munich, Germany
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Dual-layer detector CT of the head: Initial experience in visualization of intracranial hemorrhage and hypodense brain lesions using virtual monoenergetic images. Eur J Radiol 2018; 108:177-183. [DOI: 10.1016/j.ejrad.2018.09.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 09/07/2018] [Accepted: 09/10/2018] [Indexed: 01/31/2023]
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Guberina N, Dietrich U, Radbruch A, Goebel J, Deuschl C, Ringelstein A, Köhrmann M, Kleinschnitz C, Forsting M, Mönninghoff C. Detection of early infarction signs with machine learning-based diagnosis by means of the Alberta Stroke Program Early CT score (ASPECTS) in the clinical routine. Neuroradiology 2018; 60:889-901. [PMID: 30066278 DOI: 10.1007/s00234-018-2066-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 07/20/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE New software solutions emerged to support radiologists in image interpretation in acute ischemic stroke. This study aimed to validate the performance of computer-aided assessment of the Alberta Stroke Program Early CT score (ASPECTS) for detecting signs of early infarction. METHODS ASPECT scores were assessed in 119 CT scans of patients with acute middle cerebral artery ischemia. Patient collective was differentiated according to (I) normal brain, (II) leukoencephalopathic changes, (III) infarcts, and (IV) atypical parenchymal defects (multiple sclerosis, etc.). ASPECTS assessments were automatically provided by the software package e-ASPECTS (Brainomix®, UK) (A). Subsequently, three neuroradiologists (B), (C), and (D) examined independently 2380 brain regions. Interrater comparison was performed with the definite infarct core as reference standard after best medical care (thrombolysis and/or thrombectomy). RESULTS Interrater comparison revealed higher correlation coefficient of (B) 0.71, (C) 0.76, and of (D) 0.80 with definite infarct core compared to (A) 0.59 for ASPECTS assessment in the acute ischemic stroke setting. While (B), (C), and (D) showed a significant correlation for individual patient groups (I), (II), (III), and (IV), except for (D) (II), (A) was not significant in patient groups with pre-existing changes (II), (III), and (IV). The following sensitivities, specificities, PPV, NPV, and accuracies given in percent were achieved: (A) 83, 57, 55, 82, and 67; (B) 74, 76, 69, 83, and 77; (C) 80.8, 85.2, 76, 84, and 80; (D) 63, 90.7, 82, 79, and 80, respectively. CONCLUSION For ASPECTS assessment, the examined software may provide valid data in case of normal brain. It may enhance the work of neuroradiologists in clinical decision making. A final human check for plausibility is needed, particularly in patient groups with pre-existing cerebral changes.
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Affiliation(s)
- Nika Guberina
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany.
| | - U Dietrich
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - A Radbruch
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - J Goebel
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - C Deuschl
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - A Ringelstein
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany.,Department of Radiology and Neuroradiology, Mariahilf Mönchengladbach, Mönchengladbach, Germany
| | - M Köhrmann
- Clinic for Neurology, University Hospital Essen, Essen, Germany
| | - C Kleinschnitz
- Clinic for Neurology, University Hospital Essen, Essen, Germany
| | - M Forsting
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - C Mönninghoff
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
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Nagel S, Wang X, Carcel C, Robinson T, Lindley RI, Chalmers J, Anderson CS. Clinical Utility of Electronic Alberta Stroke Program Early Computed Tomography Score Software in the ENCHANTED Trial Database. Stroke 2018; 49:1407-1411. [DOI: 10.1161/strokeaha.117.019863] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/20/2018] [Accepted: 01/30/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Simon Nagel
- From the Department of Neurology, Heidelberg University Hospital, Germany (S.N.)
| | - Xia Wang
- Neurological and Mental Health Division, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., R.I.L., J.C., C.S.A.)
| | | | - Thompson Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, United Kingdom (T.R.)
| | - Richard I. Lindley
- Neurological and Mental Health Division, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., R.I.L., J.C., C.S.A.)
- Sydney Medical School, Westmead Hospital, University of Sydney, New South Wales, Australia (R.I.L.)
| | - John Chalmers
- Neurological and Mental Health Division, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., R.I.L., J.C., C.S.A.)
| | - Craig S. Anderson
- Neurological and Mental Health Division, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., R.I.L., J.C., C.S.A.)
- the George Institute China at Peking University Health Science Center, Beijing (C.S.A.)
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Murayama K, Suzuki S, Matsukiyo R, Takenaka A, Hayakawa M, Tsutsumi T, Fujii K, Katada K, Toyama H. Preliminary study of time maximum intensity projection computed tomography imaging for the detection of early ischemic change in patient with acute ischemic stroke. Medicine (Baltimore) 2018; 97:e9906. [PMID: 29489691 PMCID: PMC5851726 DOI: 10.1097/md.0000000000009906] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Noncontrast computed tomography (NCCT) has been used for the detection of early ischemic change (EIC); however, correct interpretation of NCCT findings requires much clinical experience. This study aimed to assess the accuracy of time maximum intensity projection computed tomography technique (tMIP), which reflects the maximum value for the time phase direction from the dynamic volume data for each projected plane, for detection of EIC, against that of NCCT.Retrospective review of NCCT, cerebral blood volume in CT perfusion (CTP-CBV), and tMIP of 186 lesions from 280 regions evaluated by Alberta Stroke Program Early CT Score (ASPECTS) in 14 patients with acute middle cerebral artery stroke who had undergone whole-brain CTP using 320-row area detector CT was performed. Four radiologists reviewed EIC on NCCT, CTP-CBV, and tMIP in each ASPECTS region at onset using the continuous certainty factor method. Receiver operating characteristic analysis was performed to compare the relative performance for detection of EIC. The correlations were evaluated.tMIP-color showed the best discriminative value for detection of EIC. There were significant differences in the area under the curve for NCCT and tMIP-color, CTP-CBV (P < .05). Scatter plots of ASPECTS showed a positive significant correlation between NCCT, tMIP-gray, tMIP-color, and the follow-up study (NCCT, r = 0.32, P = .0166; tMIP-gray, r = 0.44, P = .0007; tMIP-color, r = 0.34, P = .0104).Because tMIP provides a high contrast parenchymal image with anatomical and vascular information in 1 sequential scan, it showed greater accuracy for detection of EIC and predicted the final infarct extent more accurately than NCCT based on ASPECTS.
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Affiliation(s)
| | | | | | | | | | - Takashi Tsutsumi
- Clinical Application Research Center, Toshiba Medical Systems Corporation, Otawara
| | - Kenji Fujii
- Clinical Application Research Center, Toshiba Medical Systems Corporation, Otawara
| | - Kazuhiro Katada
- Joint Research Laboratory of Advanced Medical Imaging, Fujita Health University, Toyoake, Japan
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Rao MR, Stewart NJ, Griffiths PD, Norquay G, Wild JM. Imaging Human Brain Perfusion with Inhaled Hyperpolarized 129Xe MR Imaging. Radiology 2018; 286:659-665. [PMID: 28858563 DOI: 10.1148/radiol.2017162881] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Purpose To evaluate the feasibility of directly imaging perfusion of human brain tissue by using magnetic resonance (MR) imaging with inhaled hyperpolarized xenon 129 (129Xe). Materials and Methods In vivo imaging with 129Xe was performed in three healthy participants. The combination of a high-yield spin-exchange optical pumping 129Xe polarizer, custom-built radiofrequency coils, and an optimized gradient-echo MR imaging protocol was used to achieve signal sensitivity sufficient to directly image hyperpolarized 129Xe dissolved in the human brain. Conventional T1-weighted proton (hydrogen 1 [1H]) images and perfusion images by using arterial spin labeling were obtained for comparison. Results Images of 129Xe uptake were obtained with a signal-to-noise ratio of 31 ± 9 and demonstrated structural similarities to the gray matter distribution on conventional T1-weighted 1H images and to perfusion images from arterial spin labeling. Conclusion Hyperpolarized 129Xe MR imaging is an injection-free means of imaging the perfusion of cerebral tissue. The proposed method images the uptake of inhaled xenon gas to the extravascular brain tissue compartment across the intact blood-brain barrier. This level of sensitivity is not readily available with contemporary MR imaging methods. ©RSNA, 2017.
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Affiliation(s)
- Madhwesha R Rao
- From the Academic Unit of Radiology, University of Sheffield, Royal Hallamshire Hospital, Glossop Road, C Floor, Sheffield S10 2JF, England (M.R.R., N.J.S., P.D.G., G.N., J.M.W.)
| | - Neil J Stewart
- From the Academic Unit of Radiology, University of Sheffield, Royal Hallamshire Hospital, Glossop Road, C Floor, Sheffield S10 2JF, England (M.R.R., N.J.S., P.D.G., G.N., J.M.W.)
| | - Paul D Griffiths
- From the Academic Unit of Radiology, University of Sheffield, Royal Hallamshire Hospital, Glossop Road, C Floor, Sheffield S10 2JF, England (M.R.R., N.J.S., P.D.G., G.N., J.M.W.)
| | - Graham Norquay
- From the Academic Unit of Radiology, University of Sheffield, Royal Hallamshire Hospital, Glossop Road, C Floor, Sheffield S10 2JF, England (M.R.R., N.J.S., P.D.G., G.N., J.M.W.)
| | - Jim M Wild
- From the Academic Unit of Radiology, University of Sheffield, Royal Hallamshire Hospital, Glossop Road, C Floor, Sheffield S10 2JF, England (M.R.R., N.J.S., P.D.G., G.N., J.M.W.)
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Bhaskar S, Stanwell P, Cordato D, Attia J, Levi C. Reperfusion therapy in acute ischemic stroke: dawn of a new era? BMC Neurol 2018; 18:8. [PMID: 29338750 PMCID: PMC5771207 DOI: 10.1186/s12883-017-1007-y] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 12/14/2017] [Indexed: 12/14/2022] Open
Abstract
Following the success of recent endovascular trials, endovascular therapy has emerged as an exciting addition to the arsenal of clinical management of patients with acute ischemic stroke (AIS). In this paper, we present an extensive overview of intravenous and endovascular reperfusion strategies, recent advances in AIS neurointervention, limitations of various treatment paradigms, and provide insights on imaging-guided reperfusion therapies. A roadmap for imaging guided reperfusion treatment workflow in AIS is also proposed. Both systemic thrombolysis and endovascular treatment have been incorporated into the standard of care in stroke therapy. Further research on advanced imaging-based approaches to select appropriate patients, may widen the time-window for patient selection and would contribute immensely to early thrombolytic strategies, better recanalization rates, and improved clinical outcomes.
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Affiliation(s)
- Sonu Bhaskar
- Western Sydney University (WSU), School of Medicine, South West Sydney Clinical School, Sydney, NSW 2170 Australia
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Peter Stanwell
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Dennis Cordato
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- School of Medicine, University of New South Wales (UNSW), Sydney, NSW Australia
| | - John Attia
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
- Centre for Clinical Epidemiology & Biostatistics, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW Australia
| | - Christopher Levi
- Western Sydney University (WSU), School of Medicine, South West Sydney Clinical School, Sydney, NSW 2170 Australia
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- School of Medicine, University of New South Wales (UNSW), Sydney, NSW Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia
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Smith AG, Rowland Hill C. Imaging assessment of acute ischaemic stroke: a review of radiological methods. Br J Radiol 2017; 91:20170573. [PMID: 29144166 DOI: 10.1259/bjr.20170573] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Acute ischaemic stroke is the second largest cause of death worldwide and a cause of major physical and psychological morbidity. Current evidence based treatment includes intravenous thrombolysis (IVT) and mechanical thrombectomy (MT), both requiring careful patient selection and to be administered as quickly as possible within a limited time window from symptom onset. Imaging plays a crucial role identifying patients who may benefit from MT or IVT whilst excluding those that may be harmed. For IVT, imaging must as a minimum exclude haemorrhage, stroke mimics and provide an estimate of non-viable brain. For MT, imaging must in addition detect and characterize intra-arterial thrombus and assess the intra and extracranial arterial architecture. More advanced imaging techniques may be used to assess more accurately the volume of non-viable and potentially salvageable brain tissue. It is highly likely that further research will identify patients who would benefit from treatment beyond currently accepted time windows for IVT (4.5 h) and MT (6 h) and patients with an unknown time of symptom onset. Current evidence indicates that best outcomes are achieved when treatment is instituted as soon as possible after symptom onset. A rapid, efficient imaging pathway including interpretation is fundamental to achieving the best outcomes. This review summarizes current techniques for imaging assessment of acute stroke, highlighting strengths and limitations of each. The optimum pathway is a balance between diagnostic information, local resources, specialization and the time taken to acquire, process and interpret the data. As new evidence emerges, it is likely that the minimum required imaging data will change.
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Thorén M, Azevedo E, Dawson J, Egido JA, Falcou A, Ford GA, Holmin S, Mikulik R, Ollikainen J, Wahlgren N, Ahmed N. Predictors for Cerebral Edema in Acute Ischemic Stroke Treated With Intravenous Thrombolysis. Stroke 2017; 48:2464-2471. [PMID: 28775140 DOI: 10.1161/strokeaha.117.018223] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 07/03/2017] [Accepted: 07/06/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Cerebral edema (CED) is a severe complication of acute ischemic stroke. There is uncertainty regarding the predictors for the development of CED after cerebral infarction. We aimed to determine which baseline clinical and radiological parameters predict development of CED in patients treated with intravenous thrombolysis. METHODS We used an image-based classification of CED with 3 degrees of severity (less severe CED 1 and most severe CED 3) on postintravenous thrombolysis imaging scans. We extracted data from 42 187 patients recorded in the SITS International Register (Safe Implementation of Treatments in Stroke) during 2002 to 2011. We did univariate comparisons of baseline data between patients with or without CED. We used backward logistic regression to select a set of predictors for each CED severity. RESULTS CED was detected in 9579/42 187 patients (22.7%: 12.5% CED 1, 4.9% CED 2, 5.3% CED 3). In patients with CED versus no CED, the baseline National Institutes of Health Stroke Scale score was higher (17 versus 10; P<0.001), signs of acute infarct was more common (27.9% versus 19.2%; P<0.001), hyperdense artery sign was more common (37.6% versus 14.6%; P<0.001), and blood glucose was higher (6.8 versus 6.4 mmol/L; P<0.001). Baseline National Institutes of Health Stroke Scale, hyperdense artery sign, blood glucose, impaired consciousness, and signs of acute infarct on imaging were independent predictors for all edema types. CONCLUSIONS The most important baseline predictors for early CED are National Institutes of Health Stroke Scale, hyperdense artery sign, higher blood glucose, decreased level of consciousness, and signs of infarct at baseline. The findings can be used to improve selection and monitoring of patients for drug or surgical treatment.
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Affiliation(s)
- Magnus Thorén
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.).
| | - Elsa Azevedo
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
| | - Jesse Dawson
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
| | - Jose A Egido
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
| | - Anne Falcou
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
| | - Gary A Ford
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
| | - Staffan Holmin
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
| | - Robert Mikulik
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
| | - Jyrki Ollikainen
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
| | - Nils Wahlgren
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
| | - Niaz Ahmed
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
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Abstract
The early identification of patients with large hemisphere infarctions (LHIs) at risk of fatal brain edema may result in better outcomes. A quantitative model using parameters obtained at admission may be a predictor of in-hospital mortality from LHI.This prospective study enrolled all patients with LHI involving >50% of the middle cerebral artery (MCA) admitted to our neurological intensive care unit within 48 hours of symptom onset. Early clinical and radiographic parameters and the baseline CHADS2 score (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke [double weight]) were analyzed regarding their ability to predict patient outcomes.Seventy-seven patients with LHIs were identified, 33 (42.9%) with complete MCA infarction (CMCA), and 44 (57.1%) with incomplete MCA infarction (IMCA). The predictors of CMCA score included: >1/3 early hypodensity in computed tomography findings, hyperdense MCA sign, brain edema, initial National Institutes of Health Stroke Scale (NIHSS) score ≥17, and stroke in progression during the 1st 5 days of admission. The cutoff CMCA score was 2, with a sensitivity of 81.8% and specificity of 70.5%. Mortality score 1, used for predicting in-hospital mortality from LHI, included CMCA and CHADS2 scores ≥4 (sensitivity 100.0%, specificity 57.4%), and mortality score 2 included CMCA and CHADS2 scores ≥4, and NIHSS score ≥26, during the 1st 5 days (sensitivity 100.0%, specificity 91.7%).Patients qualifying for a mortality score of 2 were at high-risk of in-hospital mortality from LHI. These findings may aid in identifying patients who may benefit from invasive therapeutic strategies, and in better describing the characteristics of those at risk of mortality.
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Affiliation(s)
- Chien-Fu Chen
- Department of Neurology, Kaohsiung Medical University Hospital
| | - Ruey-Tay Lin
- Department of Neurology, Kaohsiung Medical University Hospital
- Department of Neurology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsiu-Fen Lin
- Department of Neurology, Kaohsiung Medical University Hospital
- Department of Neurology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - A-Ching Chao
- Department of Neurology, Kaohsiung Medical University Hospital
- Department of Neurology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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von Kummer R, Dzialowski I. Imaging of cerebral ischemic edema and neuronal death. Neuroradiology 2017; 59:545-553. [PMID: 28540400 DOI: 10.1007/s00234-017-1847-6] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 05/03/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE In acute cerebral ischemia, the assessment of irreversible injury is crucial for treatment decisions and the patient's prognosis. There is still uncertainty how imaging can safely differentiate reversible from irreversible ischemic brain tissue in the acute phase of stroke. METHODS We have searched PubMed and Google Scholar for experimental and clinical papers describing the pathology and pathophysiology of cerebral ischemia under controlled conditions. RESULTS Within the first 6 h of stroke onset, ischemic cell injury is subtle and hard to recognize under the microscope. Functional impairment is obvious, but can be induced by ischemic blood flow allowing recovery with flow restoration. The critical cerebral blood flow (CBF) threshold for irreversible injury is ~15 ml/100 g × min. Below this threshold, ischemic brain tissue takes up water in case of any residual capillary flow (ionic edema). Because tissue water content is linearly related to X-ray attenuation, computed tomography (CT) can detect and measure ionic edema and, thus, determine ischemic brain infarction. In contrast, diffusion-weighted magnetic resonance imaging (DWI) detects cytotoxic edema that develops at higher thresholds of ischemic CBF and is thus highly sensitive for milder levels of brain ischemia, but not specific for irreversible brain tissue injury. CONCLUSION CT and MRI are complimentary in the detection of ischemic stroke pathology and are valuable for treatment decisions.
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Affiliation(s)
- Rüdiger von Kummer
- Institut für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Germany.
| | - Imanuel Dzialowski
- Elblandklinikum Meißen, Neurologische Rehabilitationsklinik Großenhain, Nassauweg 7, 01662, Meißen, Germany
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Ryu CW, Shin HS, Park S, Suh SH, Koh JS, Choi HY. Alberta Stroke Program Early CT Score in the Prognostication after Endovascular Treatment for Ischemic Stroke: A Meta-analysis. Neurointervention 2017; 12:20-30. [PMID: 28316866 PMCID: PMC5355457 DOI: 10.5469/neuroint.2017.12.1.20] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 02/20/2017] [Indexed: 01/19/2023] Open
Abstract
Purpose The Alberta Stroke Program Early CT Score (ASPECTS) was devised to quantify the extent of early ischemic changes in the middle cerebral artery territory on brain CT. We performed a systematic review and meta-analysis of studies that presented clinical outcomes and baseline ASPECTS in ischemic stroke patients managed with endovascular methods to validate the use of ASPECTS for risk prognostication. Materials and Methods We searched the MEDLINE, EMBASE, and Cochran databases for observational or interventional studies that reported clinical outcomes and baseline ASPECTS in ischemic stroke patients treated with endovascular methods. Data were pooled to perform a meta-analysis for comparisons of clinical outcomes between high and low ASPECTS patients. Results A meta-analysis of 13 studies (six observational and seven interventional) revealed favorable outcomes (mRS sore 0-2 at 90 days) for high baseline ASPECTS (odds ratio=2.22; 95% CI: 1.74-2.86). Conclusion High ASPECTS is a predictor of favorable outcome after endovascular therapy for ischemic stroke.
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Affiliation(s)
- Chang-Woo Ryu
- Department of Radiology, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, South Korea
| | - Hee Shup Shin
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, South Korea
| | - Soonchan Park
- Department of Radiology, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, South Korea
| | - Sang Hyun Suh
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Seok Koh
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, South Korea
| | - Hye-Yeon Choi
- Department of Neurology, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, South Korea
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McLaughlin PD, Moloney F, O'Neill SB, James K, Crush L, Flanagan O, Maher MM, Wyse G, Fanning N. CT of the head for acute stroke: Diagnostic performance of a tablet computer prior to intravenous thrombolysis. J Med Imaging Radiat Oncol 2017; 61:334-338. [PMID: 28156051 DOI: 10.1111/1754-9485.12585] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 12/08/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The authors propose that tablet computers could benefit patients with acute stroke in the remote care setting, where time to and accuracy of CT interpretation greatly influences patient outcome. METHODS One hundred and fifty consecutive patients who presented to the Emergency Department of a tertiary referral neurosciences centre within a time window suitable for intravenous thrombolytic therapy were included. Images were wirelessly transmitted to a tablet computer (iPad 3rd Generation, model = A1430, Apple, Cupertino, CA) and were reviewed by radiologists with three levels of experience for signs of intracranial haemorrhage, large vessel occlusion and parenchymal infarction. Reference standard interpretation was performed by two neuroradiologists using a diagnostic monochrome display. RESULTS Consensus neuroradiologist review on the tablet display found and correctly classified all of the 23 cases of intracranial haemorrhage including 21 cases of parenchymal haematoma, two cases of petechial haemorrhage and one patient with an acute subdural haematoma. Less experienced readers missed cases of petechial and subdural haematomas. There was excellent agreement between the tablet and diagnostic monochrome display in cases with no infarct or extensive parenchymal infarction. CONCLUSIONS Tablet computers can be used to facilitate rapid preliminary CT interpretation in patients with acute stroke in the remote setting.
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Affiliation(s)
| | - Fiachra Moloney
- Department of Radiology, Cork University Hospital, Cork, Ireland
| | | | - Karl James
- Department of Radiology, Cork University Hospital, Cork, Ireland
| | - Lee Crush
- Department of Radiology, Cork University Hospital, Cork, Ireland
| | - Oisin Flanagan
- Department of Radiology, Cork University Hospital, Cork, Ireland
| | - Michael M Maher
- Department of Radiology, Cork University Hospital, Cork, Ireland
| | - Gerald Wyse
- Department of Radiology, Cork University Hospital, Cork, Ireland
| | - Noel Fanning
- Department of Radiology, Cork University Hospital, Cork, Ireland
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Schröder J, Thomalla G. A Critical Review of Alberta Stroke Program Early CT Score for Evaluation of Acute Stroke Imaging. Front Neurol 2017; 7:245. [PMID: 28127292 PMCID: PMC5226934 DOI: 10.3389/fneur.2016.00245] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 12/29/2016] [Indexed: 01/19/2023] Open
Abstract
Assessment of ischemic stroke lesions on computed tomography (CT) or MRI using the Alberta Stroke Program Early CT Score (ASPECTS) is widely used to guide acute stroke treatment. We aimed to review the current evidence on ASPECTS. Originally, the score was developed for standardized lesion assessment on non-contrast CT (NCCT). Early studies described ASPECTS as a predictor of functional outcome and symptomatic intracranial hemorrhage after iv-thrombolysis with a threshold of ≤7 suggested to identify patients at high risk. Following studies rather pointed toward a linear relationship between ASPECTS and functional outcome. ASPECTS has also been applied to assess perfusion CT and diffusion-weighted MRI (DWI). Cerebral blood volume ASPECTS proved to be the best predictor of outcome, outperforming NCCT-ASPECTS in some studies. For DWI-ASPECTS varying thresholds to identify patients at risk for poor outcome were reported. ASPECTS has been used for patient selection in three of the five groundbreaking trials proving efficacy of mechanical thrombectomy published in 2015. ASPECTS values predict functional outcome after thrombectomy. Moreover, treatment effect of thrombectomy appears to depend on ASPECTS values being smaller or not present in low ASPECTS, while patients with ASPECTS 5–10 do clearly benefit from mechanical thrombectomy. However, as patients with low ASPECTS values were excluded from recent trials data on this subgroup is limited. There are several limitations to ASPECTS addressed in a growing number of studies. The score is limited to the anterior circulation, the template is unequally weighed and correlation with lesion volume depends on lesion location. Overall ASPECTS is a useful and easily applicable tool for assessment of prognosis in acute stroke treatment and to help guide acute treatment decisions regardless whether MRI or CT is used. Patients with low ASPECTS values are unlikely to achieve good outcome. However, methodological constraints of ASPECTS have to be considered, and based on present data, a clear cutoff value to define “low ASPECTS values” cannot be given.
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Affiliation(s)
- Julian Schröder
- Department of Neurology, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
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Bouchez L, Sztajzel R, Vargas MI, Machi P, Kulcsar Z, Poletti PA, Pereira VM, Lövblad KO. CT imaging selection in acute stroke. Eur J Radiol 2016; 96:153-161. [PMID: 28277288 DOI: 10.1016/j.ejrad.2016.10.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 10/21/2016] [Accepted: 10/23/2016] [Indexed: 11/27/2022]
Abstract
Acute stroke has become an increasingly treatable cause of acute neurological deficits. Indeed, over the last two decades, the introduction of first thrombolysis, and now thrombectomy has improved patient outcomes and extended the therapeutic window. Computed tomography has been established as the most simple and readily available technique for the diagnosis and management of patients with acute stroke. Indeed, CT allows easy confirmation or exclusion of acute hemorrhage on the one hand, and on the other hand the early signs are quite reliable in the detection of ischemia. In the early phase the clot can be seen as well as exchanges related to early changes in water concentration in ischemia and the surrounding penumbra. Additional techniques such as angio-CT show the location of the clot and perfusion techniques reveal local hemodynamics as well as potential tissue viability. Newer techniques such as double energy CT and late phase CT should provide information on collateral flow as well as on the presence of early hemorrhagic transformation. All these techniques should thus make available new information on tissue viability,that is indispensable in the choice of revascularization technique. Thus CT techniques allow a quick and reliable triage as well as a finer characterization of the ischemic process. The use of all these CT techniques in an optimal way should help improve patient triage and selection of the most adequate treatment with further improvements in clinical outcomes as a result.
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Affiliation(s)
- Laurie Bouchez
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals and Medical School, 1211, Geneva, Switzerland
| | - Roman Sztajzel
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals and Medical School, 1211, Geneva, Switzerland
| | - Maria Isabel Vargas
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals and Medical School, 1211, Geneva, Switzerland
| | - Paolo Machi
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals and Medical School, 1211, Geneva, Switzerland
| | - Zsolt Kulcsar
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals and Medical School, 1211, Geneva, Switzerland
| | - Pierre-Alexandre Poletti
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals and Medical School, 1211, Geneva, Switzerland
| | - Vitor Mendes Pereira
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals and Medical School, 1211, Geneva, Switzerland
| | - Karl-Olof Lövblad
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals and Medical School, 1211, Geneva, Switzerland.
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Payabvash S, Noorbaloochi S, Qureshi AI. Topographic Assessment of Acute Ischemic Changes for Prognostication of Anterior Circulation Stroke. J Neuroimaging 2016; 27:227-231. [PMID: 27593522 DOI: 10.1111/jon.12383] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 07/06/2016] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The location of acute ischemic infarct can affect the clinical outcome of stroke patients. We aimed to develop a prognostic tool based on the topographic distribution of early ischemic changes on admission computed tomography (CT) scans. METHODS Using the albumin in acute stroke (ALIAS) trials dataset, patients with anterior circulation stroke were included for analysis. A 3-month modified Rankin scale (mRs) score > 2 defined disability/death; and ≤2 defined favorable outcome. A penalized logistic regression determined independent predictors of disability/death among components of admission CT scan Alberta Stroke Program Early CT score (ASPECTS). Follow-up 24-hour CT/MRI scans were reviewed for intracranial hemorrhage (ICH). RESULTS A simplified ASPECTS (sASPECTS) was developed including the caudate, lentiform nucleus, insula, and M5 components of ASPECTS-which were independent predictors of disability/death on multivariate analysis. There was no significant difference between ASPECTS and sASPECTS in prediction of disability/death (P = .738). Among patients with sASPECTS ≥ 1, the rate of favorable outcome was higher in those with intravenous (IV) thrombolytic therapy (501/837, 59.9%) versus those without treatment (91/183, 49.7%, P = .013); whereas among patients with sASPECTS of 0, IV thrombolysis was not associated with improved outcome. Also, patients with sASPECTS of 0 were more likely to develop symptomatic ICH (odds ratio = 2.62, 95% confidence interval: 1.49-4.62), compared to those with sASPECTS ≥ 1 (P = .004). CONCLUSIONS Topographic assessment of acute ischemic changes using the sASPECTS (including caudate, lentiform nucleus, insula, and M5) can predict disability/death in anterior circulation stroke as accurately as the ASPECTS; and may help predict response to treatment and risk of developing symptomatic ICH.
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Affiliation(s)
- Seyedmehdi Payabvash
- Zeenat Qureshi Stroke Institute, St. Cloud, MN.,Neuroradiology Section, Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA
| | - Siamak Noorbaloochi
- Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN
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Affiliation(s)
| | - N. Tambasco
- Dipartimento di Neurologia, Villa Pini d'Abruzzo; Chieti
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Lövblad KO, Kiefer C, Oswald H, Arnold M, Nedeltchev K, Mattle H, Schroth G. Imaging the Ischemic Penumbra. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/197140090301600534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | - M. Arnold
- Department of Neurology, Inselspital, Bern; Switzerland
| | - K. Nedeltchev
- Department of Neurology, Inselspital, Bern; Switzerland
| | - H. Mattle
- Department of Neurology, Inselspital, Bern; Switzerland
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Wenz H, Maros ME, Meyer M, Gawlitza J, Förster A, Haubenreisser H, Kurth S, Schoenberg SO, Groden C, Henzler T. Intra-individual diagnostic image quality and organ-specific-radiation dose comparison between spiral cCT with iterative image reconstruction and z-axis automated tube current modulation and sequential cCT. Eur J Radiol Open 2016; 3:182-90. [PMID: 27504476 PMCID: PMC4969238 DOI: 10.1016/j.ejro.2016.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 05/31/2016] [Indexed: 11/16/2022] Open
Abstract
Superiority of spiral versus sequential cCT in image quality and organ-specific-radiation dose. Spiral cCT: lower organ-specific-radiation-dose in eye lense compared to tilted sequential cCT. State-of-the-art IR spiral cCT techniques has significant advantages over sequential cCT techniques.
Objectives To prospectively evaluate image quality and organ-specific-radiation dose of spiral cranial CT (cCT) combined with automated tube current modulation (ATCM) and iterative image reconstruction (IR) in comparison to sequential tilted cCT reconstructed with filtered back projection (FBP) without ATCM. Methods 31 patients with a previous performed tilted non-contrast enhanced sequential cCT aquisition on a 4-slice CT system with only FBP reconstruction and no ATCM were prospectively enrolled in this study for a clinical indicated cCT scan. All spiral cCT examinations were performed on a 3rd generation dual-source CT system using ATCM in z-axis direction. Images were reconstructed using both, FBP and IR (level 1–5). A Monte-Carlo-simulation-based analysis was used to compare organ-specific-radiation dose. Subjective image quality for various anatomic structures was evaluated using a 4-point Likert-scale and objective image quality was evaluated by comparing signal-to-noise ratios (SNR). Results Spiral cCT led to a significantly lower (p < 0.05) organ-specific-radiation dose in all targets including eye lense. Subjective image quality of spiral cCT datasets with an IR reconstruction level 5 was rated significantly higher compared to the sequential cCT acquisitions (p < 0.0001). Consecutive mean SNR was significantly higher in all spiral datasets (FBP, IR 1–5) when compared to sequential cCT with a mean SNR improvement of 44.77% (p < 0.0001). Conclusions Spiral cCT combined with ATCM and IR allows for significant-radiation dose reduction including a reduce eye lens organ-dose when compared to a tilted sequential cCT while improving subjective and objective image quality.
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Key Words
- ASPECTS, Alberta Stroke Program Early CT score
- ATCM, automated tube current modulation
- Automatic tube current modulation
- DSCT, dual-source computed tomography
- FBP, filtered back projection
- HU, hounsfield units
- ICRP, International Commission on Radiological Protection
- IR, iterative image reconstruction
- Iterative reconstruction
- MDCT, multi-detector computed tomography
- NC, caudate nucleus
- ND, normally distributed data
- NI, non-inferiority analysis
- Organ-specific-radiation dose
- SNR, signal-to-noise ratios
- Sequential cranial CT
- Spiral cranial CT
- WM, white matter
- cCT, cranial CT
- cCT, cranial computed tomography
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Affiliation(s)
- Holger Wenz
- Department of Neuroradiology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Máté E Maros
- Department of Neuroradiology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Mathias Meyer
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Joshua Gawlitza
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Alex Förster
- Department of Neuroradiology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Holger Haubenreisser
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Stefan Kurth
- Department of Neuroradiology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Stefan O Schoenberg
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Christoph Groden
- Department of Neuroradiology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Thomas Henzler
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany
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von Kummer R. Early CT Score to establish stroke treatment. Lancet Neurol 2016; 15:651-653. [DOI: 10.1016/s1474-4422(16)30032-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 03/29/2016] [Indexed: 11/28/2022]
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Gomolka RS, Chrzan RM, Urbanik A, Nowinski WL. A Quantitative Method Using Head Noncontrast CT Scans to Detect Hyperacute Nonvisible Ischemic Changes in Patients With Stroke. J Neuroimaging 2016; 26:581-587. [PMID: 27238914 DOI: 10.1111/jon.12363] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 04/20/2016] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Because clinical evaluation of noncontrast computed tomography (CT) has a poor sensitivity in the evaluation of acute ischemic stroke, computer-aided diagnosis may be able to facilitate the performance. Recently, we introduced a computational method for the detection and localization of visible infarcts. Herein, we aimed to evaluate and extend a previous method, the Stroke Imaging Marker (SIM), to localize nonvisible hyperacute ischemia. MATERIALS AND METHODS On the basis of the SIM and its components-the ratio of percentile differences in subranges of Hounsfield Unit (HU) distribution (P-ratio), ratio of voxels count in ranges of brain CT intensity, median HU attenuation value-the infarct localization was performed in 140 early and follow-up scans of 70 patients. In none of the early scans was the infarct visible to a radiologist or an experienced stroke neuroradiologist. The infarcted hemisphere detection rate (HDR) and sensitivity of infarct localization were measured by overlapping the region of detected tissue in the initial scan, with the gold standard set for the fully visible stroke in the follow-up scan. RESULTS The best performance of the algorithm was found for the P-ratio including seven percentile subranges within the range of 35th-75th percentile. The modified SIM provided a 76% ischemic HDR and 54% sensitivity in spatial localization of hyperacute ischemia (68% among properly detected infarct sides). CONCLUSION The improved SIM is a dedicated and potentially useful tool for hyperacute nonvisible brain infarct detection from CT scans and may contribute to reduction of image-to-needle time in patients eligible for revascularization therapy.
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Affiliation(s)
- Ryszard S Gomolka
- Faculty of Electronics and Information Technology, Warsaw University of Technology, Warsaw, Poland. .,Biomedical Imaging Lab, Agency for Science Technology and Research, Singapore.
| | - Robert M Chrzan
- Department of Radiology, Jagiellonian University, The Cracow University Hospital, Kraków, Poland
| | - Andrzej Urbanik
- Department of Radiology, Jagiellonian University, The Cracow University Hospital, Kraków, Poland
| | - Wieslaw L Nowinski
- Department of Radiology, University of Washington, University District Building, Seattle, WA.,John Paul II Center for Virtual Anatomy and Surgical Simulation, Cardinal Stefan Wyszyński University, Warsaw, Poland
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