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Nowinski WL. Taxonomy of Acute Stroke: Imaging, Processing, and Treatment. Diagnostics (Basel) 2024; 14:1057. [PMID: 38786355 PMCID: PMC11119045 DOI: 10.3390/diagnostics14101057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/01/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024] Open
Abstract
Stroke management employs a variety of diagnostic imaging modalities, image processing and analysis methods, and treatment procedures. This work categorizes methods for stroke imaging, image processing and analysis, and treatment, and provides their taxonomies illustrated by a state-of-the-art review. Imaging plays a critical role in stroke management, and the most frequently employed modalities are computed tomography (CT) and magnetic resonance (MR). CT includes unenhanced non-contrast CT as the first-line diagnosis, CT angiography, and CT perfusion. MR is the most complete method to examine stroke patients. MR angiography is useful to evaluate the severity of artery stenosis, vascular occlusion, and collateral flow. Diffusion-weighted imaging is the gold standard for evaluating ischemia. MR perfusion-weighted imaging assesses the penumbra. The stroke image processing methods are divided into non-atlas/template-based and atlas/template-based. The non-atlas/template-based methods are subdivided into intensity and contrast transformations, local segmentation-related, anatomy-guided, global density-guided, and artificial intelligence/deep learning-based. The atlas/template-based methods are subdivided into intensity templates and atlases with three atlas types: anatomy atlases, vascular atlases, and lesion-derived atlases. The treatment procedures for arterial and venous strokes include intravenous and intraarterial thrombolysis and mechanical thrombectomy. This work captures the state-of-the-art in stroke management summarized in the form of comprehensive and straightforward taxonomy diagrams. All three introduced taxonomies in diagnostic imaging, image processing and analysis, and treatment are widely illustrated and compared against other state-of-the-art classifications.
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Affiliation(s)
- Wieslaw L Nowinski
- Sano Centre for Computational Personalised Medicine, Czarnowiejska 36, 30-054 Krakow, Poland
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Discrimination between progressive penumbra and benign oligemia of the diffusion-perfusion mismatch region by amide proton transfer-weighted imaging. Magn Reson Imaging 2023; 99:123-129. [PMID: 36822450 DOI: 10.1016/j.mri.2023.02.006] [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: 11/05/2022] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 02/25/2023]
Abstract
PURPOSE Amide proton transfer-weighted (APTw) imaging was an effective tool to reveal the tissue acidosis of acute ischemic stroke. This study aimed to evaluate the ability of APTw MRI to distinguish progressive penumbra and benign oligemia in the diffusion-perfusion mismatch region. MATERIALS AND METHODS 38 acute cerebral infarction patients who underwent a comprehensive MRI examination, including diffusion-weighted imaging (DWI), perfusion-weighted imaging (PWI), APT imaging, and a follow-up scan in one week were recruited. There were 12 DWI/PWI match cases. The DWI/PWI mismatch patients were divided into 10 progressive cases and 16 stable cases according to the lesion size on the follow-up DWI image compared to the admission scan. Three ROIs: infarction lesion, peripheral, and contralateral normal regions were measured on each subject's MTRasym map. The Friedman test was used to compare the changes of MTRasym among three different regions within each group. The Kruskal-Wallis ANOVA test was used to compare them among the same region of different groups. The correlation between the MTRasym of the peripheral region and the lesion enlargement was analyzed by the Spearman test. RESULTS The MTRasym at the infarction lesion of all three groups showed significant decrease to the contralateral normal tissue. In the progressive mismatch group, the MTRasym at the peripheral region within the DWI/PWI mismatch showed a significant difference with the contralateral normal region and no difference with the infarct core. Whereas both the MTRasym at the peripheral region of the stable mismatch and match groups had no significant difference with the contralateral side, but the differences were significant from those of the central core. When comparing the peripheral region of three groups, the MTRasym of the progressive mismatch group showed a significant decrease to that of the stable mismatch and match groups. The MTRasym of the peripheral region showed a negative correlation with lesion enlargement. CONCLUSION APTw imaging is promising to stratify the heterogeneous PWI/DWI mismatch region and benefit the clinical treatment.
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Lee MH, Im SH, Jo KW, Yoo DS. Recanalization Rate and Clinical Outcomes of Intravenous Tissue Plasminogen Activator Administration for Large Vessel Occlusion Stroke Patients. J Korean Neurosurg Soc 2023; 66:144-154. [PMID: 36825298 PMCID: PMC10009240 DOI: 10.3340/jkns.2022.0120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 09/17/2022] [Indexed: 02/25/2023] Open
Abstract
OBJECTIVE Stroke caused from large vessel occlusion (LVO) has emerged as the most common stroke subtype worldwide. Intravenous tissue plasminogen activator administration (IV-tPA) and additional intraarterial thrombectomy (IA-Tx) is regarded as standard treatment. In this study, the authors try to find the early recanalization rate of IV-tPA in LVO stroke patients. METHODS Total 300 patients undertook IA-Tx with confirmed anterior circulation LVO, were analyzed retrospectively. Brain computed tomography angiography (CTA) was the initial imaging study and acute stroke magnetic resonance angiography (MRA) followed after finished IV-tPA. Early recanalization rate was evaluated by acute stroke MRA within 2 hours after the IV-tPA. In 167 patients undertook IV-tPA only and 133 non-recanalized patients by IV-tPA, additional IA-Tx tried (IV-tPA + IA-Tx group). And 131 patients, non-recanalized by IV-tPA (IV-tPA group) additional IA-Tx recommend and tried according to the patient condition and compliance. RESULTS Early recanalization rate of LVO after IV-tPA was 12.0% (36/300). In recanalized patients, favorable outcome (modified Rankin Scale, 0-2) was 69.4% (25/36) while it was 32.1% (42/131, p<0.001) in non-recanalized patients. Among 133 patients, nonrecanalized after intravenous recombinant tissue plasminogen activator and undertook additional IA-Tx, the clinical outcome was better than not undertaken additional IA-Tx (favorable outcome was 42.9% vs. 32.1%, p=0.046). Analysis according to the perfusion/diffusion (P/D)-mismatching or not, in patient with IV-tPA with IA-Tx (133 patients), favorable outcome was higher in P/ D-mismatching patient (52/104; 50.0%) than P/D-matching patients (5/29; 17.2%; p=0.001). Which treatment tired, P/D-mismatching was favored in clinical outcome (iv-tPA only, p=0.008 and IV-tPA with IA-Tx, p=0.001). CONCLUSION The P/D-mismatching influences on the recanalization and clinical outcomes of IV-tPA and IA-Tx. The authors would like to propose that we had better prepare IA-Tx when LVO is diagnosed on initial diagnostic imaging. Furthermore, if the patient shows P/D-mismatching on MRA after IV-tPA, additional IA-Tx improves treatment results and lessen the futile recanalization.
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Affiliation(s)
- Min-Hyung Lee
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang-Hyuk Im
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kwang Wook Jo
- Department of Neurosurgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do-Sung Yoo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Fan H, Su P, Lin DDM, Goldberg EB, Walker A, Leigh R, Hillis AE, Lu H. Simultaneous Hemodynamic and Structural Imaging of Ischemic Stroke With Magnetic Resonance Fingerprinting Arterial Spin Labeling. Stroke 2022; 53:2016-2025. [PMID: 35291820 DOI: 10.1161/strokeaha.121.037066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Perfusion and structural imaging play an important role in ischemic stroke. Magnetic resonance fingerprinting (MRF) arterial spin labeling (ASL) is a novel noninvasive method of ASL perfusion that allows simultaneous estimation of cerebral blood flow (CBF), bolus arrival time (BAT), and tissue T1 map in a single scan of <4 minutes. Here, we evaluated the utility of MRF-ASL in patients with ischemic stroke in terms of detecting hemodynamic and structural damage and predicting neurological deficits and disability. METHODS A total of 34 patients were scanned on 3T magnetic resonance imaging. MRF-ASL, standard single-delay pseudo-continuous ASL, T2-weighted, and diffusion magnetic resonance imaging were performed. Regions of interest of lesion and contralateral normal tissues were manually delineated. CBF (with 2 different compartmental models), BAT, and tissue T1 parameters were quantified. Cross-sectional linear regression analyses were performed to examine the relationship between MRF-ASL parameters and National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale. Receiver operating characteristic analyses were performed to determine the utility of MRF-ASL in the classification of stroke lesion voxels. RESULTS MRF-ASL derived parameters revealed a significant difference between stroke lesion and contralateral normal regions of interest, in that lesion regions manifested a lower CBF1-compartment (P<0.001), lower CBF2-compartment (P<0.001), longer BAT (P=0.002), and longer T1 (P<0.001) compared with normal regions of interest. NIHSS scores at acute stage revealed a strong association with lesion-normal differences in CBF1-compartment,diff (β=-0.11, P=0.008), CBF2-compartment,diff (β=-0.16, P=0.003), and T1,diff (β=0.008, P=0.001). MRF-ASL parameters were also predictive of NIHSS score and modified Rankin Scale scale measured at a later stage, although the degree of the associations was weaker. These associations tended to be even stronger when the MRF-ASL data were acquired at the acute/subacute stage. Compared with standard pseudo-continuous ASL, the multiparametric capability of MRF-ASL yielded higher area under curve values in the receiver operating characteristic analyses of stroke voxel classifications. CONCLUSIONS MRF-ASL may provide a new approach for quantitative hemodynamic and structural imaging in ischemic stroke.
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Affiliation(s)
- Hongli Fan
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD. (H.F., H.L.).,The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD. (H.F., P.S., D.D.M.L., H.L.)
| | - Pan Su
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD. (H.F., P.S., D.D.M.L., H.L.)
| | - Doris Da May Lin
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD. (H.F., P.S., D.D.M.L., H.L.)
| | - Emily B Goldberg
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD. (E.B.G., A.W., R.L., A.E.H.)
| | - Alexandra Walker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD. (E.B.G., A.W., R.L., A.E.H.)
| | - Richard Leigh
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD. (E.B.G., A.W., R.L., A.E.H.)
| | - Argye E Hillis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD. (E.B.G., A.W., R.L., A.E.H.)
| | - Hanzhang Lu
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD. (H.F., H.L.).,The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD. (H.F., P.S., D.D.M.L., H.L.).,F. M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD (H.L.)
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Chalet L, Boutelier T, Christen T, Raguenes D, Debatisse J, Eker OF, Becker G, Nighoghossian N, Cho TH, Canet-Soulas E, Mechtouff L. Clinical Imaging of the Penumbra in Ischemic Stroke: From the Concept to the Era of Mechanical Thrombectomy. Front Cardiovasc Med 2022; 9:861913. [PMID: 35355966 PMCID: PMC8959629 DOI: 10.3389/fcvm.2022.861913] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/11/2022] [Indexed: 01/01/2023] Open
Abstract
The ischemic penumbra is defined as the severely hypoperfused, functionally impaired, at-risk but not yet infarcted tissue that will be progressively recruited into the infarct core. Early reperfusion aims to save the ischemic penumbra by preventing infarct core expansion and is the mainstay of acute ischemic stroke therapy. Intravenous thrombolysis and mechanical thrombectomy for selected patients with large vessel occlusion has been shown to improve functional outcome. Given the varying speed of infarct core progression among individuals, a therapeutic window tailored to each patient has recently been proposed. Recent studies have demonstrated that reperfusion therapies are beneficial in patients with a persistent ischemic penumbra, beyond conventional time windows. As a result, mapping the penumbra has become crucial in emergency settings for guiding personalized therapy. The penumbra was first characterized as an area with a reduced cerebral blood flow, increased oxygen extraction fraction and preserved cerebral metabolic rate of oxygen using positron emission tomography (PET) with radiolabeled O2. Because this imaging method is not feasible in an acute clinical setting, the magnetic resonance imaging (MRI) mismatch between perfusion-weighted imaging and diffusion-weighted imaging, as well as computed tomography perfusion have been proposed as surrogate markers to identify the penumbra in acute ischemic stroke patients. Transversal studies comparing PET and MRI or using longitudinal assessment of a limited sample of patients have been used to define perfusion thresholds. However, in the era of mechanical thrombectomy, these thresholds are debatable. Using various MRI methods, the original penumbra definition has recently gained a significant interest. The aim of this review is to provide an overview of the evolution of the ischemic penumbra imaging methods, including their respective strengths and limitations, as well as to map the current intellectual structure of the field using bibliometric analysis and explore future directions.
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Affiliation(s)
- Lucie Chalet
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Olea Medical, La Ciotat, France
| | | | - Thomas Christen
- Grenoble Institut Neurosciences, INSERM, U1216, Univ. Grenoble Alpes, Grenoble, France
| | | | - Justine Debatisse
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Omer Faruk Eker
- CREATIS, CNRS UMR-5220, INSERM U1206, Université Lyon 1, Villeurbanne, France
- Neuroradiology Department, Hospices Civils of Lyon, Lyon, France
| | - Guillaume Becker
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Norbert Nighoghossian
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Stroke Department, Hospices Civils of Lyon, Lyon, France
| | - Tae-Hee Cho
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Stroke Department, Hospices Civils of Lyon, Lyon, France
| | - Emmanuelle Canet-Soulas
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Laura Mechtouff
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Stroke Department, Hospices Civils of Lyon, Lyon, France
- *Correspondence: Laura Mechtouff
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van den Berg R, Wildeman JJ, Berkhemer OA, Immink RV, Marquering HA, Majoie CBLM, Verbaan D, van Bavel ET. Arterial Steal to the Penumbra Area in Patients with Acute MCA Occlusion: A Quantitative Angiographic Analysis. Neurointervention 2020; 15:126-132. [PMID: 33070511 PMCID: PMC7608501 DOI: 10.5469/neuroint.2020.00269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 09/30/2020] [Indexed: 11/26/2022] Open
Abstract
Purpose In acute middle cerebral artery (MCA) occlusion, collateral vessels provide retrograde supply to the occluded territory. We hypothesized that such collateral flow reduces perfusion of the non-occluded donor region (steal effect). Materials and Methods Patients with an MCA occlusion with opacification of both ipsi- and contralateral anterior cerebral arteries (ACA) on angiography prior to endovascular treatment were selected. Arteriovenous transit time (AVTT) for both ACA territories was compared for different grades of collateral supply to the MCA territory. In addition, the influence of diabetes and hypertension was analyzed. After successful revascularization, AVTT was re-assessed to determine reversibility. Results Forty-one patients were analyzed. An AVTT of 8.6 seconds (standard deviation [SD] 2.4 seconds) was seen in the ACA territory of the affected hemisphere in comparison to 6.6 seconds (SD 2.1 seconds) for the contralateral side (P<0.001). A more prolonged (but not significant) AVTT was seen in cases with a higher collateral grade. No difference in AVTT was seen in patients with diabetes or hypertension. After successful MCA revascularization, AVTT delay was 7.4 seconds (SD 2.1 seconds). Conclusion A cerebral steal effect occurs in patients with an acute MCA occlusion, probably related to augmented flow to the penumbra area.
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Affiliation(s)
- René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (AMC), Amsterdam, The Netherlands
| | - Jenna J Wildeman
- Department of Biomedical Sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Olvert A Berkhemer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (AMC), Amsterdam, The Netherlands
| | - Rogier V Immink
- Department of Anesthesiology, Amsterdam University Medical Centers (AMC), Amsterdam, The Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (AMC), Amsterdam, The Netherlands.,Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers (AMC), Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (AMC), Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam University Medical Centers (AMC), Amsterdam, The Netherlands
| | - Ed T van Bavel
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers (AMC), Amsterdam, The Netherlands
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Nitroglycerin Is Not Associated with Improved Cerebral Perfusion in Acute Ischemic Stroke. Can J Neurol Sci 2020; 48:349-357. [PMID: 32799944 DOI: 10.1017/cjn.2020.179] [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] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The study was conducted to test the hypothesis that nitroglycerin (NTG) increases cerebral perfusion focally and globally in acute ischemic stroke patients, using serial perfusion-weighted imaging (PWI) magnetic resonance imaging measurements. PATIENTS AND METHODS Thirty-five patients underwent PWI immediately before and 72 h after administration of a transdermal NTG patch or no treatment. Patients with baseline mean arterial pressure (MAP) > 100 mmHg (NTG group, n = 20) were treated with transdermal NTG (0.2 mg/h) for 72 h, without a nitrate-free interval. Patients with MAP ≤ 100 mmHg (untreated group, n = 15) were not treated. The primary outcome measure was absolute cerebral blood flow (CBF) in the hypoperfused region at 72 h. RESULTS The mean baseline absolute CBF in the hypoperfused region was similar in the NTG group (33.3 ± 10.2 ml/100 g/min) and untreated (32.7 ± 8.4 ml/100 g/min, p = 0.4) groups. The median (IQR) baseline infarct volume was 10.4 (2.5-49.3) ml in the NTG group and 32.6 (8.6-96.7) ml in the untreated group (p = 0.09). MAP change in the NTG group was 1.2 ± 12.6 and 8 ± 20.7 mmHg at 2 h and 72 h, respectively. Mean absolute CBF in the hypoperfused region at 72 h was similar in the NTG (29.9 ± 12 ml/100 g/min) and untreated groups (24.1 ± 10 ml/100 g/min, p = 0.8). The median infarct volume increased in untreated (11.8 (5.7-44.2) ml) than the NTG group (3.2 (0.5-16.5) ml; p = 0.033) on univariate analysis, however, there was no difference on regression analysis. CONCLUSION NTG was not associated with improvement in cerebral perfusion in acute ischemic stroke patients.
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Kate M, Asdaghi N, Gioia LC, Buck B, Majumdar SR, Jeerakathil T, Shuaib A, Emery D, Beaulieu C, Butcher K. Blood pressure reduction in hypertensive acute ischemic stroke patients does not affect cerebral blood flow. J Cereb Blood Flow Metab 2019; 39:1878-1887. [PMID: 29737226 PMCID: PMC6727146 DOI: 10.1177/0271678x18774708] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The effect of blood pressure (BP) reduction on cerebral blood flow (CBF) in acute ischemic stroke is unknown. We measured regional CBF with perfusion-weighted MRI before and after BP treatment in a three-armed non-randomized prospective controlled trial. Treatment arm assignment was based on acute mean arterial pressure (MAP). Patients with (MAP) >120 mmHg (n = 14) were treated with intravenous labetalol and sublingual (SL) nitroglycerin (labetalol group). Those with MAP 100-120 mmHg (n = 17) were treated with SL nitroglycerin (0.3 mg) ('NTG Group') and those with baseline MAP<100 mmHg (n = 18) were not treated with antihypertensive drugs (untreated group). Forty-nine patients (18 female, mean age 65.3 ± 12.9 years) were serially imaged. Labetalol reduced MAP by 12.5 (5.7-17.7) mmHg, p = 0.0002. MAP remained stable in the NTG (6.0 (0.4-16, p = 0.3) mmHg and untreated groups (-0.3 (-2.3-7.0, p = 0.2) mmHg. The volume of total hypoperfused tissue (CBF<18 ml/100 g/min) did not increase after labetalol (-1.1 ((-6.5)-(-0.2)) ml, p = 0.1), NTG (0 ((-1.5)-4.5) ml, p = 0.72), or no treatment 0.25 ((-10.1)-4.5) ml, p = 0.87). Antihypertensive therapy, based on presenting BP, in acute stroke patients was not associated with an increased volume of total hypoperfused tissue.
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Affiliation(s)
- Mahesh Kate
- 1 Division of Neurology, University of Alberta, Edmonton, Canada
| | - Negar Asdaghi
- 2 Department of Neurology, University of Miami, Miami, FL, USA
| | - Laura C Gioia
- 1 Division of Neurology, University of Alberta, Edmonton, Canada
| | - Brian Buck
- 1 Division of Neurology, University of Alberta, Edmonton, Canada
| | - Sumit R Majumdar
- 3 Department of Medicine, Division of General Internal Medicine, University of Alberta, Edmonton, Canada
| | | | - Ashfaq Shuaib
- 1 Division of Neurology, University of Alberta, Edmonton, Canada
| | - Derek Emery
- 4 Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Canada
| | - Christian Beaulieu
- 5 Department of Biomedical Engineering, University of Alberta, Edmonton, Canada
| | - Kenneth Butcher
- 1 Division of Neurology, University of Alberta, Edmonton, Canada
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Lorenzano S, Rost NS, Khan M, Li H, Batista LM, Chutinet A, Green RE, Thankachan TK, Thornell B, Muzikansky A, Arai K, Som AT, Pham LDD, Wu O, Harris GJ, Lo EH, Blumberg JB, Milbury PE, Feske SK, Furie KL. Early molecular oxidative stress biomarkers of ischemic penumbra in acute stroke. Neurology 2019; 93:e1288-e1298. [PMID: 31455665 DOI: 10.1212/wnl.0000000000008158] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 04/28/2019] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES To assess whether plasma biomarkers of oxidative stress predict diffusion-perfusion mismatch in patients with acute ischemic stroke (AIS). METHODS We measured plasma levels of oxidative stress biomarkers such as F2-isoprostanes (F2-isoPs), total and perchloric acid Oxygen Radical Absorbance Capacity (ORACTOT and ORACPCA), urinary levels of 8-oxo-7,8-dihydro-2'-deoxyguoanosine, and inflammatory and tissue-damage biomarkers (high-sensitivity C-reactive protein, matrix metalloproteinase-2 and -9) in a prospective study of patients with AIS presenting within 9 hours of symptom onset. Diffusion-weighted (DWI) and perfusion-weighted (PWI) MRI sequences were analyzed with a semiautomated volumetric method. Mismatch was defined as baseline mean transit time volume minus DWI volume. A percent mismatch cutoff of >20% was considered clinically significant. A stricter definition of mismatch was also used. Mismatch salvage was the region free of overlap by final infarction. RESULTS Mismatch >20% was present in 153 of 216 (70.8%) patients (mean [±SD] age 69.2 ± 14.3 years, 41.2% women). Patients with mismatch >20% were more likely to have higher baseline plasma levels of ORACPCA (p = 0.020) and F2-isoPs (p = 0.145). Multivariate binary logistic regression demonstrated that lnF2-isoP (odds ratio [OR] 2.44, 95% confidence interval [CI] 1.19-4.98, p = 0.014) and lnORACPCA (OR 4.18, 95% CI 1.41-12.41, p = 0.010) were independent predictors of >20% PWI-DWI mismatch and the stricter mismatch definition, respectively. lnORACTOT significantly predicted mismatch salvage volume (>20% mismatch p = 0.010, stricter mismatch definition p = 0.003). CONCLUSIONS Elevated hyperacute plasma levels of F2-isoP and ORAC are associated with radiographic evidence of mismatch and mismatch salvage in patients with AIS. If validated, these findings may add to our understanding of the role of oxidative stress in cerebral tissue fate during acute ischemia.
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Affiliation(s)
- Svetlana Lorenzano
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Natalia S Rost
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Muhib Khan
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Hua Li
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Leonardo M Batista
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Aurauma Chutinet
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Rebecca E Green
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Tijy K Thankachan
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Brenda Thornell
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Alona Muzikansky
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ken Arai
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Angel T Som
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Loc-Duyen D Pham
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ona Wu
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gordon J Harris
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Eng H Lo
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Jeffrey B Blumberg
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Paul E Milbury
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Steven K Feske
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Karen L Furie
- From the J. Philip Kistler Stroke Research Center (S.L., N.S.R., L.M.B., A.C., R.E.G., T.K.T., B.T.), Department of Neurology, and Department of Radiology (H.L., G.J.H.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurology (M.K., K.L.F.), Rhode Island Hospital, Alpert Medical School of Brown University, Providence; Massachusetts General Hospital Biostatistics Center (A.M.), Boston; Neuroprotection Research Laboratory (K.A., A.T.S., L.-D.D.P., E.H.L.), Neuroscience Center, Departments of Neurology and Radiology, Massachusetts General Hospital and Harvard Medical School; Athinoula A. Martinos Center for Biomedical Imaging (O.W.), Massachusetts General Hospital and Harvard Medical School, Charlestown; Antioxidant Research Laboratory (J.B.B.), Jean Mayer USDA Human Nutrition Research Center on Aging, and Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy (P.E.M.), Tufts University; and Department of Neurology (S.K.F.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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10
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Zaro-Weber O, Fleischer H, Reiblich L, Schuster A, Moeller-Hartmann W, Heiss WD. Penumbra detection in acute stroke with perfusion magnetic resonance imaging: Validation with 15 O-positron emission tomography. Ann Neurol 2019; 85:875-886. [PMID: 30937950 PMCID: PMC6593670 DOI: 10.1002/ana.25479] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 03/20/2019] [Accepted: 03/31/2019] [Indexed: 12/17/2022]
Abstract
Objective Accurate identification of the ischemic penumbra, the therapeutic target in acute clinical stroke, is of critical importance to identify patients who might benefit from reperfusion therapies beyond the established time windows. Therefore, we aimed to validate magnetic resonance imaging (MRI) mismatch–based penumbra detection against full quantitative positron emission tomography (15O‐PET), the gold standard for penumbra detection in acute ischemic stroke. Methods Ten patients (group A) with acute and subacute ischemic stroke underwent perfusion‐weighted (PW)/diffusion‐weighted MRI and consecutive full quantitative 15O‐PET within 48 hours of stroke onset. Penumbra as defined by 15O‐PET cerebral blood flow (CBF), oxygen extraction fraction, and oxygen metabolism was used to validate a wide range of established PW measures (eg, time‐to‐maximum [Tmax]) to optimize penumbral tissue detection. Validation was carried out using a voxel‐based receiver‐operating‐characteristic curve analysis. The same validation based on penumbra as defined by quantitative 15O‐PET CBF was performed for comparative reasons in 23 patients measured within 48 hours of stroke onset (group B). Results The PW map Tmax (area‐under‐the‐curve = 0.88) performed best in detecting penumbral tissue up to 48 hours after stroke onset. The optimal threshold to discriminate penumbra from oligemia was Tmax >5.6 seconds with a sensitivity and specificity of >80%. Interpretation The performance of the best PW measure Tmax to detect the upper penumbral flow threshold in ischemic stroke is excellent. Tmax >5.6 seconds–based penumbra detection is reliable to guide treatment decisions up to 48 hours after stroke onset and might help to expand reperfusion treatment beyond the current time windows. ANN NEUROL 2019;85:875–886.
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Affiliation(s)
- Olivier Zaro-Weber
- Max Planck Institute for Neurological Research, Cologne, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Hermann Fleischer
- Max Planck Institute for Neurological Research, Cologne, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Lucas Reiblich
- Max Planck Institute for Neurological Research, Cologne, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
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11
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Chiu FY, Kuo DP, Chen YC, Kao YC, Chung HW, Chen CY. Diffusion Tensor-Derived Properties of Benign Oligemia, True "at Risk" Penumbra, and Infarct Core during the First Three Hours of Stroke Onset: A Rat Model. Korean J Radiol 2018; 19:1161-1171. [PMID: 30386147 PMCID: PMC6201972 DOI: 10.3348/kjr.2018.19.6.1161] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/27/2018] [Indexed: 11/15/2022] Open
Abstract
Objective The aim of this study was to investigate diffusion tensor (DT) imaging-derived properties of benign oligemia, true “at risk” penumbra (TP), and the infarct core (IC) during the first 3 hours of stroke onset. Materials and Methods The study was approved by the local animal care and use committee. DT imaging data were obtained from 14 rats after permanent middle cerebral artery occlusion (pMCAO) using a 7T magnetic resonance scanner (Bruker) in room air. Relative cerebral blood flow and apparent diffusion coefficient (ADC) maps were generated to define oligemia, TP, IC, and normal tissue (NT) every 30 minutes up to 3 hours. Relative fractional anisotropy (rFA), pure anisotropy (rq), diffusion magnitude (rL), ADC (rADC), axial diffusivity (rAD), and radial diffusivity (rRD) values were derived by comparison with the contralateral normal brain. Results The mean volume of oligemia was 24.7 ± 14.1 mm3, that of TP was 81.3 ± 62.6 mm3, and that of IC was 123.0 ± 85.2 mm3 at 30 minutes after pMCAO. rFA showed an initial paradoxical 10% increase in IC and TP, and declined afterward. The rq, rL, rADC, rAD, and rRD showed an initial discrepant decrease in IC (from −24% to −36%) as compared with TP (from −7% to −13%). Significant differences (p < 0.05) in metrics, except rFA, were found between tissue subtypes in the first 2.5 hours. The rq demonstrated the best overall performance in discriminating TP from IC (accuracy = 92.6%, area under curve = 0.93) and the optimal cutoff value was −33.90%. The metric values for oligemia and NT remained similar at all time points. Conclusion Benign oligemia is small and remains microstructurally normal under pMCAO. TP and IC show a distinct evolution of DT-derived properties within the first 3 hours of stroke onset, and are thus potentially useful in predicting the fate of ischemic brain.
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Affiliation(s)
- Fang-Ying Chiu
- Department of Medical Imaging and Radiological Sciences, College of Medicine, I-Shou University, Kaohsiung 82445, Taiwan
| | - Duen-Pang Kuo
- Department of Radiology, Taoyuan Armed Forces General Hospital, Taoyuan 32551, Taiwan
| | - Yung-Chieh Chen
- Department of Medical Imaging, Taipei Medical University Hospital, Taipei Medical University, Taipei 11031, Taiwan.,Translational Imaging Research Center, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Yu-Chieh Kao
- Translational Imaging Research Center, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Hsiao-Wen Chung
- Graduate Institute of Biomedical Electrics and Bioinformatics, National Taiwan. University, Taipei 10617, Taiwan
| | - Cheng-Yu Chen
- Department of Medical Imaging, Taipei Medical University Hospital, Taipei Medical University, Taipei 11031, Taiwan.,Translational Imaging Research Center, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan.,Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan.,Department of Radiology, Tri-Service General Hospital, Taipei 11490, Taiwan.,Department of Radiology, National Defense Medical Center, Taipei 11490, Taiwan
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12
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Bahr Hosseini M, Woolf G, Sharma LK, Hinman JD, Rao NM, Yoo B, Jahan R, Starkman S, Nour M, Raychev R, Liebeskind DS, Saver JL. The Frequency of Substantial Salvageable Penumbra in Thrombectomy-ineligible Patients with Acute Stroke. J Neuroimaging 2018; 28:676-682. [PMID: 30010229 DOI: 10.1111/jon.12544] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/21/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Endovascular therapy (ET) has become the standard of care for selected patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). However, many LVO or medium vessel occlusion (MVO) patients are ineligible for ET, including some who harbor salvageable tissues. To develop complementary therapies for these patients, it is important to delineate their prevalence, clinical features, and outcomes. METHODS In a prospectively maintained database, we reviewed consecutive AIS patients between December 2015 and September 2016. Based on the first multimodal computed tomography or magnetic resonance imaging, patients were categorized as having substantial penumbra if perfusion lesion volume (Tmax >6 seconds) exceeded ischemic core volume (relative cerebral blood flow <30% on CT perfusion or apparent diffusion coefficient <620 on diffusion weighted image) by ≥20%. RESULTS Among 174 consecutive AIS patients presenting within 24 hours of last known well time, 29 (17%) had LVO or MVO and substantial penumbra, but were deemed ET ineligible. Among these patients, mean age was 81 (±13), 45% were female, and median National Institute of Health Stroke Scale score was 11 (interquartile range [IQR]: 5-19). The most common reasons for not pursuing ET were: distal occlusion (28%), mild neurologic deficit (16%), and temporally advanced core injury (16%). Ischemic core volume was 20 mL (±31), penumbral volume was 54 mL (±63), and mismatch ratio median was 5.6 (IQR: 2-infinite). Severe disability or death at discharge (modified Rankin scale: 4-6) occurred in 72% of the patients. CONCLUSION Even in the modern stent retriever era, 1 in 6 AIS patients presents with substantial penumbra judged not appropriate for ET. This population may benefit from the development of alternative therapies, including collateral enhancement, neuroprotection, and thrombectomy devices deployable in distal arteries.
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Affiliation(s)
- Mersedeh Bahr Hosseini
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at the University of California-Los Angeles (UCLA), Los Angeles, CA
| | - Graham Woolf
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at the University of California-Los Angeles (UCLA), Los Angeles, CA
| | - Latisha K Sharma
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at the University of California-Los Angeles (UCLA), Los Angeles, CA
| | - Jason D Hinman
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at the University of California-Los Angeles (UCLA), Los Angeles, CA
| | - Neal M Rao
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at the University of California-Los Angeles (UCLA), Los Angeles, CA
| | - Bryan Yoo
- Division of Neuroradiology and Comprehensive Stroke Center, David Geffen School of Medicine at the University of California-Los Angeles (UCLA), Los Angeles, CA
| | - Reza Jahan
- Division of Neuroradiology and Comprehensive Stroke Center, David Geffen School of Medicine at the University of California-Los Angeles (UCLA), Los Angeles, CA
| | - Sidney Starkman
- Departments of Emergency Medicine and Neurology, and Comprehensive Stroke Center, David Geffen School of Medicine at the University of California-Los Angeles (UCLA), Los Angeles, CA
| | - May Nour
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at the University of California-Los Angeles (UCLA), Los Angeles, CA
| | - Radoslav Raychev
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at the University of California-Los Angeles (UCLA), Los Angeles, CA
| | - David S Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at the University of California-Los Angeles (UCLA), Los Angeles, CA
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at the University of California-Los Angeles (UCLA), Los Angeles, CA
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13
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Wannamaker R, Guinand T, Menon BK, Demchuk A, Goyal M, Frei D, Bharatha A, Jovin TG, Shankar J, Krings T, Baxter B, Holmstedt C, Swartz R, Dowlatshahi D, Chan R, Tampieri D, Choe H, Burns P, Gentile N, Rempel J, Shuaib A, Buck B, Bivard A, Hill M, Butcher K. Computed Tomographic Perfusion Predicts Poor Outcomes in a Randomized Trial of Endovascular Therapy. Stroke 2018; 49:1426-1433. [DOI: 10.1161/strokeaha.117.019806] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 03/02/2018] [Accepted: 04/03/2018] [Indexed: 12/30/2022]
Abstract
Background and Purpose—
In the ESCAPE trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times), patients with large vessel occlusions and small infarct cores identified with computed tomography (CT)/CT angiography were randomized to endovascular therapy or standard of care. CT perfusion (CTP) was obtained in some cases but was not used to select patients. We tested the hypothesis that patients with penumbral CTP patterns have higher rates of good clinical outcome.
Methods—
All CTP data acquired in ESCAPE patients were analyzed centrally using a semiautomated perfusion threshold-based approach. A penumbral pattern was defined as an infarct core <70 mL, penumbral volume >15 mL, and a total hypoperfused volume:core volume ratio of >1.8. The primary outcome was good functional outcome at 90 days (modified Rankin Scale score, 0–2).
Results—
CTP was acquired in 138 of 316 ESCAPE patients. Penumbral patterns were present in 116 of 128 (90.6%) of patients with interpretable CTP data. The rate of good functional outcome in penumbral pattern patients (53 of 114; 46%) was higher than that in nonpenumbral patients (2 of 12; 17%;
P
=0.041). In penumbral patients, endovascular therapy increased the likelihood of a good clinical outcome (34 of 58; 57%) compared with those in the control group (19 of 58; 33%; odds ratio, 2.68; 95% confidence interval, 1.25–5.76;
P
=0.011). Only 3 of 12 nonpenumbral patients were randomized to the endovascular group, preventing an analysis of treatment effect.
Conclusions—
The majority of patients with CTP imaging in the ESCAPE trial had penumbral patterns, which were associated with better outcomes overall. Patients with penumbra treated with endovascular therapy had the greatest odds of good functional outcome. Nonpenumbral patients were much less likely to achieve good outcomes.
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Affiliation(s)
| | - Taurian Guinand
- From the Division of Neurology (R.W., T.G., A.S., B. Buck, K.B.)
| | - Bijoy K. Menon
- Division of Neurology, University of Calgary, Alberta, Canada (B.K.M., A.D., M.G., M.H.)
| | - Andrew Demchuk
- Division of Neurology, University of Calgary, Alberta, Canada (B.K.M., A.D., M.G., M.H.)
| | - Mayank Goyal
- Division of Neurology, University of Calgary, Alberta, Canada (B.K.M., A.D., M.G., M.H.)
| | - Donald Frei
- Department of Medical Imaging, Swedish Medical Center, Denver, CO (D.F.)
| | - Aditya Bharatha
- Department of Medical Imaging, St. Michael’s Hospital (A. Bharatha)
| | | | - Jai Shankar
- Department of Diagnostic Radiology, Dalhousie University, Halifax, Nova Scotia, Canada (J.S.)
| | | | - Blaise Baxter
- Department of Radiology, University of Tennessee, Chattanooga (B. Baxter)
| | - Christine Holmstedt
- Division of Neurology, Medical University of South Carolina, Charleston (C.H.)
| | - Richard Swartz
- Division of Neurology (R.S.), University of Toronto, Ontario, Canada
| | - Dar Dowlatshahi
- Division of Neurology, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada (D.D.)
| | - Richard Chan
- Division of Neurology, University of Western Ontario, London, Canada (R.C.)
| | - Donatella Tampieri
- Department of Radiology, McGill University Health Center, Montreal, Quebec, Canada (D.T.)
| | - Hana Choe
- Neurovascular Associates, Abington Jefferson Health, Philadelphia, PA (H.C.)
| | - Paul Burns
- Division of Neurology, Royal Victoria Hospital, Belfast, United Kingdom (P.B.)
| | - Nina Gentile
- Division of Neurology, Temple University, Philadelphia, PA (N.G.)
| | - Jeremy Rempel
- Department of Diagnostic Imaging (J.R.), University of Alberta, Edmonton, Canada
| | - Ashfaq Shuaib
- From the Division of Neurology (R.W., T.G., A.S., B. Buck, K.B.)
| | - Brian Buck
- From the Division of Neurology (R.W., T.G., A.S., B. Buck, K.B.)
| | - Andrew Bivard
- Hunter Medical Research Institute, University of Newcastle, New South Wales, Australia (A. Bivard)
| | - Michael Hill
- Division of Neurology, University of Calgary, Alberta, Canada (B.K.M., A.D., M.G., M.H.)
| | - Kenneth Butcher
- From the Division of Neurology (R.W., T.G., A.S., B. Buck, K.B.)
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14
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Bivard A, Parsons M. Tissue is more important than time: insights into acute ischemic stroke from modern brain imaging. Curr Opin Neurol 2018; 31:23-27. [DOI: 10.1097/wco.0000000000000520] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Burkhardt JK, Winklhofer S, Fierstra J, Wegener S, Esposito G, Luft A, Bozinov O, Regli L. Emergency Extracranial-Intracranial Bypass to Revascularize Salvageable Brain Tissue in Acute Ischemic Stroke Patients. World Neurosurg 2018; 109:e476-e485. [DOI: 10.1016/j.wneu.2017.10.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 10/01/2017] [Accepted: 10/03/2017] [Indexed: 11/24/2022]
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16
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Takamura T, Hori M, Kamagata K, Kumamaru KK, Irie R, Hagiwara A, Hamasaki N, Aoki S. Slice-accelerated gradient-echo echo planar imaging dynamic susceptibility contrast-enhanced MRI with blipped CAIPI: effect of increasing temporal resolution. Jpn J Radiol 2017; 36:40-50. [PMID: 29086345 DOI: 10.1007/s11604-017-0695-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 10/13/2017] [Indexed: 01/02/2023]
Abstract
PURPOSE To assess the influence of high temporal resolution on the perfusion measurements and image quality of perfusion maps, by applying simultaneous-multi-slice acquisition (SMS) dynamic susceptibility contrast-enhanced (DSC) magnetic resonance imaging (MRI). MATERIALS AND METHODS DSC-MRI data using SMS gradient-echo echo planar imaging sequences in 10 subjects with no intracranial abnormalities were retrospectively analyzed. Three additional data sets with temporal resolution of 1.0, 1.5, and 2.0 s were created from the raw data sets of 0.5 s. Cerebral blood flow (CBF), cerebral blood volume, mean transit time (MTT), time to peak (TTP), and time to maximum tissue residue function (T max) measurements were performed, as was visual perfusion map analysis. The perfusion parameter for temporal resolution of 0.5 s (reference) was compared with each synthesized perfusion parameter. RESULTS CBF, MTT, and TTP values at temporal resolutions of 1.5 and 2.0 s differed significantly from the reference. The image quality of MTT, TTP, and T max maps deteriorated with decreasing temporal resolution. CONCLUSION The temporal resolution of DSC-MRI influences perfusion parameters and SMS DSC-MRI provides better image quality for MTT, TTP, and T max maps.
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Affiliation(s)
- Tomohiro Takamura
- Department of Radiology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Masaaki Hori
- Department of Radiology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Koji Kamagata
- Department of Radiology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Kanako K Kumamaru
- Department of Radiology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Ryusuke Irie
- Department of Radiology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Akifumi Hagiwara
- Department of Radiology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
- Department of Radiology, Graduate School of Medicine, University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Nozomi Hamasaki
- Department of Radiology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Shigeki Aoki
- Department of Radiology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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17
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Seker F, Pfaff J, Potreck A, Mundiyanapurath S, Ringleb PA, Bendszus M, Möhlenbruch MA. Correlation of Tmax volumes with clinical outcome in anterior circulation stroke. Brain Behav 2017; 7:e00772. [PMID: 28948072 PMCID: PMC5607541 DOI: 10.1002/brb3.772] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 06/09/2017] [Accepted: 06/13/2017] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND PURPOSE The recent thrombectomy trials have shown that perfusion imaging is helpful in proper patient selection in thromboembolic stroke. In this study, we analyzed the correlation of pretreatment Tmax volumes in MR and CT perfusion with clinical outcome after thrombectomy. METHODS Forty-one consecutive patients with middle cerebral artery occlusion (MCA) or carotid T occlusion treated with thrombectomy were included. Tmax volumes at delays of >4, 6, 8, and 10 s as well as infarct core and mismatch ratio were automatically estimated in preinterventional MRI or CT perfusion using RAPID software. These perfusion parameters were correlated with clinical outcome. Outcome was assessed using modified Rankin scale at 90 days. RESULTS In patients with successful recanalization of MCA occlusion, Tmax > 8 and 10 s showed the best linear correlation with clinical outcome (r = 0.75; p = .0139 and r = 0.73; p = .0139), better than infarct core (r = 0.43; p = .2592). In terminal internal carotid artery occlusions, none of the perfusion parameters showed a significant correlation with clinical outcome. CONCLUSIONS Tmax at delays of >8 and 10 s is a good predictor for clinical outcome in MCA occlusions. In carotid T occlusion, however, Tmax volumes do not correlate with outcome.
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Affiliation(s)
- Fatih Seker
- Department of Neuroradiology Heidelberg University Hospital Heidelberg Germany
| | - Johannes Pfaff
- Department of Neuroradiology Heidelberg University Hospital Heidelberg Germany
| | - Arne Potreck
- Department of Neuroradiology Heidelberg University Hospital Heidelberg Germany
| | | | - Peter A Ringleb
- Department of Neurology Heidelberg University Hospital Heidelberg Germany
| | - Martin Bendszus
- Department of Neuroradiology Heidelberg University Hospital Heidelberg Germany
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18
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Zaro-Weber O, Moeller-Hartmann W, Siegmund D, Kandziora A, Schuster A, Heiss WD, Sobesky J. MRI-based mismatch detection in acute ischemic stroke: Optimal PWI maps and thresholds validated with PET. J Cereb Blood Flow Metab 2017; 37:3176-3183. [PMID: 28029273 PMCID: PMC5584696 DOI: 10.1177/0271678x16685574] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Perfusion-weighted (PW) magnetic resonance imaging (MRI) is used to detect penumbral tissue in acute stroke, but the selection of optimal PW-maps and thresholds for tissue at risk detection remains a matter of debate. We validated the performance of PW-maps with 15O-water-positron emission tomography (PET) in a large comparative PET-MR cohort of acute stroke patients. In acute and subacute stroke patients with back-to-back MRI and PET imaging, PW-maps were validated with 15O-water-PET. We pooled two different cerebral blood flow (CBF) PET-maps to define the critical flow (CF) threshold, (i) quantitative (q)CBF-PET with the CF threshold <20 ml/100 g/min and (ii) normalized non-quantitative (nq)CBF-PET with a CF threshold of <70% (corresponding to <20 ml/100 g/min according to a previously published normogram). A receiver operating characteristic (ROC) curve analysis was performed to specify the accuracy and the optimal critical flow threshold of each PW-map as defined by PET. In 53 patients, (stroke to imaging: 9.8 h; PET to MRI: 52 min) PW-time-to-maximum (Tmax) with a threshold >6.1 s (AUC = 0.94) and non-deconvolved PW-time-to-peak (TTP) >4.8 s (AUC = 0.93) showed the best performance to detect the CF threshold as defined by PET. PW-Tmax with a threshold >6.1 s and TTP with a threshold >4.8 s are the most predictive in detecting the CF threshold for MR-based mismatch definition.
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Affiliation(s)
- Olivier Zaro-Weber
- 1 Max-Planck-Institute for Neurological Research, Cologne, Germany.,3 Department of Neurology, Charité-Universitätsmedizin, Berlin, Germany.,4 Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
| | | | - Dora Siegmund
- 1 Max-Planck-Institute for Neurological Research, Cologne, Germany
| | | | | | | | - Jan Sobesky
- 3 Department of Neurology, Charité-Universitätsmedizin, Berlin, Germany.,4 Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
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19
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Xu Y, Ringgaard S, Mariager CØ, Bertelsen LB, Schroeder M, Qi H, Laustsen C, Stødkilde-Jørgensen H. Hyperpolarized 13C Magnetic Resonance Imaging Can Detect Metabolic Changes Characteristic of Penumbra in Ischemic Stroke. ACTA ACUST UNITED AC 2017; 3:67-73. [PMID: 30042973 PMCID: PMC6024450 DOI: 10.18383/j.tom.2017.00106] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Magnetic resonance imaging (MRI) is increasingly the method of choice for rapid stroke assessment in patients and for guiding patient selection in clinical trials. The underlying metabolic status during stroke and following treatment is recognized as an important prognostic factor; thus, new methods are required to monitor local biochemistry following cerebral infarction, rapidly and in vivo. Hyperpolarized MRI with the tracer [1-13C]pyruvate enables rapid detection of localized [1-13C]lactate production, which has recently been shown in patients, supporting its translation to assess clinical stroke. Here we show the ability of hyperpolarized 13C MRI to detect the metabolic alterations characteristic of endothelin-1-induced ischemic stroke in rodents. In the region of penumbra, determined via T2-weighted 1H MRI, both [1-13C]pyruvate delivery and [1-13C]pyruvate cellular uptake independently increased. Furthermore, we observed a 33% increase in absolute [1-13C]lactate signal in the penumbra, and we determined that half of this increase was due to increased intracellular [1-13C]pyruvate supply and half was mediated by enhanced lactate dehydrogenase-mediated [1-13C]lactate production. Future work to characterize the kinetics of delivery, uptake, and enzymatic conversions of hyperpolarized tracers following ischemic stroke could position hyperpolarized 13C MRI as an ideal technology for rapid assessment of the penumbra during the critical time window following ischemic stroke in patients.
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Affiliation(s)
- Yafang Xu
- Department of Clinical Medicine, MR Research Centre, Aarhus University, Aarhus, Denmark
| | - Steffen Ringgaard
- Department of Clinical Medicine, MR Research Centre, Aarhus University, Aarhus, Denmark
| | | | - Lotte Bonde Bertelsen
- Department of Clinical Medicine, MR Research Centre, Aarhus University, Aarhus, Denmark
| | - Marie Schroeder
- Department of Clinical Medicine, MR Research Centre, Aarhus University, Aarhus, Denmark
| | - Haiyun Qi
- Department of Clinical Medicine, MR Research Centre, Aarhus University, Aarhus, Denmark
| | - Christoffer Laustsen
- Department of Clinical Medicine, MR Research Centre, Aarhus University, Aarhus, Denmark
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20
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Ye Z, Ai X, Zheng J, Hu X, Lin S, You C, Li H. Antihypertensive treatments for spontaneous intracerebral hemorrhage in patients with cerebrovascular stenosis: A randomized clinical trial (ATICHST). Medicine (Baltimore) 2017; 96:e7289. [PMID: 28658126 PMCID: PMC5500048 DOI: 10.1097/md.0000000000007289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Antihypertensive treatment is associated with clinical outcomes in patients with spontaneous intracerebral hemorrhage (sICH). ADAPT showed that intensive blood pressure lowering (<140 mm Hg) does not reduce peri-hematoma regional cerebral blood flow (rCBF) in patients with sICH. However, the stenosis of main cerebral arteries that has a high presence in patients with sICH is well-known related to the brain ischemia. The effect of intensive BP lowering for sICH in patients with cerebrovascular stenosis is still unknown. AIM The aim of this study was to determine the safety and effectiveness of intensive BP lowering for sICH in patients with cerebrovascular stenosis. METHODS AND ANALYSIS A pilot trial has been conducted to calculate the sample size and 80 patients of sICH with cerebrovascular stenosis will be involved. The target of systolic blood pressure (SBP) will be maintained at from 120 to 140 mm Hg or from 140 to 180 mm Hg for 7 days. Cerebral ischemia will be assessed at 24 hours after onset by computed tomography (CT) perfusion imaging and the follow-up will be conducted at 30-day and 90-day. The primary outcome is the reduction of peri-hematoma rCBF. The other cerebral perfusion indexes and the rate of ischemic stroke are regarded as other primary outcomes. The secondary outcomes include clinical outcome at 30 days and 90 days, complications, and hospital stays. DISCUSSION The ATICHST trial has been signed as a parallel, prospective, randomized, assessor-blinded clinical trial to determine the effects of intensive BP lowering on sICH in patients with cerebrovascular stenosis, the results of which will contribute to guide the management of blood pressure in sICH. CONCLUSION The protocol will determine the safety and effectiveness of intensive BP lowering for sICH with cerebrovascular stenosis.
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21
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Bateman M, Slater LA, Leslie-Mazwi T, Simonsen CZ, Stuckey S, Chandra RV. Diffusion and Perfusion MR Imaging in Acute Stroke: Clinical Utility and Potential Limitations for Treatment Selection. Top Magn Reson Imaging 2017; 26:77-82. [PMID: 28277459 DOI: 10.1097/rmr.0000000000000124] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Magnetic resonance (MR) diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) offer unique insight into acute ischemic stroke pathophysiology. These techniques may offer the ability to apply pathophysiology to accurately individualize acute stroke reperfusion treatment, including extending the opportunity of reperfusion treatment to well beyond the current time-based treatment windows.This review examines the use of DWI and PWI in the major stroke trials, their current clinical utility, and potential limitations for reperfusion treatment selection. DWI and PWI continue to be investigated in ongoing randomized controlled trials, and continued research into these techniques will help achieve the goal of tissue-based decision making and individualized acute stroke treatment.
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Affiliation(s)
- Mathew Bateman
- *Neuroradiology Service, Monash Imaging, Monash Health †School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia ‡NeuroEndovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA §Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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22
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Liu S, Buch S, Chen Y, Choi HS, Dai Y, Habib C, Hu J, Jung JY, Luo Y, Utriainen D, Wang M, Wu D, Xia S, Haacke EM. Susceptibility-weighted imaging: current status and future directions. NMR IN BIOMEDICINE 2017; 30:10.1002/nbm.3552. [PMID: 27192086 PMCID: PMC5116013 DOI: 10.1002/nbm.3552] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 04/01/2016] [Accepted: 04/11/2016] [Indexed: 05/14/2023]
Abstract
Susceptibility-weighted imaging (SWI) is a method that uses the intrinsic nature of local magnetic fields to enhance image contrast in order to improve the visibility of various susceptibility sources and to facilitate diagnostic interpretation. It is also the precursor to the concept of the use of phase for quantitative susceptibility mapping (QSM). Nowadays, SWI has become a widely used clinical tool to image deoxyhemoglobin in veins, iron deposition in the brain, hemorrhages, microbleeds and calcification. In this article, we review the basics of SWI, including data acquisition, data reconstruction and post-processing. In particular, the source of cusp artifacts in phase images is investigated in detail and an improved multi-channel phase data combination algorithm is provided. In addition, we show a few clinical applications of SWI for the imaging of stroke, traumatic brain injury, carotid vessel wall, siderotic nodules in cirrhotic liver, prostate cancer, prostatic calcification, spinal cord injury and intervertebral disc degeneration. As the clinical applications of SWI continue to expand both in and outside the brain, the improvement of SWI in conjunction with QSM is an important future direction of this technology. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Saifeng Liu
- The MRI Institute for Biomedical Research, Waterloo, ON, Canada
| | - Sagar Buch
- The MRI Institute for Biomedical Research, Waterloo, ON, Canada
| | - Yongsheng Chen
- Department of Radiology, Wayne State University, Detroit, MI, US
| | - Hyun-Seok Choi
- Department of Radiology, St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Yongming Dai
- The MRI Institute of Biomedical Research, Detroit, Michigan, US
| | - Charbel Habib
- Department of Radiology, Wayne State University, Detroit, MI, US
| | - Jiani Hu
- Department of Radiology, Wayne State University, Detroit, MI, US
| | - Joon-Yong Jung
- Department of Radiology, St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Yu Luo
- Department of Radiology, the Branch of Shanghai First Hospital, Shanghai, China
| | - David Utriainen
- The MRI Institute of Biomedical Research, Detroit, Michigan, US
| | - Meiyun Wang
- Department of Radiology, Henan Provincial People’s Hospital, Zhengzhou, Henan, China
| | - Dongmei Wu
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, Shanghai, China
| | - Shuang Xia
- Department of Radiology, Tianjin First Central Hospital, Tianjin, China
| | - E. Mark Haacke
- The MRI Institute for Biomedical Research, Waterloo, ON, Canada
- Department of Radiology, Wayne State University, Detroit, MI, US
- The MRI Institute of Biomedical Research, Detroit, Michigan, US
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, Shanghai, China
- Address correspondence to: E. Mark Haacke, Ph.D., 3990 John R Street, MRI Concourse, Detroit, MI 48201. 313-745-1395,
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23
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Revisiting Current Golden Rules in Managing Acute Ischemic Stroke: Evaluation of New Strategies to Further Improve Treatment Selection and Outcome. AJR Am J Roentgenol 2017; 208:32-41. [DOI: 10.2214/ajr.16.16557] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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24
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Robson H, Specht K, Beaumont H, Parkes LM, Sage K, Lambon Ralph MA, Zahn R. Arterial spin labelling shows functional depression of non-lesion tissue in chronic Wernicke's aphasia. Cortex 2016; 92:249-260. [PMID: 28525836 PMCID: PMC5480775 DOI: 10.1016/j.cortex.2016.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 08/15/2016] [Accepted: 11/02/2016] [Indexed: 11/23/2022]
Abstract
Behavioural impairment post-stroke is a consequence of structural damage and altered functional network dynamics. Hypoperfusion of intact neural tissue is frequently observed in acute stroke, indicating reduced functional capacity of regions outside the lesion. However, cerebral blood flow (CBF) is rarely investigated in chronic stroke. This study investigated CBF in individuals with chronic Wernicke's aphasia (WA) and examined the relationship between lesion, CBF and neuropsychological impairment. Arterial spin labelling CBF imaging and structural MRIs were collected in 12 individuals with chronic WA and 13 age-matched control participants. Joint independent component analysis (jICA) investigated the relationship between structural lesion and hypoperfusion. Partial correlations explored the relationship between lesion, hypoperfusion and language measures. Joint ICA revealed significant differences between the control and WA groups reflecting a large area of structural lesion in the left posterior hemisphere and an associated area of hypoperfusion extending into grey matter surrounding the lesion. Small regions of remote cortical hypoperfusion were observed, ipsilateral and contralateral to the lesion. Significant correlations were observed between the neuropsychological measures (naming, repetition, reading and semantic association) and the jICA component of interest in the WA group. Additional ROI analyses found a relationship between perfusion surrounding the core lesion and the same neuropsychological measures. This study found that core language impairments in chronic WA are associated with a combination of structural lesion and abnormal perfusion in non-lesioned tissue. This indicates that post-stroke impairments are due to a wider disruption of neural function than observable on structural T1w MRI.
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Affiliation(s)
- Holly Robson
- Department of Psychology and Clinical Language Sciences, University of Reading, UK.
| | - Karsten Specht
- Department of Biological and Medical Psychology, University of Bergen, Norway; Department of Clinical Engineering, Haukeland University Hospital, Bergen, Norway
| | | | - Laura M Parkes
- Centre for Imaging Science, Institute of Population Health, University of Manchester, UK
| | - Karen Sage
- Centre for Health and Social Care Research, Sheffield Hallam University, Sheffield, UK
| | - Matthew A Lambon Ralph
- Neuroscience and Aphasia Research Unit, School Psychological Sciences, University of Manchester, UK
| | - Roland Zahn
- Department of Psychological Medicine, Kings College London, UK
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25
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Malhotra K, Liebeskind DS. Imaging in Endovascular Stroke Trials. J Neuroimaging 2016; 25:517-27. [PMID: 26179500 DOI: 10.1111/jon.12272] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 05/21/2015] [Indexed: 01/19/2023] Open
Abstract
Ischemic stroke remains a leading cause of death and disability worldwide. Various endovascular trials have addressed clinical outcomes without elucidating the impact of imaging studies in patient selection. The success of recent endovascular trials was bolstered by the use of advanced imaging techniques for optimal selection of reperfusion candidates. This seminal juncture in the history of stroke trials warrants further consideration on the use of imaging to guide future refinements in the treatment of acute stroke. In this article, we systematically review the imaging methodology and key facets used in all published endovascular stroke trials to date, discuss the success of recent trials using latest advanced imaging techniques and focus on the importance of imaging studies for future patient selection.
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Affiliation(s)
| | - David S Liebeskind
- Neurovascular Imaging Research Core and the UCLA Stroke Center, Los Angeles, CA
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Shi L, Liang F, Li Y, Shao A, Zhou K, Yu J, Zhang J. Desmoteplase for Acute Ischemic Stroke within 3 to 9 Hours after Symptom Onset: Evidence from Randomized Controlled Trials. Sci Rep 2016; 6:33989. [PMID: 27671010 PMCID: PMC5037417 DOI: 10.1038/srep33989] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 09/02/2016] [Indexed: 11/13/2022] Open
Abstract
Recent studies have shown inconsistent results regarding the value of desmoteplase for treating acute ischemic stroke (AIS) when administered within an extended time window. We performed a meta-analysis to explore the value of desmoteplase in AIS treatment. The MEDLINE, EMBASE, and Cochrane Library databases were searched for randomized controlled trials (RCTs) that had evaluated desmoteplase versus placebo for AIS. The primary outcomes were intracranial hemorrhage (ICH) within 72 hours and favorable outcome at Day 90. We pooled 819 patients from 5 RCTs. Desmoteplase treatment showed a neutral effect on favorable outcome (P = 0.42) but a favorable safety profile in terms of ICH (P = 0.64) compared with the placebo group. In the subgroup analysis, 90 μg/kg desmoteplase, a late time to treatment (6–9 hours), and serious stroke symptoms at baseline (NIHSS > 12) subgroups showed high risks of ICH (P ≤ 0.02). A high dose of desmoteplase (125 μg/kg) showed a tendency to improve recanalization (P = 0.05), but was also associated with an increased risk of death (P = 0.04). In conclusion, desmoteplase administered over an extended time window had no significant effect on functional recovery but exhibited a favorable safety profile in patients with AIS.
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Affiliation(s)
- Ligen Shi
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Feng Liang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yunping Li
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Anwen Shao
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Keren Zhou
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jun Yu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jianmin Zhang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Brain Research Institute, Zhejiang University, Hangzhou, Zhejiang, China.,Collaborative Innovation Center for Brain Science, Zhejiang University, Hangzhou, Zhejiang, China
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27
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Chang CZ, Wu SC. 4'-O-β-D-Glucosyl-5-O-Methylvisamminol, A Natural Histone H3 Phosphorylation Epigenetic Suppressor, Exerts a Neuroprotective Effect Through PI3K/Akt Signaling Pathway on Focal Cerebral Ischemia in Rats. World Neurosurg 2016; 89:474-88. [PMID: 26868427 DOI: 10.1016/j.wneu.2016.01.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 01/15/2016] [Accepted: 01/19/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND A bursting inflammation has been observed that compromises neurologic function in patients who experience stroke. We sought to examine the neuroprotective efficacy of 4'-O-β-D-glucosyl-5-O-methylvisamminol (OGOMV), a novel histone H3 phosphorylation epigenetic suppressor) in a transient middle cerebral artery occlusion (tMCAO). METHODS A rodent tMCAO model was used. Administration with 400 μg/kg/day OGOMV was initiated 12 hours before (prevention) and 1 hour after animals were subjected to tMCAO (reversal). The cerebral cortex was harvested to examine protein kinase B (PI3D/Akt), 5-bromo-2'-deoxyuridine (Western blot), and caspases (reverse-transcription polymerase chain reaction). In addition, cerebrospinal fluid samples were collected to examine interleukin 1-β, interleukin-6, monocyte chemoattractant protein-1, and tumor necrosis factor-α (reverse-transcription polymerase chain reaction). RESULTS Cortical 5-bromo-2'-deoxyuridine and phospho-PI3D/Akt were reduced in tMCAO animals, compared with the healthy controls but increased in the OGOMV treatment and prevention groups. Activated cortical caspase-3,-6, and -9a as well as increased IL-1β and TNF-α levels were observed in the tMCAO animals (P < 0.05). Both prevention and treatment with OGOMV significantly reduced cleaved caspase-3 and -9a groups, but no significant change in caspase-6 was noted. Perifosine, an Akt inhibitor, was added to reduce the bioexpression of phospho-P13D/Akt, and Bcl-2 level and increased cleaved caspase-9a level in both OGOMV prevention and treatment tMCAO groups (P > 0.05). CONCLUSION Our study suggests that OGOMV could exert a neuroprotective effect by inhibiting the P13D/Akt protein, attenuating inflammation, and cleaved caspase-3- and -9a-related apoptosis. This study also lends credence to support the notion that the prevention of OGOMV could attenuate proinflammatory cytokine mRNA and late-onset caspases in tMCAO and merits further study.
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Affiliation(s)
- Chih-Zen Chang
- Department of Surgery, Faculty of Medicine, School of Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Surgery, Kaohsiung Municipal Ta Tung Hospital, Kaohsiung, Taiwan.
| | - Shu-Chuan Wu
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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Abstract
Progress in finding a better alternative to alteplase has been slow. Tenecteplase and desmoteplase have better pharmacological profiles compared with alteplase, but definite clinical evidence of their superiority is lacking. The two major phase III studies that have tested the efficacy and safety of desmoteplase in ischemic stroke patients have shown neutral results and a promising safety profile, but the trials compared desmoteplase with placebo only in late admitted patients. Future trials should focus on testing novel thrombolytics in the early time window either as the sole acute recanalizing treatment or combined with thrombectomy.
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Breuer L, Knott M, Struffert T, Kloska S, Kurka N, Schwab S, Dörfler A, Köhrmann M, Engelhorn T. Limited versus Whole-Brain Perfusion for the Indication of Thrombolysis in the Extended Time Window of Acute Cerebral Ischemia. J Stroke Cerebrovasc Dis 2015; 24:2491-6. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.06.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 06/14/2015] [Indexed: 11/27/2022] Open
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Meijs M, Christensen S, Lansberg MG, Albers GW, Calamante F. Analysis of perfusion MRI in stroke: To deconvolve, or not to deconvolve. Magn Reson Med 2015; 76:1282-90. [PMID: 26519871 DOI: 10.1002/mrm.26024] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 08/28/2015] [Accepted: 09/30/2015] [Indexed: 11/06/2022]
Abstract
PURPOSE There is currently controversy regarding the benefits of deconvolution-based parameters in stroke imaging, with studies suggesting a similar infarct prediction using summary parameters. We investigate here the performance of deconvolution-based parameters and summary parameters for dynamic-susceptibility contrast (DSC) MRI analysis, with particular emphasis on precision. METHODS Numerical simulations were used to assess the contribution of noise and arterial input function (AIF) variability to measurement precision. A realistic AIF range was defined based on in vivo data from an acute stroke clinical study. The simulated tissue curves were analyzed using two popular singular value decomposition (SVD) based algorithms, as well as using summary parameters. RESULTS SVD-based deconvolution methods were found to considerably reduce the AIF-dependency, but a residual AIF bias remained on the calculated parameters. Summary parameters, in turn, show a lower sensitivity to noise. The residual AIF-dependency for deconvolution methods and the large AIF-sensitivity of summary parameters was greatly reduced when normalizing them relative to normal tissue. CONCLUSION Consistent with recent studies suggesting high performance of summary parameters in infarct prediction, our results suggest that DSC-MRI analysis using properly normalized summary parameters may have advantages in terms of lower noise and AIF-sensitivity as compared to commonly used deconvolution methods. Magn Reson Med 76:1282-1290, 2016. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Midas Meijs
- Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Soren Christensen
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, California, USA
| | - Maarten G Lansberg
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, California, USA
| | - Gregory W Albers
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, California, USA
| | - Fernando Calamante
- The Florey Institute of Neuroscience and Mental Health, Melbourne, Australia. .,The Florey Department of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia. .,Department of Medicine, Austin Health and Northern Health, University of Melbourne, Melbourne, Australia.
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31
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Wang D, Zhu F, Fung KM, Zhu W, Luo Y, Chu WCW, Tong Mok VC, Wu J, Shi L, Ahuja AT, Mao Y. Predicting Cerebral Hyperperfusion Syndrome Following Superficial Temporal Artery to Middle Cerebral Artery Bypass based on Intraoperative Perfusion-Weighted Magnetic Resonance Imaging. Sci Rep 2015; 5:14140. [PMID: 26365751 PMCID: PMC4568478 DOI: 10.1038/srep14140] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 05/19/2015] [Indexed: 11/09/2022] Open
Abstract
Moyamoya disease leads to the formation of stenosis in the cerebrovasculature. A superficial temporal artery to middle cerebral artery (STA-MCA) bypass is an effective treatment for the disease, yet it is usually associated with postoperative cerebral hyperperfusion syndrome (CHS). This study aimed to evaluate cerebral hemodynamic changes immediately after surgery and assess whether a semiquantitative analysis of an intraoperative magnetic resonance perfusion-weighted image (PWI) is useful for predicting postoperative CHS. Fourteen patients who underwent the STA-MCA bypass surgery were included in this study. An atlas-based registration method was employed for studying hemodynamics in different cerebral regions. Pre- versus intraoperative and group-wise comparisons were conducted to evaluate the hemodynamic changes. A postoperative increase in relative cerebral blood flow (CBF) at the terminal MCA territory (P = 0.035) and drop in relative mean-time-transit at the central MCA territory (P = 0.012) were observed in all patients. However, a significant raise in the increasing ratio of relative-CBF at the terminal MCA territory was only found in CHS patients (P = 0.023). The cerebrovascular changes of the patients after revascularization treatment were confirmed. Intraoperative PWI might be helpful in predicting the change in relative-CBF at MCA terminal territory which might indicate a risk of CHS.
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Affiliation(s)
- Defeng Wang
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China.,Research Center for Medical Image Computing, Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China.,Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen, China.,Department of Biomedical Engineering and Shun Hing Institute of Advanced Engineering, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Fengping Zhu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China.,Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
| | - Ka Ming Fung
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Wei Zhu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yishan Luo
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China.,Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen, China
| | - Winnie Chiu Wing Chu
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Vincent Chung Tong Mok
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China.,Lui Che Woo Institute of Innovative Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Jinsong Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Lin Shi
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China.,Lui Che Woo Institute of Innovative Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Anil T Ahuja
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
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Zaro-Weber O, Livne M, Martin SZ, von Samson-Himmelstjerna FC, Moeller-Hartmann W, Schuster A, Brunecker P, Heiss WD, Sobesky J, Madai VI. Comparison of the 2 Most Popular Deconvolution Techniques for the Detection of Penumbral Flow in Acute Stroke. Stroke 2015; 46:2795-9. [PMID: 26306755 DOI: 10.1161/strokeaha.115.010246] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 07/15/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Dynamic susceptibility-weighted contrast-enhanced (DSC) magnetic resonance imaging (MRI) is used to identify the tissue-at-risk in acute stroke, but the choice of optimal DSC postprocessing in the clinical setting remains a matter of debate. Using 15O-water positron emission tomography (PET), we validated the performance of 2 common deconvolution methods for DSC-MRI. METHODS In (sub)acute stroke patients with consecutive MRI and PET imaging, DSC maps were calculated applying 2 deconvolution methods, standard and block-circulant single value decomposition. We used 2 standardized analysis methods, a region of interest-based and a voxel-based analysis, where PET cerebral blood flow masks of <20 mL/100 g per minute (penumbral flow) and gray matter masks were overlaid on DSC parameter maps. For both methods, receiver operating characteristic curve analysis was performed to identify the accuracy of each DSC-MR map for the detection of PET penumbral flow. RESULTS In 18 data sets (median time after stroke onset: 18 hours; median time PET to MRI: 101 minutes), block-circulant single value decomposition showed significantly better performance to detect PET penumbral flow only for mean transit time maps. Time-to-maximum (Tmax) had the highest performance independent of the deconvolution method. CONCLUSIONS Block-circulant single value decomposition seems only significantly beneficial for mean transit time maps in (sub)acute stroke. Tmax is likely the most stable deconvolved parameter for the detection of tissue-at-risk using DSC-MRI.
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Affiliation(s)
- Olivier Zaro-Weber
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.).
| | - Michelle Livne
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.)
| | - Steve Z Martin
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.)
| | - Federico C von Samson-Himmelstjerna
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.)
| | - Walter Moeller-Hartmann
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.)
| | - Alexander Schuster
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.)
| | - Peter Brunecker
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.)
| | - Wolf-Dieter Heiss
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.)
| | - Jan Sobesky
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.)
| | - Vince I Madai
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.).
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Mikkelsen IK, Jones PS, Ribe LR, Alawneh J, Puig J, Bekke SL, Tietze A, Gillard JH, Warburton EA, Pedraza S, Baron JC, Østergaard L, Mouridsen K. Biased visualization of hypoperfused tissue by computed tomography due to short imaging duration: improved classification by image down-sampling and vascular models. Eur Radiol 2015; 25:2080-8. [PMID: 25894005 DOI: 10.1007/s00330-015-3602-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 12/22/2014] [Accepted: 01/15/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Lesion detection in acute stroke by computed-tomography perfusion (CTP) can be affected by incomplete bolus coverage in veins and hypoperfused tissue, so-called bolus truncation (BT), and low contrast-to-noise ratio (CNR). We examined the BT-frequency and hypothesized that image down-sampling and a vascular model (VM) for perfusion calculation would improve normo- and hypoperfused tissue classification. METHODS CTP datasets from 40 acute stroke patients were retrospectively analysed for BT. In 16 patients with hypoperfused tissue but no BT, repeated 2-by-2 image down-sampling and uniform filtering was performed, comparing CNR to perfusion-MRI levels and tissue classification to that of unprocessed data. By simulating reduced scan duration, the minimum scan-duration at which estimated lesion volumes came within 10% of their true volume was compared for VM and state-of-the-art algorithms. RESULTS BT in veins and hypoperfused tissue was observed in 9/40 (22.5%) and 17/40 patients (42.5%), respectively. Down-sampling to 128 × 128 resolution yielded CNR comparable to MR data and improved tissue classification (p = 0.0069). VM reduced minimum scan duration, providing reliable maps of cerebral blood flow and mean transit time: 5 s (p = 0.03) and 7 s (p < 0.0001), respectively). CONCLUSIONS BT is not uncommon in stroke CTP with 40-s scan duration. Applying image down-sampling and VM improve tissue classification. KEY POINTS • Too-short imaging duration is common in clinical acute stroke CTP imaging. • The consequence is impaired identification of hypoperfused tissue in acute stroke patients. • The vascular model is less sensitive than current algorithms to imaging duration. • Noise reduction by image down-sampling improves identification of hypoperfused tissue by CTP.
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Affiliation(s)
- Irene Klærke Mikkelsen
- Center of Functionally Integrative Neuroscience, Aarhus University Hospital, Nørrebrogade 44, Building 10G, 5th Floor, DK-8000, Aarhus C, Denmark,
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Roldan-Valadez E, Lopez-Mejia M. Current concepts on magnetic resonance imaging (MRI) perfusion-diffusion assessment in acute ischaemic stroke: a review & an update for the clinicians. Indian J Med Res 2015; 140:717-28. [PMID: 25758570 PMCID: PMC4365345 DOI: pmid/25758570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Recently, several medical societies published joint statements about imaging recommendations for acute stroke and transient ischaemic attack patients. In following with these published guidelines, we considered it appropriate to present a brief, practical and updated review of the most relevant concepts on the MRI assessment of acute stroke. Basic principles of the clinical interpretation of diffusion, perfusion, and MRI angiography (as part of a global MRI protocol) are discussed with accompanying images for each sequence. Brief comments on incidence and differential diagnosis are also included, together with limitations of the techniques and levels of evidence. The purpose of this article is to present knowledge that can be applied in day-to-day clinical practice in specialized stroke units or emergency rooms to attend patients with acute ischaemic stroke or transient ischaemic attack according to international standards.
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Abstract
OPINION STATEMENT Recent years have seen the development of novel neuroimaging techniques whose roles in the management of acute stroke are sometimes confusing and controversial. This may be attributable in part to a focus on establishing simplified algorithms and terminology that omit consideration of the basic pathophysiology of cerebral ischemia and, consequently, of the full potential for optimizing patients' care based upon their individual imaging findings. This review begins by discussing cerebral hemodynamic physiology and of the effects of hemodynamic disturbances upon the brain. Particular attention will be paid to the hemodynamic measurements and markers of tissue injury that are provided by common clinical imaging techniques, with the goal of enabling greater confidence and flexibility in understanding the potential uses of these techniques in various clinical roles, which will be discussed in the remainder of the review.
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Affiliation(s)
- William A Copen
- Massachusetts General Hospital, Division of Neuroradiology, GRB-273A, 55 Fruit Street, Boston, MA, 02114, USA,
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Appireddy RMR, Demchuk AM, Goyal M, Menon BK, Eesa M, Choi P, Hill MD. Endovascular therapy for ischemic stroke. J Clin Neurol 2015; 11:1-8. [PMID: 25628731 PMCID: PMC4302170 DOI: 10.3988/jcn.2015.11.1.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 10/23/2014] [Accepted: 10/23/2014] [Indexed: 01/19/2023] Open
Abstract
The utility of intravenous tissue plasminogen activator (IV t-PA) in improving the clinical outcomes after acute ischemic stroke has been well demonstrated in past clinical trials. Though multiple initial small series of endovascular stroke therapy had shown good outcomes as compared to IV t-PA, a similar beneficial effect had not been translated in multiple randomized clinical trials of endovascular stroke therapy. Over the same time, there have been parallel advances in imaging technology and better understanding and utility of the imaging in therapy of acute stroke. In this review, we will discuss the evolution of endovascular stroke therapy followed by a discussion of the key factors that have to be considered during endovascular stroke therapy and directions for future endovascular stroke trials.
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Affiliation(s)
- Ramana M R Appireddy
- Department of Clinical Neurosciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrew M Demchuk
- Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mayank Goyal
- Departments of Clinical Neurosciences and Radiology, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Muneer Eesa
- Department of Radiology, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Philip Choi
- Department of Clinical Neurosciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael D Hill
- Departments of Clinical Neurosciences, Medicine, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
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Danière F, Lobotesis K, Machi P, Eker O, Mourand I, Riquelme C, Ayrignac X, Vendrell JF, Gascou G, Fendeleur J, Dargazanli C, Schaub R, Brunel H, Arquizan C, Bonafé A, Costalat V. Patient selection for stroke endovascular therapy--DWI-ASPECTS thresholds should vary among age groups: insights from the RECOST study. AJNR Am J Neuroradiol 2015; 36:32-9. [PMID: 25273535 DOI: 10.3174/ajnr.a4104] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to evaluate the benefits of endovascular intervention in large-vessel occlusion strokes, depending on age class. MATERIALS AND METHODS A clinical management protocol including intravenous treatment and mechanical thrombectomy was instigated in our center in 2009 (Prognostic Factors Related to Clinical Outcome Following Thrombectomy in Ischemic Stroke [RECOST] study). All patients with acute ischemic stroke with an anterior circulation major-vessel occlusion who presented within 6 hours were evaluated with an initial MR imaging examination and were analyzed according to age subgroups (younger than 50 years, 50-59 years, 60-69 years, 70-79 years; 80 years or older). The mRS score at 3 months was the study end point. RESULTS One hundred sixty-five patients were included in the analysis. The mean age was 67.4 years (range, 29-90 years). The mean baseline NIHSS score was 17.24 (range, 3-27). The mean DWI-derived ASPECTS was 6.4. Recanalization of TICI 2b/3 was achieved in 80%. At 3 months, 41.72% of patients had a good outcome, with a gradation of prognosis depending on the age subgroup and a clear cutoff at 70 years. Only 19% of patients older than 80 years had a good outcome at 3 months (mean ASPECTS = 7.4) with 28% for 70-79 years (mean ASPECTS = 6.8), but 58% for 60-69 years (mean ASPECTS = 6), 52% for 50-59 years (mean ASPECTS = 5.91), and 72% for younger than 50 years (mean ASPECTS = 6.31). In contrast, the mortality rate was 35% for 80 years and older, and 26% for 70-79 versus 5%-9% for younger than 70 years. CONCLUSIONS The elderly may benefit from thrombectomy when their ischemic core volume is low in comparison with younger patients who still benefit from acute recanalization despite larger infarcts. Stroke volume thresholds should, therefore, be related and adjusted to the patient's age group.
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Affiliation(s)
- F Danière
- From the Departments of Neuroradiology (F.D., P.M., O.E., C.R., J.F.V., G.G., C.D., A.B., V.C.)
| | - K Lobotesis
- Imaging Department (K.L.), Imperial College Healthcare National Health Service Trust, Charing Cross Hospital, London, United Kingdom
| | - P Machi
- From the Departments of Neuroradiology (F.D., P.M., O.E., C.R., J.F.V., G.G., C.D., A.B., V.C.)
| | - O Eker
- From the Departments of Neuroradiology (F.D., P.M., O.E., C.R., J.F.V., G.G., C.D., A.B., V.C.)
| | | | - C Riquelme
- From the Departments of Neuroradiology (F.D., P.M., O.E., C.R., J.F.V., G.G., C.D., A.B., V.C.)
| | | | - J F Vendrell
- From the Departments of Neuroradiology (F.D., P.M., O.E., C.R., J.F.V., G.G., C.D., A.B., V.C.)
| | - G Gascou
- From the Departments of Neuroradiology (F.D., P.M., O.E., C.R., J.F.V., G.G., C.D., A.B., V.C.)
| | - J Fendeleur
- Anesthesiology (J.F.), CHU Montpellier, Montpellier, France
| | - C Dargazanli
- From the Departments of Neuroradiology (F.D., P.M., O.E., C.R., J.F.V., G.G., C.D., A.B., V.C.)
| | - R Schaub
- Department of Medical Statistics (R.S.), CHU Montpellier, Arnaud de Villeneuve Hospital, University of Montpellier, Montpellier, France
| | - H Brunel
- Department of Neuroradiology (H.B.), CHU Marseille, Hôpital La Timone, Marseille, France
| | | | - A Bonafé
- From the Departments of Neuroradiology (F.D., P.M., O.E., C.R., J.F.V., G.G., C.D., A.B., V.C.)
| | - V Costalat
- From the Departments of Neuroradiology (F.D., P.M., O.E., C.R., J.F.V., G.G., C.D., A.B., V.C.)
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Abstract
In acute ischemic stroke, the volume of threatened but potentially salvageable tissue, i.e. the ischemic penumbra, is critical to the success of all acute therapeutic interventions, most notably thrombolysis. Despite the availability of both CT and MRI based techniques to detect and assess the penumbra, advanced imaging of this type remains under-utilized. Although the optimal selection criteria are still being refined and technical improvements are ongoing, rapid imaging of the penumbra appears to be the most promising approach to expanding the acute thrombolysis population, as well as tailoring treatment based on specific pathophysiological findings. This second article in a two-part series reviews current evidence for penumbral-based treatment selection and discusses the barriers to implementation of these advanced imaging techniques in acute stroke management protocols.
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Penumbra pattern assessment in acute stroke patients: comparison of quantitative and non-quantitative methods in whole brain CT perfusion. PLoS One 2014; 9:e105413. [PMID: 25144396 PMCID: PMC4140765 DOI: 10.1371/journal.pone.0105413] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 07/21/2014] [Indexed: 11/19/2022] Open
Abstract
Background And Purpose While penumbra assessment has become an important part of the clinical decision making for acute stroke patients, there is a lack of studies measuring the reliability and reproducibility of defined assessment techniques in the clinical setting. Our aim was to determine reliability and reproducibility of different types of three-dimensional penumbra assessment methods in stroke patients who underwent whole brain CT perfusion imaging (WB-CTP). Materials And Methods We included 29 patients with a confirmed MCA infarction who underwent initial WB-CTP with a scan coverage of 100 mm in the z-axis. Two blinded and experienced readers assessed the flow-volume-mismatch twice and in two quantitative ways: Performing a volumetric mismatch analysis using OsiriX imaging software (MMVOL) and visual estimation of mismatch (MMEST). Complementarily, the semiquantitative Alberta Stroke Programme Early CT Score for CT perfusion was used to define mismatch (MMASPECTS). A favorable penumbral pattern was defined by a mismatch of ≥30% in combination with a cerebral blood flow deficit of ≤90 ml and an MMASPECTS score of ≥1, respectively. Inter- and intrareader agreement was determined by Kappa-values and ICCs. Results Overall, MMVOL showed considerably higher inter-/intrareader agreement (ICCs: 0.751/0.843) compared to MMEST (0.292/0.749). In the subgroup of large (≥50 mL) perfusion deficits, inter- and intrareader agreement of MMVOL was excellent (ICCs: 0.961/0.942), while MMEST interreader agreement was poor (0.415) and intrareader agreement was good (0.919). With respect to penumbra classification, MMVOL showed the highest agreement (interreader agreement: 25 agreements/4 non-agreements/κ: 0.595; intrareader agreement 27/2/0.833), followed by MMEST (22/7/0.471; 23/6/0.577), and MMASPECTS (18/11/0.133; 21/8/0.340). Conclusion The evaluated approach of volumetric mismatch assessment is superior to pure visual and ASPECTS penumbra pattern assessment in WB-CTP and helps to precisely judge the extent of 3-dimensional mismatch in acute stroke patients.
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Using longitudinal metamorphosis to examine ischemic stroke lesion dynamics on perfusion-weighted images and in relation to final outcome on T2-w images. NEUROIMAGE-CLINICAL 2014; 5:332-40. [PMID: 25161899 PMCID: PMC4141979 DOI: 10.1016/j.nicl.2014.07.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 06/25/2014] [Accepted: 07/21/2014] [Indexed: 01/18/2023]
Abstract
We extend the image-to-image metamorphosis into constrained longitudinal metamorphosis. We apply it to estimate an evolution scenario, in patients with acute ischemic stroke, of both scattered and solitary ischemic lesions visible on serial MR perfusion weighted imaging from acute to subacute stages. We then estimate a patient-specific residual map that enables us to capture the most relevant shape and intensity changes, continuously, as the lesion evolves from acute through subacute to chronic timepoints until merging into the final image. We detect areas with high residuals (i.e., high dynamics) and identify areas that became part of the final T2-w lesion obtained at ≥ 1 month after stroke. This allows the investigation of the dynamic influence of perfusion values on the final lesion outcome as seen on T2-w imaging. The model provides detailed insights into stroke lesion dynamic evolution in space and time that will help identify factors that determine final outcome and identify targets for interventions to improve outcome. Development of longitudinal metamorphosis that goes exactly through the observations Tracking the 4D evolution of stroke lesions in both shape and intensity Estimation of signed residual maps and exploring their relation to final T2-w lesion
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Abstract
BACKGROUND Most strokes are due to blockage of an artery in the brain by a blood clot. Prompt treatment with thrombolytic drugs can restore blood flow before major brain damage has occurred and improve recovery after stroke in some people. Thrombolytic drugs, however, can also cause serious bleeding in the brain, which can be fatal. One drug, recombinant tissue plasminogen activator (rt-PA), is licensed for use in selected patients within 4.5 hours of stroke in Europe and within three hours in the USA. There is an upper age limit of 80 years in some countries, and a limitation to mainly non-severe stroke in others. Forty per cent more data are available since this review was last updated in 2009. OBJECTIVES To determine whether, and in what circumstances, thrombolytic therapy might be an effective and safe treatment for acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched November 2013), MEDLINE (1966 to November 2013) and EMBASE (1980 to November 2013). We also handsearched conference proceedings and journals, searched reference lists and contacted pharmaceutical companies and trialists. SELECTION CRITERIA Randomised trials of any thrombolytic agent compared with control in people with definite ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors applied the inclusion criteria, extracted data and assessed trial quality. We verified the extracted data with investigators of all major trials, obtaining additional unpublished data if available. MAIN RESULTS We included 27 trials, involving 10,187 participants, testing urokinase, streptokinase, rt-PA, recombinant pro-urokinase or desmoteplase. Four trials used intra-arterial administration, while the rest used the intravenous route. Most data come from trials that started treatment up to six hours after stroke. About 44% of the trials (about 70% of the participants) were testing intravenous rt-PA. In earlier studies very few of the participants (0.5%) were aged over 80 years; in this update, 16% of participants are over 80 years of age due to the inclusion of IST-3 (53% of participants in this trial were aged over 80 years). Trials published more recently utilised computerised randomisation, so there are less likely to be baseline imbalances than in previous versions of the review. More than 50% of trials fulfilled criteria for high-grade concealment; there were few losses to follow-up for the main outcomes.Thrombolytic therapy, mostly administered up to six hours after ischaemic stroke, significantly reduced the proportion of participants who were dead or dependent (modified Rankin 3 to 6) at three to six months after stroke (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.78 to 0.93). Thrombolytic therapy increased the risk of symptomatic intracranial haemorrhage (OR 3.75, 95% CI 3.11 to 4.51), early death (OR 1.69, 95% CI 1.44 to 1.98; 13 trials, 7458 participants) and death by three to six months after stroke (OR 1.18, 95% CI 1.06 to 1.30). Early death after thrombolysis was mostly attributable to intracranial haemorrhage. Treatment within three hours of stroke was more effective in reducing death or dependency (OR 0.66, 95% CI 0.56 to 0.79) without any increase in death (OR 0.99, 95% CI 0.82 to 1.21; 11 trials, 2187 participants). There was heterogeneity between the trials. Contemporaneous antithrombotic drugs increased the risk of death. Trials testing rt-PA showed a significant reduction in death or dependency with treatment up to six hours (OR 0.84, 95% CI 0.77 to 0.93, P = 0.0006; 8 trials, 6729 participants) with significant heterogeneity; treatment within three hours was more beneficial (OR 0.65, 95% CI 0.54 to 0.80, P < 0.0001; 6 trials, 1779 participants) without heterogeneity. Participants aged over 80 years benefited equally to those aged under 80 years, particularly if treated within three hours of stroke. AUTHORS' CONCLUSIONS Thrombolytic therapy given up to six hours after stroke reduces the proportion of dead or dependent people. Those treated within the first three hours derive substantially more benefit than with later treatment. This overall benefit was apparent despite an increase in symptomatic intracranial haemorrhage, deaths at seven to 10 days, and deaths at final follow-up (except for trials testing rt-PA, which had no effect on death at final follow-up). Further trials are needed to identify the latest time window, whether people with mild stroke benefit from thrombolysis, to find ways of reducing symptomatic intracranial haemorrhage and deaths, and to identify the environment in which thrombolysis may best be given in routine practice.
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Affiliation(s)
- Joanna M Wardlaw
- University of EdinburghCentre for Clinical Brain SciencesThe Chancellor's Building49 Little France CrescentEdinburghUKEH16 4SB
| | - Veronica Murray
- Danderyd HospitalDepartment of Clinical Sciences, Karolinska InstitutetStockholmSwedenSE‐182 88
| | - Eivind Berge
- Oslo University HospitalDepartment of Internal MedicineOsloNorwayNO‐0407
| | - Gregory J del Zoppo
- University of WashingtonDepartment of Medicine (Division of Hematology), Department of Neurology325 Ninth AvenueBox 359756SeattleWashingtonUSA98104
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Fiebach JB, Galinovic I. MR Imaging for Acute Stroke. CURRENT RADIOLOGY REPORTS 2014. [DOI: 10.1007/s40134-014-0053-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Spatial distribution of perfusion abnormality in acute MCA occlusion is associated with likelihood of later recanalization. J Cereb Blood Flow Metab 2014; 34:813-9. [PMID: 24473482 PMCID: PMC4013754 DOI: 10.1038/jcbfm.2014.13] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 11/29/2013] [Accepted: 12/23/2013] [Indexed: 11/08/2022]
Abstract
The aim of this study is to investigate whether different spatial perfusion-deficit patterns, which indicate differing compensatory mechanisms, can be recognized and used to predict recanalization success of intravenous fibrinolytic therapy in acute stroke patients. Twenty-seven acute stroke data sets acquired within 6 hours from symptom onset including diffusion- (DWI) and perfusion-weighted magnetic resonance (MR) imaging (PWI) were analyzed and dichotomized regarding recanalization outcome using time-of-flight follow-up data sets. The DWI data sets were used for calculation of apparent diffusion coefficient (ADC) maps and subsequent infarct core segmentation. A patient-individual three-dimensional (3D) shell model was generated based on the segmentation and used for spatial analysis of the ADC as well as cerebral blood volume (CBV), cerebral blood flow, time to peak (TTP), and mean transit time (MTT) parameters derived from PWI. Skewness, kurtosis, area under the curve, and slope were calculated for each parameter curve and used for classification (recanalized/nonrecanalized) using a LogitBoost Alternating Decision Tree (LAD Tree). The LAD tree optimization revealed that only ADC skewness, CBV kurtosis, and MTT kurtosis are required for best possible prediction of recanalization success with a precision of 85%. Our results suggest that the propensity for macrovascular recanalization after intravenous fibrinolytic therapy depends not only on clot properties but also on distal microvascular bed perfusion. The 3D approach for characterization of perfusion parameters seems promising for further research.
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Patel R, Ispoglou S, Apostolakis S. Desmoteplase as a potential treatment for cerebral ischaemia. Expert Opin Investig Drugs 2014; 23:865-73. [DOI: 10.1517/13543784.2014.911285] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ma H, Wright P, Allport L, Phan TG, Churilov L, Ly J, Zavala JA, Arakawa S, Campbell B, Davis SM, Donnan GA. Salvage of the PWI/DWI mismatch up to 48 h from stroke onset leads to favorable clinical outcome. Int J Stroke 2014; 10:565-70. [PMID: 24612428 DOI: 10.1111/ijs.12203] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 08/20/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE In acute ischemic stroke perfusion/diffusion-weighted image, mismatch using magnetic resonance imaging approximates the ischemic penumbra. For early time windows, mismatch salvage improves clinical outcomes, but uncertainty exists at later time epochs. We hypothesized that (a) mismatch may exist up to 48 h; (b) the proportion of mismatch salvage is time independent; and (c) when salvaged, it improves clinical outcomes. METHODS Magnetic resonance imaging was performed within 48 h of ischemic stroke. Perfusion-weighted image was defined by relative Tmax two-second delay. Perfusion/diffusion-weighted image mismatch was the perfusion-weighted image not overlapped by the diffusion-weighted image when coregistered. Infarct volume and disability (modified Rankin Score) were assessed at three-months. Mismatch salvage was the region not overlapped by final infarction. Favorable outcome was defined as modified Rankin Score 0-1. RESULTS Sixty-six patients were studied [mean age 69.9 years (standard deviation 13.1), initial median National Institute of Health Stroke Scale 9.0 (interquartile range 6.0, 18.3)]. There was no relationship between time of stroke onset and the proportion of mismatch salvaged (P = 0.73). Age (adjusted odds ratio = 0.92, 95% confidence interval 0.86-0.98, P = 0.01), initial National Institute of Health Stroke Scale (adjusted odds ratio = 0.80, 95% confidence interval 0.70-0.92, P < 0.01), mismatch volume (adjusted odds ratio = 0.98, 95% confidence interval 0.968-0.1, P = 0.05), and percentage of mismatch salvage (adjusted odds ratio = 1.04, 95% confidence interval 0.99-1.07, P = 0.05) were independently associated with favorable outcome. CONCLUSION Using coregistered perfusion/diffusion-weighted image criteria, mismatch persists up to 48 h post stroke. For the whole group, the proportion of mismatch salvage remains independent of time and, although the effect is small, its salvage is independently associated with improved clinical outcomes at three-months. Larger sample sizes are needed to determine the time limit for mismatch salvage.
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Affiliation(s)
- H Ma
- National Stroke Research Institute, Florey Neuroscience Institutes, University of Melbourne, Melbourne, Vic, Australia.,Department of Medicine, Monash Medical Centre, Monash University, Melbourne, Vic, Australia
| | - P Wright
- National Stroke Research Institute, Florey Neuroscience Institutes, University of Melbourne, Melbourne, Vic, Australia
| | - L Allport
- Department of Medicine, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - T G Phan
- Department of Medicine, Monash Medical Centre, Monash University, Melbourne, Vic, Australia
| | - L Churilov
- National Stroke Research Institute, Florey Neuroscience Institutes, University of Melbourne, Melbourne, Vic, Australia
| | - J Ly
- Department of Medicine, Monash Medical Centre, Monash University, Melbourne, Vic, Australia
| | - J A Zavala
- National Stroke Research Institute, Florey Neuroscience Institutes, University of Melbourne, Melbourne, Vic, Australia
| | - S Arakawa
- National Stroke Research Institute, Florey Neuroscience Institutes, University of Melbourne, Melbourne, Vic, Australia
| | - B Campbell
- Department of Medicine, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - S M Davis
- Department of Medicine, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - G A Donnan
- National Stroke Research Institute, Florey Neuroscience Institutes, University of Melbourne, Melbourne, Vic, Australia
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Ford AL, An H, Kong L, Zhu H, Vo KD, Powers WJ, Lin W, Lee JM. Clinically relevant reperfusion in acute ischemic stroke: MTT performs better than Tmax and TTP. Transl Stroke Res 2014; 5:415-421. [PMID: 24500786 DOI: 10.1007/s12975-014-0325-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 12/11/2013] [Accepted: 01/05/2014] [Indexed: 10/25/2022]
Abstract
While several MRI parameters are used to assess tissue perfusion during hyperacute stroke, it is unclear which is optimal for measuring clinically relevant reperfusion. We directly compared mean transit time (MTT) prolongation (MTTp), time-to-peak (TTP), and time-to-maximum (Tmax) to determine which best predicted neurological improvement and tissue salvage following early reperfusion. Acute ischemic stroke patients underwent three MRIs: <4.5 h (tp1), at 6 h (tp2), and at 1 month after onset. Perfusion deficits at tp1 and tp2 were defined by MTTp, TTP, or Tmax beyond four commonly used thresholds. Percent reperfusion (%Reperf) was calculated for each parameter and threshold. Regression analysis was used to fit %Reperf for each parameter and threshold as a predictor of neurological improvement [defined as admission National Institutes of Health Stroke Scale (NIHSS)-1 month NIHSS (∆NIHSS)] after adjusting for baseline clinical variables. Volume of reperfusion, for each parameter and threshold, was correlated with tissue salvage, defined as tp1 perfusion deficit volume-final infarct volume. Fifty patients were scanned at 2.7 and 6.2 h after stroke onset. %Reperf predicted ∆NIHSS for all MTTp thresholds, for Tmax >6 s and >8 s, but for no TTP thresholds. Tissue salvage significantly correlated with reperfusion for all MTTp thresholds and with Tmax >6 s, while there was no correlation with any TTP threshold. Among all parameters, reperfusion defined by MTTp was most strongly associated with ∆NIHSS (MTTp >3 s, P = 0.0002) and tissue salvage (MTTp >3 s and 4 s, P < 0.0001). MTT-defined reperfusion was the best predictor of neurological improvement and tissue salvage in hyperacute ischemic stroke.
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Affiliation(s)
- Andria L Ford
- Department of Neurology, Washington University School of Medicine
| | - Hongyu An
- Department of Radiology, University of North Carolina at Chapel Hill
| | - Linglong Kong
- Department of Mathematical and Statistical Sciences, University of Alberta
| | - Hongtu Zhu
- Department of Biostatistics, University of North Carolina at Chapel Hill
| | - Katie D Vo
- Department of Radiology, Washington University School of Medicine
| | - William J Powers
- Department of Neurology, University of North Carolina at Chapel Hill
| | - Weili Lin
- Department of Radiology, University of North Carolina at Chapel Hill
| | - Jin-Moo Lee
- Department of Neurology, Washington University School of Medicine.,Department of Radiology, Washington University School of Medicine
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Nael K, Meshksar A, Ellingson B, Pirastehfar M, Salamon N, Finn P, Liebeskind DS, Villablanca JP. Combined low-dose contrast-enhanced MR angiography and perfusion for acute ischemic stroke at 3T: A more efficient stroke protocol. AJNR Am J Neuroradiol 2014; 35:1078-84. [PMID: 24503557 DOI: 10.3174/ajnr.a3848] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE There is need to improve image acquisition speed for MR imaging in evaluation of patients with acute ischemic stroke. The purpose of this study was to evaluate the feasibility of a 3T MR stroke protocol that combines low-dose contrast-enhanced MRA and dynamic susceptibility contrast perfusion, without additional contrast. METHODS Thirty patients with acute stroke who underwent 3T MR imaging followed by DSA were retrospectively enrolled. TOF-MRA of the neck and brain and 3D contrast-enhanced MRA of the craniocervical arteries were obtained. A total of 0.1 mmol/kg of gadolinium was used for both contrast-enhanced MRA (0.05 mmol/kg) and dynamic susceptibility contrast perfusion (0.05 mmol/kg) (referred to as half-dose). An age-matched control stroke population underwent TOF-MRA and full-dose (0.1 mmol/kg) dynamic susceptibility contrast perfusion. The cervicocranial arteries were divided into 25 segments. Degree of arterial stenosis on contrast-enhanced MRA and TOF-MRA was compared with DSA. Time-to-maximum maps (>6 seconds) were evaluated for image quality and hypoperfusion. Quantitative analysis of arterial input function curves, SNR, and maximum T2* effects were compared between half- and full-dose groups. RESULTS The intermodality agreements (k) for arterial stenosis were 0.89 for DSA/contrast-enhanced MRA and 0.63 for DSA/TOF-MRA. Detection specificity of >50% arterial stenosis was lower for TOF-MRA (89%) versus contrast-enhanced MRA (97%) as the result of overestimation of 10% (39/410) of segments by TOF-MRA. The DWI-perfusion mismatch was identified in both groups with high interobserver agreement (r = 1). There was no significant difference between full width at half maximum of the arterial input function curves (P = .14) or the SNR values (0.6) between the half-dose and full-dose groups. CONCLUSIONS In patients with acute stroke, combined low-dose contrast-enhanced MRA and dynamic susceptibility contrast perfusion at 3T is feasible and results in significant scan time and contrast dose reductions.
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Affiliation(s)
- K Nael
- From the Department of Medical Imaging (K.N., A.M.), University of Arizona, Tucson, Arizona
| | - A Meshksar
- From the Department of Medical Imaging (K.N., A.M.), University of Arizona, Tucson, Arizona
| | - B Ellingson
- Department of Radiological Sciences (B.E., M.P., N.S., P.F., J.P.V.)
| | - M Pirastehfar
- Department of Radiological Sciences (B.E., M.P., N.S., P.F., J.P.V.)
| | - N Salamon
- Department of Radiological Sciences (B.E., M.P., N.S., P.F., J.P.V.)
| | - P Finn
- Department of Radiological Sciences (B.E., M.P., N.S., P.F., J.P.V.)
| | - D S Liebeskind
- Department of Neurology, Stroke Center (D.S.L.), University of California, Los Angeles, Los Angeles, California
| | - J P Villablanca
- Department of Radiological Sciences (B.E., M.P., N.S., P.F., J.P.V.)
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Abstract
It has been proposed that the spatial mismatch between deficits on perfusion-weighted imaging (PWI) and diffusion-weighted imaging (DWI) in MRI can be used to decide regarding thrombolytic treatment in acute stroke. However, uncertainty remains about the meaning and reversibility of the perfusion deficit and even part of the diffusion deficit. Thus, there remains a need for continued development of imaging technology that can better define a potentially salvageable ischemic area at risk of infarction. Amide proton transfer (APT) imaging is a novel MRI method that can map tissue pH changes, thus providing the potential to separate the PWI/DWI mismatch into an acidosis-based penumbra and a zone of benign oligemia. In this totally noninvasive method, the pH dependence of the chemical exchange between amide protons in endogenous proteins and peptides and water protons is exploited. Early results in animal models of ischemia show promise to derive an acidosis penumbra. Possible translation to the clinic and hurdles standing in the way of achieving this are discussed.
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Broussalis E, Trinka E, Wallner A, Hitzl W, Killer M. Thrombectomy in patients with large cerebral artery occlusion: a single-center experience with a new stent retriever. Vasc Endovascular Surg 2013; 48:144-52. [PMID: 24249122 DOI: 10.1177/1538574413512378] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The Trevo device, a new stent retriever, may be utilized in patients with large cerebral artery occlusion. METHODS Fifty patients with large cerebral artery occlusion and treated with the Trevo device were analyzed. Patients may have received intravenous thrombolysis as a bridging concept in addition to thrombectomy. Outcome and recanalization parameters were documented using the National Institutes of Health Scale, the modified Ranking Scale (mRS) and Thrombolysis in Cerebral Infarction (TICI) score. RESULTS In all, 82% (95% confidence interval [CI]: 69%-91%) were documented with TICI 2b and 3. Good clinical outcome after 90 days (mRS ≤ 2) was assessed in 61% (95% CI: 46%-75%). Symptomatic intracerebral hemorrhage occurred in 6 patients (12%, 95% CI: 1%-17%). The overall mortality rate was 14% (95% CI: 6%-27%). CONCLUSION Thrombectomy with the new stent retriever device is feasible and effective and has an acceptable risk of intra-cerebral hemorrhage even in combination with pharmacological revascularization techniques.
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Affiliation(s)
- Erasmia Broussalis
- 1Department of Neuroradiology, Paracelsus Medical University, Christian Doppler Clinic, Research Institute for Neurointervention, Salzburg, Austria
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50
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Deuchar GA, Brennan D, Griffiths H, Macrae I M, Santosh C. Perfluorocarbons enhance a T2*-based MRI technique for identifying the penumbra in a rat model of acute ischemic stroke. J Cereb Blood Flow Metab 2013; 33:1422-8. [PMID: 23801243 PMCID: PMC3764387 DOI: 10.1038/jcbfm.2013.86] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 04/22/2013] [Accepted: 05/01/2013] [Indexed: 02/05/2023]
Abstract
Accurate imaging of ischemic penumbra is crucial for improving the management of acute stroke patients. T2* magnetic resonance imaging (MRI) combined with a T2*oxygen challenge (T2*OC) is being developed to detect penumbra based on changes in blood deoxyhemoglobin. Using 100% O2, T2*OC-defined penumbra exhibits ongoing glucose metabolism and tissue recovery on reperfusion. However, potential limitations in translating this technique include a sinus artefact in human scans with delivery of 100% OC and relatively small signal changes. Here we investigate whether an oxygen-carrying perfluorocarbon (PFC) emulsion can enhance the sensitivity of the technique, enabling penumbra detection with lower levels of inspired oxygen. Stroke was induced in male Sprague-Dawley rats (n=17) with ischemic injury and perfusion deficit determined by diffusion and perfusion MRI, respectively. T2* signal change was measured in regions of interest (ROIs) located within ischemic core, T2*OC-defined penumbra and equivalent contralateral areas during 40% O2±prior PFC injection. Region of interest analyses between groups showed that PFC significantly enhanced the T2* response to 40% O2 in T2*-defined penumbra (mean increase of 10.6±2.3% compared to 5.6±1.5% with 40% O2, P<0.001). This enhancement was specific to the penumbra ROI. Perfluorocarbon emulsions therefore enhances the translational potential of the T2*OC technique for identifying penumbra in acute stroke patients.
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Affiliation(s)
- Graeme A Deuchar
- Wellcome Surgical Institute, Glasgow Experimental MRI Centre, Institute of Neuroscience and Psychology, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - David Brennan
- Department of Neuroradiology, Institute of Neurological Sciences, Southern General Hospital, Glasgow, UK
| | - Hugh Griffiths
- Department of Neuroradiology, Institute of Neurological Sciences, Southern General Hospital, Glasgow, UK
| | - I Mhairi Macrae
- Wellcome Surgical Institute, Glasgow Experimental MRI Centre, Institute of Neuroscience and Psychology, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Celestine Santosh
- Department of Neuroradiology, Institute of Neurological Sciences, Southern General Hospital, Glasgow, UK
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