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Lakhani DA, Balar AB, Salim H, Koneru M, Wen S, Ozkara B, Lu H, Wang R, Hoseinyazdi M, Xu R, Nabi M, Mazumdar I, Cho A, Chen K, Sepehri S, Hyson N, Urrutia V, Luna L, Hillis AE, Heit JJ, Albers GW, Rai AT, Dmytriw AA, Faizy TD, Wintermark M, Nael K, Yedavalli VS. CT Perfusion Derived rCBV < 42% Lesion Volume Is Independently Associated with Followup FLAIR Infarct Volume in Anterior Circulation Large Vessel Occlusion. Diagnostics (Basel) 2024; 14:845. [PMID: 38667490 PMCID: PMC11049259 DOI: 10.3390/diagnostics14080845] [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: 04/03/2024] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
Pretreatment CT Perfusion (CTP) parameter rCBV < 42% lesion volume has recently been shown to predict 90-day mRS. In this study, we aim to assess the relationship between rCBV < 42% and a radiographic follow-up infarct volume delineated on FLAIR images. In this retrospective evaluation of our prospectively collected database, we included acute stroke patients triaged by multimodal CT imaging, including CT angiography and perfusion imaging, with confirmed anterior circulation large vessel occlusion between 9 January 2017 and 10 January 2023. Follow-up FLAIR imaging was used to determine the final infarct volume. Student t, Mann-Whitney-U, and Chi-Square tests were used to assess differences. Spearman's rank correlation and linear regression analysis were used to assess associations between rCBV < 42% and follow-up infarct volume on FLAIR. In total, 158 patients (median age: 68 years, 52.5% female) met our inclusion criteria. rCBV < 42% (ρ = 0.56, p < 0.001) significantly correlated with follow-up-FLAIR infarct volume. On multivariable linear regression analysis, rCBV < 42% lesion volume (beta = 0.60, p < 0.001), ASPECTS (beta = -0.214, p < 0.01), mTICI (beta = -0.277, p < 0.001), and diabetes (beta = 0.16, p < 0.05) were independently associated with follow-up infarct volume. The rCBV < 42% lesion volume is independently associated with FLAIR follow-up infarct volume.
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Affiliation(s)
- Dhairya A. Lakhani
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Aneri B. Balar
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Hamza Salim
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Manisha Koneru
- Cooper Medical School, Rowan University, Camden, NJ 08103, USA
| | - Sijin Wen
- Department of Biostatistics, West Virginia University, Morgantown, WV 26506, USA;
| | - Burak Ozkara
- Department of Neurology, Johns Hopkins University, Baltimore, MD 21218, USA (A.E.H.)
| | - Hanzhang Lu
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Richard Wang
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Meisam Hoseinyazdi
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Risheng Xu
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Mehreen Nabi
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Ishan Mazumdar
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Andrew Cho
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Kevin Chen
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Sadra Sepehri
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Nathan Hyson
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Victor Urrutia
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Licia Luna
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Argye E. Hillis
- Department of Neurology, Johns Hopkins University, Baltimore, MD 21218, USA (A.E.H.)
| | - Jeremy J. Heit
- Department of Neurology, Stanford University, Stanford, CA 94305, USA; (J.J.H.); (G.W.A.)
| | - Greg W. Albers
- Department of Neurology, Stanford University, Stanford, CA 94305, USA; (J.J.H.); (G.W.A.)
| | - Ansaar T. Rai
- Department of Neuroradiology, West Virginia University, Morgantown, WV 26506, USA;
| | - Adam A. Dmytriw
- Department of Radiology, Harvard Medical School, Boston, MA 02115, USA;
| | - Tobias D. Faizy
- Department of Radiology, Neuroendovascular Division, University Medical Center Münster, 48149 Münster, Germany;
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson Medical Center, Houston, TX 77030, USA;
| | - Kambiz Nael
- Division of Neuroradiology, Department of Radiology, University of California San Francisco (UCSF), San Francisco, CA 94143, USA;
| | - Vivek S. Yedavalli
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
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Dammavalam V, Lin S, Nessa S, Daksla N, Stefanowski K, Costa A, Bergese S. Neuroprotection during Thrombectomy for Acute Ischemic Stroke: A Review of Future Therapies. Int J Mol Sci 2024; 25:891. [PMID: 38255965 PMCID: PMC10815099 DOI: 10.3390/ijms25020891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Stroke is a major cause of death and disability worldwide. Endovascular thrombectomy has been impactful in decreasing mortality. However, many clinical results continue to show suboptimal functional outcomes despite high recanalization rates. This gap in recanalization and symptomatic improvement suggests a need for adjunctive therapies in post-thrombectomy care. With greater insight into ischemia-reperfusion injury, recent preclinical testing of neuroprotective agents has shifted towards preventing oxidative stress through upregulation of antioxidants and downstream effectors, with positive results. Advances in multiple neuroprotective therapies, including uric acid, activated protein C, nerinetide, otaplimastat, imatinib, verapamil, butylphthalide, edaravone, nelonemdaz, ApTOLL, regional hypothermia, remote ischemic conditioning, normobaric oxygen, and especially nuclear factor erythroid 2-related factor 2, have promising evidence for improving stroke care. Sedation and blood pressure management in endovascular thrombectomy also play crucial roles in improved stroke outcomes. A hand-in-hand approach with both endovascular therapy and neuroprotection may be the key to targeting disability due to stroke.
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Affiliation(s)
- Vikalpa Dammavalam
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (V.D.); (K.S.)
| | - Sandra Lin
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
| | - Sayedatun Nessa
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (V.D.); (K.S.)
| | - Neil Daksla
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
| | - Kamil Stefanowski
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (V.D.); (K.S.)
| | - Ana Costa
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
| | - Sergio Bergese
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
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Fainardi E, Busto G, Morotti A. Automated advanced imaging in acute ischemic stroke. Certainties and uncertainties. Eur J Radiol Open 2023; 11:100524. [PMID: 37771657 PMCID: PMC10523426 DOI: 10.1016/j.ejro.2023.100524] [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: 05/30/2023] [Revised: 09/12/2023] [Accepted: 09/13/2023] [Indexed: 09/30/2023] Open
Abstract
The purpose of this is study was to review pearls and pitfalls of advanced imaging, such as computed tomography perfusion and diffusion-weighed imaging and perfusion-weighted imaging in the selection of acute ischemic stroke (AIS) patients suitable for endovascular treatment (EVT) in the late time window (6-24 h from symptom onset). Advanced imaging can quantify infarct core and ischemic penumbra using specific threshold values and provides optimal selection parameters, collectively called target mismatch. More precisely, target mismatch criteria consist of core volume and/or penumbra volume and mismatch ratio (the ratio between total hypoperfusion and core volumes) with precise cut-off values. The parameters of target mismatch are automatically calculated with dedicated software packages that allow a quick and standardized interpretation of advanced imaging. However, this approach has several limitations leading to a misclassification of core and penumbra volumes. In fact, automatic software platforms are affected by technical artifacts and are not interchangeable due to a remarkable vendor-dependent variability, resulting in different estimate of target mismatch parameters. In addition, advanced imaging is not completely accurate in detecting infarct core, that can be under- or overestimated. Finally, the selection of candidates for EVT remains currently suboptimal due to the high rates of futile reperfusion and overselection caused by the use of very stringent inclusion criteria. For these reasons, some investigators recently proposed to replace advanced with conventional imaging in the selection for EVT, after the demonstration that non-contrast CT ASPECTS and computed tomography angiography collateral evaluation are not inferior to advanced images in predicting outcome in AIS patients treated with EVT. However, other authors confirmed that CTP and PWI/DWI postprocessed images are superior to conventional imaging in establishing the eligibility of patients for EVT. Therefore, the routine application of automatic assessment of advanced imaging remains a matter of debate. Recent findings suggest that the combination of conventional and advanced imaging might improving our selection criteria.
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Affiliation(s)
- Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Italy
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Giorgio Busto
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Andrea Morotti
- Department of Neurological and Vision Sciences, Neurology Unit, ASST Spedali Civili, Brescia, Italy
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de Vries L, van Herten RLM, Hoving JW, Išgum I, Emmer BJ, Majoie CBLM, Marquering HA, Gavves E. Spatio-temporal physics-informed learning: A novel approach to CT perfusion analysis in acute ischemic stroke. Med Image Anal 2023; 90:102971. [PMID: 37778103 DOI: 10.1016/j.media.2023.102971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 07/20/2023] [Accepted: 09/11/2023] [Indexed: 10/03/2023]
Abstract
CT perfusion imaging is important in the imaging workup of acute ischemic stroke for evaluating affected cerebral tissue. CT perfusion analysis software produces cerebral perfusion maps from commonly noisy spatio-temporal CT perfusion data. High levels of noise can influence the results of CT perfusion analysis, necessitating software tuning. This work proposes a novel approach for CT perfusion analysis that uses physics-informed learning, an optimization framework that is robust to noise. In particular, we propose SPPINN: Spatio-temporal Perfusion Physics-Informed Neural Network and research spatio-temporal physics-informed learning. SPPINN learns implicit neural representations of contrast attenuation in CT perfusion scans using the spatio-temporal coordinates of the data and employs these representations to estimate a continuous representation of the cerebral perfusion parameters. We validate the approach on simulated data to quantify perfusion parameter estimation performance. Furthermore, we apply the method to in-house patient data and the public Ischemic Stroke Lesion Segmentation 2018 benchmark data to assess the correspondence between the perfusion maps and reference standard infarct core segmentations. Our method achieves accurate perfusion parameter estimates even with high noise levels and differentiates healthy tissue from infarcted tissue. Moreover, SPPINN perfusion maps accurately correspond with reference standard infarct core segmentations. Hence, we show that using spatio-temporal physics-informed learning for cerebral perfusion estimation is accurate, even in noisy CT perfusion data. The code for this work is available at https://github.com/lucasdevries/SPPINN.
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Affiliation(s)
- Lucas de Vries
- Amsterdam UMC location University of Amsterdam, Biomedical Engineering and Physics, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands; Amsterdam UMC location University of Amsterdam, Radiology and Nuclear Medicine, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands; Informatics Institute, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands; Amsterdam Neuroscience, Amsterdam, The Netherlands.
| | - Rudolf L M van Herten
- Amsterdam UMC location University of Amsterdam, Biomedical Engineering and Physics, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands; Informatics Institute, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Jan W Hoving
- Amsterdam UMC location University of Amsterdam, Radiology and Nuclear Medicine, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands; Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Ivana Išgum
- Amsterdam UMC location University of Amsterdam, Biomedical Engineering and Physics, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands; Amsterdam UMC location University of Amsterdam, Radiology and Nuclear Medicine, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands; Informatics Institute, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands; Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Bart J Emmer
- Amsterdam UMC location University of Amsterdam, Radiology and Nuclear Medicine, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands; Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Amsterdam UMC location University of Amsterdam, Radiology and Nuclear Medicine, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands; Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Henk A Marquering
- Amsterdam UMC location University of Amsterdam, Biomedical Engineering and Physics, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands; Amsterdam UMC location University of Amsterdam, Radiology and Nuclear Medicine, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands; Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands; Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Efstratios Gavves
- Informatics Institute, University of Amsterdam, Amsterdam, The Netherlands
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Wu YF, Sun J, Chen M, Lin Q, Jin KY, Su SH, Hai J. Combined VEGF and bFGF loaded nanofiber membrane protects against neuronal injury and hypomyelination in a rat model of chronic cerebral hypoperfusion. Int Immunopharmacol 2023; 125:111108. [PMID: 37890380 DOI: 10.1016/j.intimp.2023.111108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 10/11/2023] [Accepted: 10/19/2023] [Indexed: 10/29/2023]
Abstract
Currently, there are no effective therapeutic targets for the treatment of chronic cerebral hypoperfusion(CCH)-induced cerebral ischemic injury. Vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) are discovered as the inducers of neurogenesis and angiogenesis. We previously made a nanofiber membrane (NFM), maintaining a long-term release of VEGF and bFGF up to 35 days, which might make VEGF and bFGF NFM as the potential protective agents against cerebral ischemic insult. In this study, the effects of VEGF and bFGF delivered by NFM into brain were investigated as well as their underlying mechanismsin a rat model of CCH. VEGF + bFGF NFM application increased the expressions of tight junction proteins, maintained BBB integrity, and alleviated vasogenic cerebral edema. Furthermore, VEGF + bFGF NFM sticking enhanced angiogenesis and elevated CBF. Besides, VEGF + bFGF NFM treatment inhibited neuronal apoptosis and decreased neuronal loss. Moreover, roofing of VEGF + bFGF NFM attenuated microglial activation and blocked the launch of NLRP3/caspase-1/IL-1β pathway. In addition, VEGF + bFGF NFM administration prevented disruption to the pre/postsynaptic membranes and loss of myelin sheath, relieving synaptic injury and demyelination. Oligodendrogenesis, neurogenesis and PI3K/AKT/mTOR pathway were involved in the treatment of VEGF + bFGF NFM against CCH-induced neuronal injury and hypomyelination. These findings supported that VEGF + bFGF NFM application constitutes a neuroprotective strategy for the treatment of CCH, which may be worth further clinical translational research as a novel neuroprotective approach, benifiting indirect surgical revascularization.
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Affiliation(s)
- Yi-Fang Wu
- Department of Neurosurgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai 200065, China
| | - Jun Sun
- Department of Neurosurgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai 200065, China
| | - Ming Chen
- Department of Neurosurgery, Xinhua hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200092, China
| | - Qi Lin
- Department of Pharmacy, Institutes of Medical Sciences, School of Medicine, Shanghai Jiao Tong University, Shanghai 200025, China
| | - Kai-Yan Jin
- Department of Neurosurgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai 200065, China
| | - Shao-Hua Su
- Department of Neurosurgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai 200065, China.
| | - Jian Hai
- Department of Neurosurgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai 200065, China.
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Thirugnanachandran T, Aitchison SG, Lim A, Ding C, Ma H, Phan T. Assessing the diagnostic accuracy of CT perfusion: a systematic review. Front Neurol 2023; 14:1255526. [PMID: 37885475 PMCID: PMC10598661 DOI: 10.3389/fneur.2023.1255526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 09/15/2023] [Indexed: 10/28/2023] Open
Abstract
Background and purpose Computed tomography perfusion (CTP) has successfully extended the time window for reperfusion therapies in ischemic stroke. However, the published perfusion parameters and thresholds vary between studies. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines, we conducted a systematic review to investigate the accuracy of parameters and thresholds for identifying core and penumbra in adult stroke patients. Methods We searched Medline, Embase, the Cochrane Library, and reference lists of manuscripts up to April 2022 using the following terms "computed tomography perfusion," "stroke," "infarct," and "penumbra." Studies were included if they reported perfusion thresholds and undertook co-registration of CTP to reference standards. The quality of studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool and Standards for Reporting of Diagnostic Accuracy (STARD) guidelines. Results A total of 24 studies were included. A meta-analysis could not be performed due to insufficient data and significant heterogeneity in the study design. When reported, the mean age was 70.2 years (SD+/-3.69), and the median NIHSS on admission was 15 (IQR 13-17). The perfusion parameter identified for the core was relative cerebral blood flow (rCBF), with a median threshold of <30% (IQR 30, 40%). However, later studies reported lower thresholds in the early time window with rapid reperfusion (median 25%, IQR 20, 30%). A total of 15 studies defined a single threshold for all brain regions irrespective of collaterals and the gray and white matter. Conclusion A single threshold and parameter may not always accurately differentiate penumbra from core and oligemia. Further refinement of parameters is needed in the current era of reperfusion therapy.
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Affiliation(s)
| | | | | | | | | | - Thanh Phan
- Stroke and Ageing Research (STAR), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
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Kan Y, Li S, Zhang B, Ding Y, Zhao W, Ji X. No-reflow phenomenon following stroke recanalization therapy: Clinical assessment advances: A narrative review. Brain Circ 2023; 9:214-221. [PMID: 38284109 PMCID: PMC10821681 DOI: 10.4103/bc.bc_37_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 07/13/2023] [Accepted: 07/19/2023] [Indexed: 01/30/2024] Open
Abstract
The no-reflow phenomenon (NRP) after successful vascular recanalization in acute ischemic stroke (AIS) has become a major cause of poor clinical prognosis and ineffective recanalization. However, there is currently no clear definition or unified clinical assessment method for the NRP. Therefore, it is urgent to clarify the clinical evaluation criteria for the NRP and develop new no-reflow evaluation techniques so that remedial treatment can be applied to AIS patients suffering from the NRP. In this brief review, a variety of NRP assessment methods and defining criteria for clinical practice are presented.
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Affiliation(s)
- Yuan Kan
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Sijie Li
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Bowei Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Wenbo Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Lyu J, Duan Q, Xiao S, Meng Z, Wu X, Chen W, Wang G, Niu Q, Li X, Bian Y, Han D, Guo W, Yang S, Bian X, Lan Y, Wang L, Zhang T, Duan C, Zhang D, Wang X, Chen L, Tian C, Zhou X, Lou X. Arterial Spin Labeling-Based MRI Estimation of Penumbral Tissue in Acute Ischemic Stroke. J Magn Reson Imaging 2023; 57:1241-1247. [PMID: 35849055 DOI: 10.1002/jmri.28364] [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: 04/10/2022] [Revised: 06/29/2022] [Accepted: 07/01/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Arterial spin labeling (ASL) has shown potential for the assessment of penumbral tissue in patients with acute ischemic stroke (AIS). The postlabeling delay (PLD) parameter is sensitive to arterial transit delays and influences cerebral blood flow measurements. PURPOSE To assess the impact of ASL acquisition at different PLDs for penumbral tissue quantification and to compare their performance regarding assisting patient selection for endovascular treatment with dynamic susceptibility contrast MRI (DSC-MRI) as the reference method. STUDY TYPE Retrospective. POPULATION A total of 53 patients (59.98 ± 12.60 years, 32% women) with AIS caused by internal carotid or middle cerebral artery occlusion. FIELD STRENGTH/SEQUENCE A 3-T, three-dimensional pseudo-continuous ASL with fast-spin echo readout. ASSESSMENT Hypoperfusion volume was measured using DSC-MRI and ASL with PLDs of 1.500 msec and 2.500 msec, respectively. Eligibility for endovascular treatment was retrospectively determined according to the imaging criteria of the Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke trial (DEFUSE 3). STATISTICAL TESTS Kruskal-Wallis tests, Bland-Altman plots, Cohen's kappa, and receiver operating characteristic analyses were used. The threshold for statistical significance was set at P ˂ 0.05. RESULTS Hypoperfusion volume for ASL with a PLD of 1.500 msec was significantly larger than that for DSC-MRI, while the hypoperfusion volume for a PLD of 2.500 msec was not significantly different from that of DSC-MRI (P = 0.435). Bland-Altman plots showed that the mean volumetric error between the hypoperfusion volume measured by DSC-MRI and ASL with PLDs of 1.500/2.500 msec was -107.0 mL vs. 4.49 mL. Cohen's kappa was 0.679 vs. 0.773 for DSC-MRI and ASL, respectively, with a PLD of 1.500/2.500 msec. The sensitivity and specificity for ASL with a PLD of 1.500/2.500 msec in identifying patients eligible for treatment were 89.74% vs. 97.44% and 92.86% vs. 64.29%, respectively. DATA CONCLUSION In AIS, PLDs for ASL acquisition may have a considerable impact on the quantification of the hypoperfusion volume. EVIDENCE LEVEL 3 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Jinhao Lyu
- Department of Radiology, Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
| | - Qi Duan
- Department of Radiology, Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
| | - Sa Xiao
- Key Laboratory of Magnetic Resonance in Biological Systems, State Key Laboratory of Magnetic Resonance and Atomic and Molecular Physics, National Center for Magnetic Resonance in Wuhan, Wuhan Institute of Physics and Mathematics, Innovation Academy for Precision Measurement Science and Technology, Chinese Academy of Sciences-Wuhan National Laboratory for Optoelectronics, Wuhan, China.,University of Chinese Academy of Sciences, Beijing, China
| | - Zhihua Meng
- Department of Radiology, Yuebei People's Hospital, Guangdong, China
| | - Xiaoyan Wu
- Department of Radiology, Anshan Changda Hospital, Liaoning, China
| | - Wen Chen
- Department of Radiology, Shiyan Taihe Hospital, Hubei, China
| | - Guohua Wang
- Department of Radiology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, China
| | - Qingliang Niu
- Department of Radiology, WeiFang Traditional Chinese Hospital, Shandong, China
| | - Xin Li
- Department of Radiology, The Second Hospital of Jilin University, Jilin, China
| | - Yitong Bian
- Department of Radiology, The First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Dan Han
- Department of Radiology, the First Affiliated Hospital of Kunming Medical University, Yunnan, China
| | - Weiting Guo
- Department of Radiology, Shanxi Provincial People's Hospital, Shanxi, China
| | - Shuai Yang
- Department of Radiology, Xiangya Hospital Central South University, Hunan, China
| | - Xiangbing Bian
- Department of Radiology, Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
| | - Yina Lan
- Department of Radiology, Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
| | - Liuxian Wang
- Department of Radiology, Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
| | - Tingyang Zhang
- Department of Radiology, Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
| | - Caohui Duan
- Department of Radiology, Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
| | - Dekang Zhang
- Department of Radiology, Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
| | - Xueyang Wang
- Department of Radiology, Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
| | - Ling Chen
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Chenglin Tian
- Department of Neurology, Chinese PLA General Hospital, Beijing, China
| | - Xin Zhou
- Key Laboratory of Magnetic Resonance in Biological Systems, State Key Laboratory of Magnetic Resonance and Atomic and Molecular Physics, National Center for Magnetic Resonance in Wuhan, Wuhan Institute of Physics and Mathematics, Innovation Academy for Precision Measurement Science and Technology, Chinese Academy of Sciences-Wuhan National Laboratory for Optoelectronics, Wuhan, China
| | - Xin Lou
- Department of Radiology, Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
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9
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Faropoulos K, Tsolaki V, Georgakopoulou VE, Trakas I, Tarantinos K, Papalexis P, Spandidos DA, Aravantinou-Fatorou A, Mathioudakis N, Trakas N, Lavdas E, Fotakopoulos G. Value of sildenafil treatment for the prevention of vasospasm‑related delayed ischemic neurological deficits and delayed brain infarction following aneurysmal subarachnoid hemorrhage. MEDICINE INTERNATIONAL 2023; 3:19. [PMID: 37032716 PMCID: PMC10080186 DOI: 10.3892/mi.2023.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 03/14/2023] [Indexed: 04/11/2023]
Abstract
Cerebral vasospasm (CV) or delayed cerebral ischemia (DCI) constitutes the main reason for the unfavorable outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH). The present retrospective cohort study, through an evaluation with computed tomography (CT) perfusion (CTP), aimed to examine the utility of an intravenous or oral administration of sildenafil in preventing DCI that develops due to vasospasm in these patients. A retrospective cohort study was conducted, which included 34 patients in a tertiary care hospital. Of these patients, 18 were males (52.9%), and the median age was 54.4 years. Of these patients, 18 (52.9%) had undergone surgery, and 16 (47.1%) had an endovascular procedure. CTP was performed on the 3rd to the 6th day. The clinical outcome was documented at 30 days using a CT scan and a complete neurological evaluation, including the Glasgow Coma Scale assessment. There was a statistically significant difference in the number of patients who developed an ischemic event at 1 month between those who did not receive sildenafil compared to those who received sildenafil (P<0.05). In addition, the multivariate analysis revealed that cerebral blood flow was an independent factor for detecting an ischemic event in 1 month (P=0.001). On the whole, the findings of the present study indicate that the intravenous or oral administration of sildenafil may be beneficial for the prevention of DCI.
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Affiliation(s)
| | - Vasiliki Tsolaki
- Department of Pulmonary and Critical Care Medicine, General University Hospital of Larissa, 41221 Larissa, Greece
| | - Vasiliki Epameinondas Georgakopoulou
- Department of Infectious Diseases-COVID19 Unit, Laiko General Hospital, 11527 Athens, Greece
- Correspondence to: Dr Vasiliki Epameinondas Georgakopoulou, Department of Infectious Diseases-COVID19 Unit, Laiko General Hospital, 17 Agiou Thoma Street, 11527 Athens, Greece
| | - Ilias Trakas
- Department of Infectious Diseases-COVID19 Unit, Laiko General Hospital, 11527 Athens, Greece
| | - Kyriakos Tarantinos
- First Department of Pulmonology, Sismanogleio Hospital, 15126 Athens, Greece
| | - Petros Papalexis
- Unit of Endocrinology, First Department of Internal Medicine, Laiko General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Department of Biomedical Sciences, University of West Attica, 12243 Athens, Greece
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Aikaterini Aravantinou-Fatorou
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | | | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Eleftherios Lavdas
- Department of Medical Radiological Technologists, Technological Education Institute of Athens, 12243 Athens, Greece
| | - George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
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10
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Zhao J, Chen F, Yang R, Li C, Lu L. Bilateral chorea due to hemodynamic ischemia associated with bilateral internal carotid artery stenosis: A case report. CNS Neurosci Ther 2022; 29:968-970. [PMID: 36575832 PMCID: PMC9928538 DOI: 10.1111/cns.14070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 12/08/2022] [Accepted: 12/11/2022] [Indexed: 12/29/2022] Open
Affiliation(s)
- Jiali Zhao
- Department of NeurologyShandong Provincial Hospital Affiliated to Shandong First Medical UniversityJinanShandongChina
| | - Fudi Chen
- Department of EmergencyShandong Provincial Hospital Affiliated to Shandong First Medical UniversityJinanShandongChina
| | - Ruirui Yang
- Department of NeurologyShandong Provincial Hospital Affiliated to Shandong First Medical UniversityJinanShandongChina
| | - Chunxia Li
- Department of NeurologyShandong Provincial Hospital Affiliated to Shandong First Medical UniversityJinanShandongChina
| | - Lin Lu
- Department of NeurologyShandong Provincial Hospital Affiliated to Shandong First Medical UniversityJinanShandongChina
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11
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Tsolaki V, Aravantinou-fatorou A, Georgakopoulou VE, Spandidos DA, Papalexis P, Mathioudakis N, Tarantinos K, Trakas N, Sklapani P, Fotakopoulos G. Early diagnosis of cerebral vasospasm associated with cerebral ischemia following subarachnoid hemorrhage: Evaluation of computed tomography perfusion and transcranial doppler as accurate methods. MEDICINE INTERNATIONAL 2022; 2:34. [PMID: 36699155 PMCID: PMC9829237 DOI: 10.3892/mi.2022.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/01/2022] [Indexed: 01/27/2023]
Abstract
Cerebral vasospasm (CV) constitutes a major post-operative complication and source of morbidity in cases of subarachnoid hemorrhage (SAH). The early detection of CV in SAH may be difficult both clinically and radiographically. The present pilot study thus aimed to evaluate the practicability of the technique in a tertiary healthcare setting and to assess the diagnostic effectiveness of various diagnostic computed tomography (CT) perfusion (CTP) aspects in predicting the clinical outcome of patients with SAH (traumatic and aneurysmal). A retrospective study including 34 patients in a tertiary care hospital was thus conducted. The results revealed that of the 34 patients, 18 (52.9%) were males, and the mean age was 54.4±18.5 years (16-85 years old; range, 69 years). In total, 15 (44.1%) patients had traumatic SAH following traumatic brain injury (TBI), 11 (33.3%) had aneurysmal SAH, and 8 patients (23.6%) presented with TBI without SAH as controls. CTP was performed on the third to the sixth day, and 15-20 min prior to CPT, a transcranial Doppler ultrasound was performed. Clinical outcomes were documented at 30 days using a CT scan and a complete neurological evaluation, including Glasgow Coma Scale assessment. The results of a multivariate analysis revealed that cerebral blood flow (CBF) was an independent factor for detecting an ischemic event in 1 month (P=0.003). On the whole, the present study demonstrates that CTP, and consequently CBF, is a considerable index that may identify the onset of cerebral ischemia in patients with SAH.
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Affiliation(s)
- Vasiliki Tsolaki
- Department of Pulmonary and Critical Care Medicine, General University Hospital of Larisa, 41221 Larisa, Greece
| | - Aikaterini Aravantinou-fatorou
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Vasiliki Epameinondas Georgakopoulou
- Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece,Correspondence to: Dr Vasiliki Epameinondas Georgakopoulou, Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma Street, 11527 Athens, Greece
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, Medical School, University of Crete, 71003 Heraklion, Greece
| | - Petros Papalexis
- Unit of Endocrinology, First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece,Department of Biomedical Sciences, University of West Attica, 12243 Athens, Greece
| | | | - Kyriakos Tarantinos
- First Department of Pulmonology, Sismanogleio Hospital, 15126 Athens, Greece
| | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Pagona Sklapani
- Department of Cytology, Mitera Hospital, 15123 Athens, Greece
| | - George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larisa, 41221 Larisa, Greece
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12
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Novel Survival Features Generated by Clinical Text Information and Radiomics Features May Improve the Prediction of Ischemic Stroke Outcome. Diagnostics (Basel) 2022; 12:diagnostics12071664. [PMID: 35885568 PMCID: PMC9324145 DOI: 10.3390/diagnostics12071664] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/17/2022] [Accepted: 07/05/2022] [Indexed: 12/18/2022] Open
Abstract
Background: Accurate outcome prediction is of great clinical significance in customizing personalized treatment plans, reducing the situation of poor recovery, and objectively and accurately evaluating the treatment effect. This study intended to evaluate the performance of clinical text information (CTI), radiomics features, and survival features (SurvF) for predicting functional outcomes of patients with ischemic stroke. Methods: SurvF was constructed based on CTI and mRS radiomics features (mRSRF) to improve the prediction of the functional outcome in 3 months (90-day mRS). Ten machine learning models predicted functional outcomes in three situations (2-category, 4-category, and 7-category) using seven feature groups constructed by CTI, mRSRF, and SurvF. Results: For 2-category, ALL (CTI + mRSRF+ SurvF) performed best, with an mAUC of 0.884, mAcc of 0.864, mPre of 0.877, mF1 of 0.86, and mRecall of 0.864. For 4-category, ALL also achieved the best mAuc of 0.787, while CTI + SurvF achieved the best score with mAcc = 0.611, mPre = 0.622, mF1 = 0.595, and mRe-call = 0.611. For 7-category, CTI + SurvF performed best, with an mAuc of 0.788, mPre of 0.519, mAcc of 0.529, mF1 of 0.495, and mRecall of 0.47. Conclusions: The above results indicate that mRSRF + CTI can accurately predict functional outcomes in ischemic stroke patients with proper machine learning models. Moreover, combining SurvF will improve the prediction effect compared with the original features. However, limited by the small sample size, further validation on larger and more varied datasets is necessary.
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13
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Yang H, Lin D, Lin X, Wu Y, Yi T, Chen W. Outcomes and CT Perfusion Thresholds of Mechanical Thrombectomy for Patients With Large Ischemic Core Lesions. Front Neurol 2022; 13:856403. [PMID: 35720105 DOI: 10.3389/fneur.2022.856403] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/02/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To explore the clinical prognosis and factors after mechanical thrombectomy (MT) in patients with large cerebral infarction assessed by computed tomographic perfusion (CTP)and the optimal threshold of cerebral blood flow (CBF) for estimating ischemic core. Methods We analyzed data from the anterior circulation database of our hospital (August 2018-June 2021). Multivariate logistic regression analyses identified the predictors of clinical outcomes for patients with large baseline infarcts (>50 ml) assessed by the MIStar software. The receiver operating characteristic (ROC) analysis was used to explore the cutoff value of factors. Results The present study included one hundred thirty-seven patients with large baseline infarcts. Moreover, 23 (16.8%) patients achieved functionally independent outcomes, and 50 (36.5%) patients died at 90 days. A total of 20 (14.7%) patients had symptomatic intracranial hemorrhage (sICH). The multivariable analysis showed that higher age and larger core volume were independent of poor outcomes. The cutoff value of core volume was 90 ml, and the age was 76 years. Hypertension and rt-PA treatment were independent factors of sICH. Higher age and larger ischemic volume were independent risk factors of mortality. Conclusions Mechanical thrombectomy can be applied in patients with large ischemic core volumes. Patients older than 76 years with large cores (>90 ml) are unlikely to benefit from MT. These findings may be helpful in selecting patients with large baseline infarcts to be treated by MT. The threshold of CBF < 30% is the independent factor, and this is worth evaluating in future studies to find the optimal threshold of CBF.
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Affiliation(s)
- Hongchao Yang
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Dinglai Lin
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Xiaohui Lin
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Yanmin Wu
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Tingyu Yi
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
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14
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Whole-Brain Permeability Analysis on Admission Improves Prediction of Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2022; 31:106312. [PMID: 35093628 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106312] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/03/2022] [Accepted: 01/06/2022] [Indexed: 12/22/2022] Open
Abstract
PURPOSE To evaluate the changes of blood-brain barrier permeability (BBBP) after aneurysmal subarachnoid hemorrhage (aSAH) and find out whether BBBP within 24 h after onset can further improve prediction of delayed cerebral ischemia (DCI). METHODS CT perfusion (CTP) was performed within 24 h after onset and in the DCI time window (DCITW). Whole brain average values of flow extraction product (mKtrans), qualitative and quantitative CTP parameters, and clinical data were compared between DCI and non-DCI groups. The changes of mKtrans were analysed using a Paired t test. Multivariate logistic regression analysis and ROC analyses were performed to identify predictors of DCI and evaluate the predictive performance. RESULTS One hundred and forty of 179 consecutive patients were included, 45 of whom (32%) developed DCI. mKtrans was higher in the DCI group both on admission and in the DCITW (P<0.001). mKtrans decreased significantly in the non-DCI group (P=0.003), but not in DCI group (P=0.285). Multivariate logistic regression analysis showed that mKtrans (OR=1.07, 95%CI: 1.03-1.11, P<0.001), World Federation of Neurosurgery Scale (OR=6.73, 95%CI: 1.09-41.41, P=0.040), Hunt-Hess grade (OR=0.16, 95%CI: 0.02-1.19, P=0.073), modified Fisher Score (OR=3.74, 95%CI: 1.30-10.75, P=0.014), and qualitative CTP (OR=4.31, 95%CI: 1.49-12.47, P=0.007) were independent predictors of DCI. The model with Ktrans produced a larger AUC of 0.88 (95%CI: 0.81-0.95), with corresponding sensitivity and specificity of 84% and 86%, respectively. CONCLUSION BBBP measurement within 24 h after onset can improve the prediction of DCI. Early moderate BBB disruption may be reversible, whereas severe BBBP disruption indicates the risk of DCI.
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15
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Fawaz AM, Wu S, Viswanathan D, Kaur K, Nuoman R, Nuoaman H, Adnan YA, Gandhi CD, Kurian C, Sahni R. Time to Wake-Up: Extending the Window for Management of Unknown-Onset Strokes. Cardiol Rev 2021; 29:26-32. [PMID: 32769626 DOI: 10.1097/crd.0000000000000336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The term "Wake-Up Stroke" is applied to a patient who displays no symptoms before sleep, but wakes with neurologic deficits suggestive of stroke. The current guidelines for acute ischemic stroke limit intravenous tissue plasminogen activator use to stroke patients in whom symptom onset or last known well is less than 4.5 hours. Approximately one-third of acute ischemic stroke patients present with unknown time of symptom onset and are often not eligible for intravenous reperfusion therapy in clinical practice. This review provides an overview of several earlier trials that used advanced neuroimaging to determine eligibility for reperfusion therapy in patients with unknown stroke onset. The reassuring results of these earlier trials that led to recent thrombolysis trials specifically targeted at "wake-up stroke" patients are discussed in this review. Ongoing studies aim to expand our knowledge regarding the safety and efficacy of thrombolysis in these patients.
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Affiliation(s)
- Al-Mufti Fawaz
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Sarah Wu
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Divya Viswanathan
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Kavneet Kaur
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Rolla Nuoman
- Department of Neurology, Maria Fareri Children's Hospital-Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Halla Nuoaman
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Yasir Ammar Adnan
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Chirag D Gandhi
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Christeena Kurian
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Ramandeep Sahni
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
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16
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Katyal A, Bhaskar SMM. Value of pre-intervention CT perfusion imaging in acute ischemic stroke prognosis. DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY (ANKARA, TURKEY) 2021; 27:774-785. [PMID: 34792033 DOI: 10.5152/dir.2021.20805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Noninvasive imaging plays an important role in acute stroke towards diagnosis and ongoing management of patients. Systemic thrombolysis and endovascular thrombectomy (EVT) are proven treatments currently used in standards of care in acute stroke settings. The role of computed tomography angiography (CTA) in selecting patients with large vessel occlusion for EVT is well established. However, the value of CT perfusion (CTP) imaging in predicting outcomes after stroke remains ambiguous. This article critically evaluates the value of multimodal CT imaging in early diagnosis and prognosis of acute ischemic stroke with a focus on the role of CTP in delineating tissue characteristics, patient selection, and outcomes after reperfusion therapy. Insights on various technical and clinical considerations relevant to CTP applications in acute ischemic stroke, recommendations for existing workflow, and future areas of research are discussed.
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Affiliation(s)
- Anubhav Katyal
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, Australia; University of New South Wales (UNSW), South Western Sydney Clinical School, NSW, Australia
| | - Sonu Menachem Maimonides Bhaskar
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, Australia; Department of Neurology - Neurophysiology, Liverpool Hospital - South West Sydney Local Health District (SWSLHD), Sydney, Australia;University of New South Wales (UNSW), South Western Sydney Clinical School, NSW, Australia; Ingham Institute for Applied Medical Research, Stroke - Neurology Research Group, Sydney, Australia; NSW Brain Clot Bank, NSW Health Statewide Biobank and NSW Health Pathology, Sydney, NSW, Australia;Thrombolysis and Endovascular WorkFLOw Network (TEFLON), Sydney, Australia
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17
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Grøan M, Ospel J, Ajmi S, Sandset EC, Kurz MW, Skjelland M, Advani R. Time-Based Decision Making for Reperfusion in Acute Ischemic Stroke. Front Neurol 2021; 12:728012. [PMID: 34790159 PMCID: PMC8591257 DOI: 10.3389/fneur.2021.728012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 09/16/2021] [Indexed: 11/13/2022] Open
Abstract
Decision making in the extended time windows for acute ischemic stroke can be a complex and time-consuming process. The process of making the clinical decision to treat has been compounded by the availability of different imaging modalities. In the setting of acute ischemic stroke, time is of the essence and chances of a good outcome diminish by each passing minute. Navigating the plethora of advanced imaging modalities means that treatment in some cases can be inefficaciously delayed. Time delays and individually based non-programmed decision making can prove challenging for clinicians. Visual aids can assist such decision making aimed at simplifying the use of advanced imaging. Flow charts are one such visual tool that can expedite treatment in this setting. A systematic review of existing literature around imaging modalities based on site of occlusion and time from onset can be used to aid decision making; a more program-based thought process. The use of an acute reperfusion flow chart helping navigate the myriad of imaging modalities can aid the effective treatment of patients.
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Affiliation(s)
- Mathias Grøan
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Johanna Ospel
- Department of Radiology, Basel University Hospital, Basel, Switzerland.,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Soffien Ajmi
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway.,University of Stavanger, Stavanger, Norway
| | - Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway.,Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Martin W Kurz
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway.,Neuroscience Research Group, Stavanger University Hospital, Stavanger, Norway
| | - Mona Skjelland
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Rajiv Advani
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway.,Neuroscience Research Group, Stavanger University Hospital, Stavanger, Norway
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Rodrigues GM, Mohammaden MH, Haussen DC, Bouslama M, Ravindran K, Pisani L, Prater A, Frankel MR, Nogueira RG. Ghost infarct core following endovascular reperfusion: A risk for computed tomography perfusion misguided selection in stroke. Int J Stroke 2021; 17:17474930211056228. [PMID: 34796765 DOI: 10.1177/17474930211056228] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Computed tomography perfusion (CTP) has been increasingly used for patient selection in mechanical thrombectomy for stroke. However, previous studies suggested that CTP might overestimate the infarct size. The term ghost infarct core (GIC) has been used to describe an overestimation of the final infarct volumes by pre-treatment CTP of >10 ml. AIM We sought to study the frequency and predictors of GIC. METHODS A prospectively collected mechanical thrombectomy database at a comprehensive stroke center between September 2010 and August 2020 was reviewed. Patients were included if they had a successful reperfusion (mTICI2b-3), a pre-procedure CTP, and final infarct volume measured on follow-up magnetic resonance imaging. Uni- and multivariable analyses were performed to identify predictors of GIC. RESULTS Among 923 eligible patients (median [IQR] age, 64 [55-75] years; NIHSS, 16 [11-21]; onset to reperfusion time, 436.5 [286-744.5] min), GIC was identified in 77 (8.3%) of the overall patients and in 14% (47/335) of those reperfused within 6 h of symptom onset. The median overestimation volume was 23.2 [16.4-38.3] mL. GIC was associated with higher NIHSS score, larger areas of infarct core and tissue at risk on CTP, unfavorable collateral scores, and shorter times from onset to image acquisition and to reperfusion as compared to non-GIC. Patients with GIC had smaller median final infarct volumes (10.7 vs. 27.1 ml, p < 0.001), higher chances of functional independence (76.2% vs. 55.5%, adjusted odds ratio (aOR) 3.829, 95% CI [1.505-9.737], p = 0.005), lower disability (one-point-mRS improvement, aOR 1.761, 95% CI [1.044-2.981], p = 0.03), and lower mortality (6.3% vs. 15%, aOR 0.119, 95% CI [0.014-0.984], p = 0.048) at 90 days. On multivariable analysis, time from onset to reperfusion ≤6 h (OR 3.184, 95% CI [1.743-5.815], p < 0.001), poor collaterals (OR 2.688, 95% CI [1.466-4.931], p = 0.001), and higher NIHSS score (OR 1.060, 95% CI [1.010-1.113], p = 0.018) were independent predictors of GIC. CONCLUSION GIC is a relatively common entity, particularly in patients with poor collateral status, higher baseline NIHSS score, and early presentation, and is associated with more favorable outcomes. Patients should not be excluded from reperfusion therapies on the sole basis of CTP findings, especially in the early window.
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Affiliation(s)
- Gabriel M Rodrigues
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Mahmoud H Mohammaden
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Diogo C Haussen
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Mehdi Bouslama
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Krishnan Ravindran
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Leonardo Pisani
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Adam Prater
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael R Frankel
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Raul G Nogueira
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
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Wang C, Shi Z, Yang M, Huang L, Fang W, Jiang L, Ding J, Wang H. Deep learning-based identification of acute ischemic core and deficit from non-contrast CT and CTA. J Cereb Blood Flow Metab 2021; 41:3028-3038. [PMID: 34102912 PMCID: PMC8756471 DOI: 10.1177/0271678x211023660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The accurate identification of irreversible infarction and salvageable tissue is important in planning the treatments for acute ischemic stroke (AIS) patients. Computed tomographic perfusion (CTP) can be used to evaluate the ischemic core and deficit, covering most of the territories of anterior circulation, but many community hospitals and primary stroke centers do not have the capability to perform CTP scan in emergency situation. This study aimed to identify AIS lesions from widely available non-contrast computed tomography (NCCT) and CT angiography (CTA) using deep learning. A total of 345AIS patients from our emergency department were included. A multi-scale 3D convolutional neural network (CNN) was used as the predictive model with inputs of NCCT, CTA, and CTA+ (8 s delay after CTA) images. An external cohort with 108 patients was included to further validate the generalization performance of the proposed model. Strong correlations with CTP-RAPID segmentations (r = 0.84 for core, r = 0.83 for deficit) were observed when NCCT, CTA, and CTA+ images were all used in the model. The diagnostic decisions according to DEFUSE3 showed high accuracy when using NCCT, CTA, and CTA+ (0.90±0.04), followed by the combination of NCCT and CTA (0.87±0.04), CTA-alone (0.76±0.06), and NCCT-alone (0.53±0.09).
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Affiliation(s)
- Chengyan Wang
- Human Phenome Institute, Fudan University, Shanghai, China.,Zhangjiang Fudan International Innovation Center, Shanghai, China
| | - Zhang Shi
- Department of Radiology, Changhai Hospital, Shanghai, China
| | - Ming Yang
- NeuroBlem Ltd. Co., Shanghai, China.,Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China
| | - Lixiang Huang
- Department of Radiology, Tianjin First Central Hospital, Tianjin, China
| | | | - Li Jiang
- NeuroBlem Ltd. Co., Shanghai, China
| | - Jing Ding
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - He Wang
- Human Phenome Institute, Fudan University, Shanghai, China.,Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China.,Key Laboratory of Computational Neuroscience and Brain-Inspired Intelligence (Fudan University), Ministry of Education, Shanghai, China
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20
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Zhang H, Han J, Sun X, Miao Z, Guo X, Xu G, Sun Y, Wen C, Wang C, Wu Y, Xu Y, Jiang Y, Zhang S, Liu C, Li D, Liu Y, Xu C, Gao F. Endovascular Recanalization and Standard Medical Management for Symptomatic Non-acute Intracranial Artery Occlusion: Study Protocol for a Non-randomized, 24-Month, Multicenter Study. Front Neurol 2021; 12:729534. [PMID: 34650509 PMCID: PMC8506001 DOI: 10.3389/fneur.2021.729534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/31/2021] [Indexed: 11/30/2022] Open
Abstract
Background: The management of patients with symptomatic non-acute intracranial artery occlusion (sNA-ICAO), which is a special subset with high morbidity and a high probability of recurrent serious ischemic events despite standard medical therapy (SMT), has been clinically challenging. A number of small-sample clinical studies have also discussed endovascular recanalization (ER) for sNA-ICAO; however, there is currently a lack of evidence from multicenter, prospective, large-sample cohort trials. The purpose of our present study was to evaluate the technical feasibility and safety of ER for sNA-ICAO. Methods: Our group is currently undertaking a multisite, non-randomized cohort, prospective registry study enrolling consecutive patients presenting with sNA-ICAO at 15 centers in China between January 1, 2020 and December 31, 2022. A cohort of patients who received SMT and a cohort of similar patients who received ER plus SMT were constructed and followed up for 2 years. The primary outcome is any stroke from enrollment to 2 years of follow-up. The secondary outcomes are all-cause mortality, mRS score, NIHSS score and cognitive function from enrollment to 30 days, 3 months, 8 months, 12 months, 18 months, and 2 years of follow-up. Descriptive statistics and linear/logistic multiple regression models will be generated. Clinical relevance will be measured as relative risk reduction, absolute risk reduction and the number needed to treat. Discussion: The management of patients with sNA-ICAO has been clinically challenging. The current protocol aims to evaluate the technical feasibility and safety of ER for sNA-ICAO. Trial Registration Number:www.ClinicalTrials.gov, identifier: NCT04864691.
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Affiliation(s)
- Huijun Zhang
- Department of Neurology, Tong Ren Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jianjia Han
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Xuan Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Xu Guo
- Department of Neurology, Beijing Anzhen Hospital, Beijing, China
| | - Guodong Xu
- Department of Neurology, Hebei General Hospital, Shijiazhuang, China
| | - Yaxuan Sun
- Department of Neurology, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Chao Wen
- Department of Neurology, Taiyuan Central Hospital, Taiyuan, China
| | - Chaobin Wang
- Department of Neurology, Liangxiang Teaching Hospital, Beijing, China
| | - Yingchun Wu
- Department of Neurology, ORDOS Central Hospital, Ordos, China
| | - Yaoming Xu
- Department of Neurology, TongLiao City Hospital, Tongliao, China
| | - Yuanfei Jiang
- Department of Neurology, Tai'an Hospital of Traditional Chinese Medicine, Tai'an, China
| | - Shiyong Zhang
- Department of Interventional Neurology, Beijing You'anmen Hospital, Beijing, China
| | - Chao Liu
- Department of Neurology, Handan Central Hospital, Handan, China
| | - Di Li
- Department of Neurology, Dalian Municipal Central Hospital, Dalian, China
| | - Yan Liu
- Department of Neurology, Jingjiang People's Hospital, Taizhou, China
| | - Chenghua Xu
- Department of Neurology, Taizhou First People's Hospital, Taizhou, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
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21
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Tomasetti L, Hollesli LJ, Engan K, Kurz KD, Kurz MW, Khanmohammadi M. Machine learning algorithms vs. thresholding to segment ischemic regions in patients with acute ischemic stroke. IEEE J Biomed Health Inform 2021; 26:660-672. [PMID: 34270438 DOI: 10.1109/jbhi.2021.3097591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Computed tomography (CT) scan is a fast and widely used modality for early assessment in patients with symptoms of a cerebral ischemic stroke. CT perfusion (CTP) is often added to the protocol and is used by radiologists for assessing the severity of the stroke. Standard parametric maps are calculated from the CTP datasets. Based on parametric value combinations, ischemic regions are separated into presumed infarct core (irreversibly damaged tissue) and penumbra (tissue-at-risk). Different thresholding approaches have been suggested to segment the parametric maps into these areas. The purpose of this study is to compare fully-automated methods based on machine learning and thresholding approaches to segment the hypoperfused regions in patients with ischemic stroke. METHODS We test two different architectures with three mainstream machine learning algorithms. We use parametric maps, as input features, and manual annotations made by two expert neuroradiologists as ground truth. RESULTS The best results are produced with random forest (RF) and Single-Step approach; we achieve an average Dice coefficient of 0.68 and 0.26, respectively for penumbra and core, for the three groups analysed. We also achieve an average in volume difference of 25.1ml for penumbra and 7.8ml for core. CONCLUSIONS Our best RF-based method outperforms the classical thresholding approaches, to segment both the ischemic regions in a group of patients regardless of the severity of vessel occlusion. SIGNIFICANCE A correct visualization of the ischemic regions will guide treatment decision better.
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22
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Controversies in Imaging of Patients with Acute Ischemic Stroke: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2021; 217:1027-1037. [PMID: 34106758 DOI: 10.2214/ajr.21.25846] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The development of reperfusion therapies has profoundly impacted stroke care, initially with the advent of IV thrombolytic (IVT) treatment and, more recently, with the development and refinement of endovascular treatment (EVT). Progress in neuroimaging has supported the paradigm shift of stroke care, and advanced neuroimaging now has a fundamental role in triaging patients for both IVT and EVT. As the standard of care for acute ischemic stroke (AIS) evolves, controversies remain in certain clinical scenarios. This article explores the use of multimodality imaging for treatment selection of AIS in the context of recent guidelines, highlighting controversial topics and providing guidance for clinical practice. Results of major randomized trials supporting EVT are reviewed. Advantages and disadvantages of CT, CTA, MRI, and MRA in stroke diagnosis are summarized, with attention to level 1 evidence supporting the role of vascular imaging and perfusion imaging. Patient selection is compared between approaches based on time thresholds and physiologic approaches based on infarct core measurement using imaging. Moreover, various imaging approaches to core measurement are described. As ongoing studies push treatment boundaries, advanced imaging is expected to help identify a widening range of patients who may benefit from therapy.
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23
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Shi Z, Li J, Zhao M, Zhang M, Wang T, Chen L, Liu Q, Wang H, Lu J, Zhao X. Baseline Cerebral Ischemic Core Quantified by Different Automatic Software and Its Predictive Value for Clinical Outcome. Front Neurosci 2021; 15:608799. [PMID: 33911999 PMCID: PMC8072147 DOI: 10.3389/fnins.2021.608799] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 02/25/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose This study aims to investigate the agreement of three software packages in measuring baseline ischemic core volume (ICV) and penumbra volume (PV), and determine their predictive values for unfavorable clinical outcome in patients with endovascular thrombectomy (EVT). Methods Patients with acute ischemic stroke who underwent computed tomographic perfusion (CTP) were recruited. Baseline CTP measurements including ICV and PV were calculated by three software packages of IntelliSpace Portal (ISP), Rapid Processing of Perfusion and Diffusion (RAPID), and fast-processing of ischemic stroke (F-STROKE). All patients received EVT, and the modified Rankin scale (mRS) at 90 days after EVT was assessed to determine the clinical outcomes (favorable: mRS = 0-2; unfavorable: mRS = 3-6). The agreement of CTP measurements among three software packages was determined using intraclass correlation coefficient (ICC). The associations between CTP measurements and unfavorable clinical outcome were analyzed using logistic regression. Receiver operating characteristic curves were conducted to calculate the area under the curve (AUC) of CTP measurements in predicting unfavorable clinical outcome. Results Of 223 recruited patients (68.2 ± 11.3 years old; 145 males), 17.0% had unfavorable clinical outcome after EVT. Excellent agreement between F-STROKE and RAPID was found in measuring ICV (ICC 0.965; 95% CI 0.956-0.973) and PV (ICC 0.966; 95% CI 0.956-0.973). ICVs measured by three software packages were significantly associated with unfavorable clinical outcome before (odds ratios 1.012-1.018, all P < 0.01) and after (odds ratios 1.003-1.014, all P < 0.05) adjusted for confounding factors (age, gender, TOAST classification, and NIHSS on admission). In predicting unfavorable clinical outcome, ICV measured by F-STROKE showed similar performance to that measured by RAPID (AUC 0.701 vs. 0.717) but higher performance than that measured by ISP (AUC 0.629). Conclusions The software of F-STROKE has excellent agreement with the widely used analysis tool of RAPID in measuring ICV and PV. The ischemic core volume measured by both F-STROKE and RAPID is a stronger predictor for unfavorable clinical outcome after EVT compared to ISP.
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Affiliation(s)
- Zhang Shi
- Department of Radiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jing Li
- Department of Radiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Ming Zhao
- Department of Neurology, The 983th Hospital of Joint Logistics Support Forces of Chinese PLA, Tianjin, China.,Department of Neurology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Minmin Zhang
- Department of Neurology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Tiegong Wang
- Department of Radiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Luguang Chen
- Department of Radiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qi Liu
- Department of Radiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - He Wang
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China
| | - Jianping Lu
- Department of Radiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xihai Zhao
- Department of Biomedical Engineering, Center for Biomedical Imaging Research, Tsinghua University School of Medicine, Beijing, China
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24
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Recanalization Therapy for Acute Ischemic Stroke with Large Vessel Occlusion: Where We Are and What Comes Next? Transl Stroke Res 2021; 12:369-381. [PMID: 33409732 PMCID: PMC8055567 DOI: 10.1007/s12975-020-00879-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/15/2020] [Accepted: 11/18/2020] [Indexed: 12/18/2022]
Abstract
In the past 5 years, the success of multiple randomized controlled trials of recanalization therapy with endovascular thrombectomy has transformed the treatment of acute ischemic stroke with large vessel occlusion. The evidence from these trials has now established endovascular thrombectomy as standard of care. This review will discuss the chronological evolution of large vessel occlusion treatment from early medical therapy with tissue plasminogen activator to the latest mechanical thrombectomy. Additionally, it will highlight the potential areas in endovascular thrombectomy for acute ischemic stroke open to exploration and further progress in the next decade.
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25
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Gao F, Sun X, Guo X, Li D, Xu GD, Miao ZR. Endovascular Recanalization of Symptomatic Nonacute Intracranial Internal Carotid Artery Occlusion: Proposal of a New Angiographic Classification. AJNR Am J Neuroradiol 2021; 42:299-305. [PMID: 33361380 DOI: 10.3174/ajnr.a6928] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 09/19/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE The optimal treatment for symptomatic nonacute intracranial ICA occlusion is uncertain, and endovascular recanalization remains a technical challenge. Our purpose was to report multicenter clinical results of endovascular recanalization for medically refractory, nonacute, intracranial ICA occlusion and to propose a new angiographic classification to explore which subgroups of patients are most amenable to this treatment. MATERIALS AND METHODS From January 2015 to December 2019, thirty-six consecutive patients who underwent endovascular recanalization for refractory, nonacute, atherosclerotic intracranial ICA occlusion at 3 stroke centers were analyzed retrospectively. The patients were divided into 3 types according to an angiographic classification. Rates of technical success, periprocedural complications, and any stroke or death within 30 days along with follow-up results were evaluated. RESULTS The overall technical success rate was 80.6% (29/36), and the rate of any stroke or death within 30 days was 16.7% (6/36). The recanalization success rate gradually decreased from type I to type III in the 3 classification groups (92.9%, 81.3%, and 50%, P = .038), and the opposite was true of the perioperative complication rates (7.1%, 18.8%, and 50%, P = .038). Type I lesions showed favorable recanalization effects, 92.9% technical success rates, and 7.1% perioperative complications. CONCLUSIONS Endovascular recanalization for nonacute atherosclerotic intracranial ICA occlusion is technically feasible, especially in patients with type I lesions, and could offer an alternative option for patients with recurrent ischemic symptoms despite aggressive medical therapy. The angiographic classification proposed is conducive to the selection of suitable patients and difficulty in grading.
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Affiliation(s)
- F Gao
- From the Departments of Interventional Neuroradiology (F.G., X.S., Z.R.M.), Beijing Tiantan Hospital
| | - X Sun
- From the Departments of Interventional Neuroradiology (F.G., X.S., Z.R.M.), Beijing Tiantan Hospital
| | - X Guo
- Interventional Neurology (X.G.), Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - D Li
- Department of Neurointervention (D.L.), Dalian Municipal Central Hospital affiliated with Dalian Medical University, Dalian City, Liaoning Province, China
| | - G D Xu
- Department of Neurointervention (G.D.X.), Hebei General Hospital, Shijiazhuang City, Hebei Province, China
| | - Z R Miao
- From the Departments of Interventional Neuroradiology (F.G., X.S., Z.R.M.), Beijing Tiantan Hospital
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26
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Wang YR, Li ZS, Huang W, Yang HQ, Gao B, Chen YT. The Value of Susceptibility-Weighted Imaging (SWI) in Evaluating the Ischemic Penumbra of Patients with Acute Cerebral Ischemic Stroke. Neuropsychiatr Dis Treat 2021; 17:1745-1750. [PMID: 34113105 PMCID: PMC8184242 DOI: 10.2147/ndt.s301870] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/06/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The aim of this study was to discuss the value of susceptibility-weighted imaging (SWI) in evaluating the ischemic penumbra of patients with acute cerebral ischemic stroke. METHODS Data were collected from 52 patients with acute cerebral ischemic stroke upon clinical diagnosis and routine examinations of magnetic resonance imaging (MRI), including SWI, diffusion-weighted imaging (DWI), and perfusion-weighted imaging (PWI) within 72 hours after onset in this retrospective study. The methods also included fusing the DWI and SWI images and calculating the volume of anomaly extension of DWI and PWI-MTT (mean transit time) using semi-automatic analysis software. The SWI-DWI and PWI-DWI mismatches were interpreted, and the statistical analysis was completed. RESULTS The two physicians found that the ischemic penumbra consistency is high throughout the SWI-DWI and PWI-DWI mismatches, without a significant difference (P > 0.05). CONCLUSION SWI-DWI mismatch can prevent the injection of contrast agents and make an accurate diagnosis of acute stroke ischemic penumbra, which helps guide the selection of the clinical therapeutic plan.
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Affiliation(s)
- Yong-Ren Wang
- Department of Radiology, Chinese Medical Hospital of Yiwu, Yiwu, 322000, People's Republic of China
| | - Zhao-Sheng Li
- Department of Radiology, Chinese Medical Hospital of Yiwu, Yiwu, 322000, People's Republic of China
| | - Wei Huang
- Department of Radiology, Chinese Medical Hospital of Yiwu, Yiwu, 322000, People's Republic of China
| | - Hui-Qiang Yang
- Department of Radiology, Chinese Medical Hospital of Yiwu, Yiwu, 322000, People's Republic of China
| | - Bo Gao
- Department of Radiology, Chinese Medical Hospital of Yiwu, Yiwu, 322000, People's Republic of China
| | - Yu-Ting Chen
- Department of Radiology, Chinese Medical Hospital of Yiwu, Yiwu, 322000, People's Republic of China
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27
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Abstract
The discovery that brain tissue could potentially be salvaged from ischaemia due to stroke, has led to major advances in the development of therapies for ischemic stroke. In this review, we detail the advances in the understanding of this area termed the ischaemic penumbra, from its discovery to the evolution of imaging techniques, and finally some of the treatments developed. Evolving from animal studies from the 70s and 80s and translated to clinical practice, the field of ischemic reperfusion therapy has largely been guided by an array of imaging techniques developed to positively identify the ischemic penumbra, including positron emission tomography, computed tomography and magnetic resonance imaging. More recently, numerous penumbral identification imaging studies have allowed for a better understanding of the progression of the ischaemic core at the expense of the penumbra, and identification of patients than can benefit from reperfusion therapies in the acute phase. Importantly, 40 years of critical imaging research on the ischaemic penumbra have allowed for considerable extension of the treatment time window and better patient selection for reperfusion therapy. The translation of the penumbra concept into routine clinical practice has shown that "tissue is at least as important as time."
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Affiliation(s)
- Charlotte M Ermine
- Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
| | - Andrew Bivard
- Department of Medicine, Melbourne Brain Centre at The Royal Melbourne Hospital, Parkville, Australia.,Department of Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, Parkville, Australia
| | - Mark W Parsons
- Department of Medicine, Melbourne Brain Centre at The Royal Melbourne Hospital, Parkville, Australia.,Department of Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, Parkville, Australia
| | - Jean-Claude Baron
- Institute of Psychiatry and Neuroscience of Paris (IPNP), Université de Paris, Paris, France.,GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte Anne, Paris, France
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28
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Gao F, Guo X, Han J, Sun X, Zhou Z, Miao Z. Endovascular recanalization for symptomatic non-acute middle cerebral artery occlusion: proposal of a new angiographic classification. J Neurointerv Surg 2020; 13:900-905. [PMID: 33122350 DOI: 10.1136/neurintsurg-2020-016692] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/08/2020] [Accepted: 10/13/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Endovascular recanalization for medically refractory non-acute middle cerebral artery (MCA) occlusion remains a clinical dilemma, and limited data are available. We report the multicenter clinical results of endovascular recanalization for symptomatic non-acute MCA occlusion and propose a new angiographic classification to explore which subgroups of patients are most suitable for this treatment. METHODS From January 2015 to December 2019, 50 consecutive patients who underwent endovascular recanalization for recurrent symptomatic non-acute MCA occlusion were analyzed retrospectively. All patients were divided into three types according to the angiographic classification. The technical success rate, periprocedural complications, rate of stroke or death within 30 days, and follow-up results were evaluated. RESULTS The overall technical success rate was 84.0% (42/50). The perioperative complication rate was 14.0% (7/50), and the rate of stroke or death within 30 days was 12.0% (6/50). The revascularization success rate was higher in patients with type I occlusion than in those with type II or type III occlusion (95.5%, 83.3%, and 60%, respectively; p=0.014), and the opposite was true for the perioperative complication rate (4.5%, 11.1%, and 40.0%, respectively; p=0.013). The median clinical follow-up period was 13.4 months (IQR 12.5-15.6), and the rate of stroke or death beyond 30 days was 8.3%. CONCLUSIONS Endovascular recanalization for non-acute MCA occlusion is technically feasible in reasonably selected patients, especially type I patients, and has potential as an alternative option for patients with recurrent stroke or transient ischemic attack in the short term despite optimal medical therapy.
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Affiliation(s)
- Feng Gao
- Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Guo
- Department of Interventional Neuroradiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ju Han
- Department of Interventional Neurology, Qianfoshan Hospital, Shandong University, Jinan, China
| | - Xuan Sun
- Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhenhua Zhou
- Department of Neurology, First Affiliated Hospital, Army Military Medical University, Chongqing, China
| | - Zhongrong Miao
- Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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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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Wadhwa A, Joundi RA, Menon B. Clinical considerations and assessment of risk factors when choosing endovascular thrombectomy for acute stroke. Expert Rev Cardiovasc Ther 2020; 18:541-556. [PMID: 32686967 DOI: 10.1080/14779072.2020.1798229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The advent of endovascular thrombectomy (EVT) has been a game changer for the management of acute ischemic stroke due to large vessel occlusion. However, the selection of suitable candidates for EVT remains a significant challenge. AREAS COVERED This review focuses on the clinical, radiological, and procedural considerations for EVT in acute stroke that assist in optimal patient selection. EXPERT OPINION All patients presenting with significant clinical deficits with treatable occlusions, who have salvageable brain tissue at presentation might benefit from treatment up to twenty-four hours from symptom onset. Neuroimaging tools form the backbone for this decision making.
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Affiliation(s)
- Ankur Wadhwa
- Calgary Stroke Program, University of Calgary, Foot Hills Medical Center , Calgary, AB, Canada
| | - Raed A Joundi
- Calgary Stroke Program, University of Calgary, Foot Hills Medical Center , Calgary, AB, Canada
| | - Bijoy Menon
- Clinical Neurosciences, University of Calgary, Foot Hills Medical Center , Calgary, AB, Canada
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Cimflova P, Volny O, Mikulik PR, Tyshchenko B, Belaskova S, Vinklarek J, Cervenak V, Krivka T, Vanicek APJ, Krajina PA. Detection of ischemic changes on baseline multimodal computed tomography: expert reading vs. Brainomix and RAPID software. J Stroke Cerebrovasc Dis 2020; 29:104978. [PMID: 32807415 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104978] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/29/2020] [Accepted: 05/17/2020] [Indexed: 11/18/2022] Open
Abstract
PURPOSE The aim of the study was to compare the assessment of ischemic changes by expert reading and available automated software for non-contrast CT (NCCT) and CT perfusion on baseline multimodal imaging and demonstrate the accuracy for the final infarct prediction. METHODS Early ischemic changes were measured by ASPECTS on the baseline neuroimaging of consecutive patients with anterior circulation ischemic stroke. The presence of early ischemic changes was assessed a) on NCCT by two experienced raters, b) on NCCT by e-ASPECTS, and c) visually on derived CT perfusion maps (CBF<30%, Tmax>10s). Accuracy was calculated by comparing presence of final ischemic changes on 24-hour follow-up for each ASPECTS region and expressed as sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The subanalysis for patients with successful recanalization was conducted. RESULTS Of 263 patients, 81 fulfilled inclusion criteria. Median baseline ASPECTS was 9 for all tested modalities. Accuracy was 0.76 for e-ASPECTS, 0.79 for consensus, 0.82 for CBF<30%, 0.80 for Tmax>10s. e-ASPECTS, consensus, CBF<30%, and Tmax>10s had sensitivity 0.41, 0.46, 0.49, 0.57, respectively; specificity 0.91, 0.93, 0.95, 0.91, respectively; PPV 0.66, 0.75, 0.82, 0.73, respectively; NPV 0.78, 0.80, 0.82, 0.83, respectively. Results did not differ in patients with and without successful recanalization. CONCLUSION This study demonstrated high accuracy for the assessment of ischemic changes by different CT modalities with the best accuracy for CBF<30% and Tmax>10s. The use of automated software has a potential to improve the detection of ischemic changes.
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Affiliation(s)
- Petra Cimflova
- Department of Medical Imaging, St. Anne´s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic; International Clinical Research Centre, Stroke Research Program, St. Anne´s University Hospital, Brno, Czech Republic.
| | - Ondrej Volny
- International Clinical Research Centre, Stroke Research Program, St. Anne´s University Hospital, Brno, Czech Republic; Departments of Clinical Neurosciences, Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, Canada; Department of Neurology, Faculty Hospital Ostrava, Ostrava, Czech Republic.
| | - Prof Robert Mikulik
- International Clinical Research Centre, Stroke Research Program, St. Anne´s University Hospital, Brno, Czech Republic; Department of Neurology, St. Anne´s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Bohdan Tyshchenko
- International Clinical Research Centre, Stroke Research Program, St. Anne´s University Hospital, Brno, Czech Republic.
| | - Silvie Belaskova
- International Clinical Research Centre, Stroke Research Program, St. Anne´s University Hospital, Brno, Czech Republic.
| | - Jan Vinklarek
- Department of Neurology, Faculty Hospital Ostrava, Ostrava, Czech Republic.
| | - Vladimir Cervenak
- Department of Medical Imaging, St. Anne´s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Tomas Krivka
- Department of Medical Imaging, St. Anne´s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Assoc Prof Jiri Vanicek
- Department of Medical Imaging, St. Anne´s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Prof Antonin Krajina
- Department of Radiology, Charles University, Faculty of Medicine and University Hospital, Hradec Kralove, Czech Republic.
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Reidler P, Mueller F, Stueckelschweiger L, Feil K, Kellert L, Fabritius MP, Liebig T, Tiedt S, Puhr-Westerheide D, Kunz WG. Diaschisis revisited: quantitative evaluation of thalamic hypoperfusion in anterior circulation stroke. NEUROIMAGE-CLINICAL 2020; 27:102329. [PMID: 32629166 PMCID: PMC7334597 DOI: 10.1016/j.nicl.2020.102329] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 06/02/2020] [Accepted: 06/21/2020] [Indexed: 11/21/2022]
Abstract
CT perfusion reveals thalamic hypoperfusion in acute anterior circulation stroke. This indirect phenomenon is referred to as ipsilateral thalamic diaschisis (ITD). Quantitative analysis indicates that ITD is a non-binary phenomenon. ITD is associated with lesion extent and involvement of the lentiform nucleus. Stroke outcome was not associated with ITD parameters.
Purpose Ipsilateral thalamic diaschisis (ITD) refers to the phenomenon of thalamic hypoperfusion or hypometabolism due to a distant cerebral injury. To further investigate the characteristics and spectrum of ITD, we analyzed quantitative measurements of thalamic hypoperfusion in acute anterior circulation stroke. Methods We selected consecutive patients with large-vessel occlusion (LVO) anterior circulation stroke and available CT perfusion (CTP) examination on admission who underwent endovascular thrombectomy. Thalamic perfusion parameters on CTP were tested between ipsi- and contralesional thalamus and ischemic territory. Values were compared with thresholds from CTP analysis software. Associations of thalamic perfusion parameters with acute imaging and clinical data were determined in uni- and multivariate logistic regression analyses. Results Ninety-nine patients were included. All perfusion parameters indicated significant non-ischemic hypoperfusion of the thalamus, not reaching the levels of ischemia in the middle cerebral artery territory due to LVO (all p < 0.002). Multiple perfusion parameters exhibited significant association with ischemic lesion extent (relative cerebral blood flow [CBF]: β = − 0.23, p = 0.022; Δtime to drain: β = 0.33, p < 0.001; ΔTmax: β = − 0.36, p < 0.001) and involvement of the Lentiform Nucleus (Δmean transit time: β = 0.64, p = 0.04; Δtime to drain: β = 0.81, p = 0.01; ΔTmax: β = − 0.82, p = 0.01). Symptom severity on admission exhibited minor significant association with reduction of thalamic CBF in uncorrected analysis (Odds ratio: 0.05, p = 0.049), but short- and long-term outcomes were unaffected by perfusion status. ITD reached guideline-based software-threshold levels in only one patient. Conclusions ITD in acute stroke is a non-binary phenomenon affected by lesion extent and involvement of the lentiform nucleus. We found uncorrected association of ITD with early clinical presentation, but no association with short- or long-term outcome was evident. Relevant misclassification of ITD by guideline-based CTP software was not indicated, which needs further dedicated testing.
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Affiliation(s)
- Paul Reidler
- Department of Radiology, University Hospital, LMU Munich, Germany
| | | | | | - Katharina Feil
- Department of Neurology, University Hospital, LMU Munich, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Germany
| | | | - Thomas Liebig
- Department of Neuroradiology, University Hospital, LMU Munich, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, LMU Munich, Germany
| | | | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Germany.
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Bonney PA, Walcott BP, Singh P, Nguyen PL, Sanossian N, Mack WJ. The Continued Role and Value of Imaging for Acute Ischemic Stroke. Neurosurgery 2020; 85:S23-S30. [PMID: 31197337 DOI: 10.1093/neuros/nyz068] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 02/26/2019] [Indexed: 11/12/2022] Open
Abstract
Advances in neuroimaging in the last 2 decades have revolutionized the management of acute ischemic stroke (AIS). Here we review the development of computed tomography (CT) and magnetic resonance imaging (MRI) modalities used to guide treatment of patients with AIS characterized by large vessel occlusion. In particular, we highlight recent randomized trials and their patient selection methodologies to detail the progression of these selection paradigms. With advanced imaging, distinction between at-risk penumbra and ischemic core in AIS may be performed using either CT or MRI. While limitations exist for methodologies to quantify core and penumbra, commercially available fully automated software packages provide useful information to guide treatment decisions. Randomized controlled trials implementing perfusion imaging to patient selection algorithms have demonstrated marked success in improving functional outcomes in patients with large vessel occlusions. As such, imaging has become a vital aspect of AIS treatment in selecting patients who may benefit from mechanical thrombectomy.
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Affiliation(s)
- Phillip A Bonney
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Brian P Walcott
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Parampreet Singh
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Peggy L Nguyen
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Nerses Sanossian
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - William J Mack
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Songsaeng D, Sangrungruang A, Boonma C, Krings T. Permeability-surface area product of the penumbra as a predictor of outcome after endovascular treatment of anterior circulation acute ischemic stroke. Acta Radiol 2020; 61:528-536. [PMID: 31446778 DOI: 10.1177/0284185119870971] [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 Permeability-surface product is a predictor of blood–brain barrier disruption, a condition that may be related to higher likelihoods of hemorrhagic transformations in acute stroke. Purpose To investigate whether permeability-surface product can be used as a parameter for predicting outcome after mechanical thrombectomy in patients with anterior circulation acute ischemic stroke. Material and Methods We retrospectively identified patients with acute middle cerebral artery stroke who underwent successful mechanical thrombectomy between November 2009 and July 2015. Multiple parameters (including age) and CT perfusion-related parameters (including permeability-surface product) were compared between patients with favorable (modified Rankin Scale [mRS] = 0–2) and unfavorable (mRS > 2) outcome. Results Thirty patients were included, 50% having favorable and 50% having unfavorable outcome. Younger age was significantly associated with favorable outcome ( P < 0.03). Other baseline characteristics, such as size of CT perfusion core infarction, perfusion abnormality, and presentation of subcortical infarction were not significantly different between groups. No significant difference was observed between groups for permeability-surface product in the ipsilateral penumbra or for the ratio between permeability-surface product penumbra value and contralateral normal brain (permeability-surface product ratio). Conclusions No significant difference was observed between patients with and without favorable outcome after mechanical thrombectomy for either permeability-surface product value or permeability-surface product ratio. Although permeability-surface product is a good predictor of blood–brain barrier disruption, this study revealed no evidence that either permeability-surface product value or permeability-surface product ratio is associated with future change in the penumbra.
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Affiliation(s)
- Dittapong Songsaeng
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Athip Sangrungruang
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chulaluck Boonma
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Timo Krings
- Division of Neuroradiology, Department of Medical Imaging, Faculty of Medicine, University of Toronto, Canada
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Siegler JE, Olsen A, Rosenberg J, Cristancho D, Pulst-Korenberg J, Raab L, Woo JH, Messé SR. Mismatch between automated CTP and ASPECTS score in patients with anterior large vessel occlusion. Clin Neurol Neurosurg 2020; 194:105797. [PMID: 32222652 DOI: 10.1016/j.clineuro.2020.105797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To evaluate the relationship between delay to computed tomography perfusion and estimated core infarct volumes in patients with large vessel occlusion (LVO). PATIENTS AND METHODS A retrospective registry of consecutive adults >18 years old who underwent CTP in clinical practice for suspected LVO within 24 h of LKN at 3 academic hospitals was queried (06/2017 - 12/2017). CT and CTP findings were compared over time as a continuous variable, and dichotomized by ≤6 h or 6-24 h from LKN. RESULTS Of 410 screened patients, 75 had LVO, of whom 60 (14.6 %) met inclusion criteria (median age 78y [IQR 64-84], 36 were female [60 %]), and 39 (65.0 %) underwent thrombectomy. Thirty (50 %) presented in the extended window (6-24 h) and had lower ASPECTS scores compared to patients in the early window (median 7 vs. 9, p < 0.01). Perfusion core (rCBF <30 %) volumes were similar (median 8 vs. 25, p = 0.10). After adjustment for age, NIHSS, and thrombolysis, there was a trend for lower ASPECTS for every hour after LKN (proportional OR 0.92, 95 %CI 0.84-1.00, p = 0.06), but no change in perfusion core (p = 0.37) or Tmax>6 s volumes (p = 0.29), or mismatch ratios (p = 0.48) after adjusting for age, NIHSS, ASPECTS, and thrombolysis. CONCLUSION As time progresses in anterior LVO, the unenhanced CT is more sensitive than CTP for detecting irreversibly damaged tissue. These results underscore the importance of carefully reviewing the unenhanced and perfusion CT when considering a patient for thrombectomy.
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Affiliation(s)
- James E Siegler
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia PA, 19104, United States.
| | - Andrew Olsen
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia PA, 19104, United States
| | - Jon Rosenberg
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia PA, 19104, United States
| | - Daniel Cristancho
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia PA, 19104, United States
| | - Johannes Pulst-Korenberg
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia PA, 19104, United States
| | - Lindsay Raab
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia PA, 19104, United States
| | - John H Woo
- Department of Radiology, Division of Neuroradiology, Hospital of the University of Pennsylvania, Philadelphia PA, 19104, United States
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia PA, 19104, United States
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Özdemir AÖ, Eryıldız ES, Akarsu FG, Kocabaş ZU, Aykaç Ö. The role of ASPECTs in patient selection for endovascular therapy – CTA source images versus noncontrast CT. J Clin Neurosci 2020; 73:195-200. [DOI: 10.1016/j.jocn.2019.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 08/28/2019] [Accepted: 10/04/2019] [Indexed: 10/25/2022]
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Nael K, Sakai Y, Khatri P, Prestigiacomo CJ, Puig J, Vagal A. Imaging-based Selection for Endovascular Treatment in Stroke. Radiographics 2019; 39:1696-1713. [DOI: 10.1148/rg.2019190030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ikemura A, Yuki I, Otani K, Ishibashi T, Dahmani C, Ebara M, Abe Y, Kajiwara I, Watanabe M, Murayama Y. Evaluation of Balloon Test Occlusion Before Therapeutic Carotid Artery Occlusion: Flat Detector Computed Tomography Cerebral Blood Volume Imaging versus Single-Photon Emission Computed Tomography. World Neurosurg 2019; 133:e522-e528. [PMID: 31550537 DOI: 10.1016/j.wneu.2019.09.077] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/13/2019] [Accepted: 09/14/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We aimed to compare flat detector computed tomography cerebral blood volume (FD-CBV) imaging to single-photon emission computed tomography (SPECT) as an adjunctive technique during balloon test occlusion (BTO) in patients with intracranial aneurysms or tumors. METHODS Twelve patients who underwent SPECT (99mTc-ethyl cysteinate dimer) and FD-CBV imaging during BTO were enrolled. Color-coded cerebral blood flow (CBF) images and color-coded FD-CBV images were generated and visually inspected whether there were asymmetries between the ipsilateral and contralateral cerebral hemispheres. Region of interest measurements were performed on the color-coded images at the same locations for both modalities. The mean interhemispheric region of interest ratios were calculated, and the ratio between these were estimated using linear regression models. RESULTS Ten patients had no symptoms during BTO. Two patients developed subtle but inconclusive neurologic changes approximately 10 minutes after balloon inflation; their images showed asymmetric color-coded images with decreased CBF and FD-CBV in the ipsilateral hemisphere. The mean interhemispheric ratio of CBF was significantly smaller in patients with subtle changes than in those without (0.84 vs. 0.98; P < 0.001). Similarly, the mean interhemispheric ratio of FD-CBV was significantly smaller in patients with subtle changes than in those without (0.88 vs. 1.06; P = 0.01). No patient showed increased CBF or FD-CBV in the ipsilateral hemisphere. CONCLUSIONS The patients with decreased CBF on SPECT also showed decreased FD-CBV in the ipsilateral hemisphere. FD-CBV imaging may be useful as an adjunctive technique for BTO before potential therapeutic carotid artery occlusion.
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Affiliation(s)
- Ayako Ikemura
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan.
| | - Ichiro Yuki
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan; Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | | | - Toshihiro Ishibashi
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
| | | | - Masaki Ebara
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
| | - Yukiko Abe
- Department of Radiology, Jikei University School of Medicine, Tokyo, Japan
| | - Ikki Kajiwara
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
| | - Mitsuyoshi Watanabe
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
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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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Hoelter P, Schmidt M, Breuer L, Kallmünzer B, Schwab S, Doerfler A, Engelhorn T. Endovascular treatment in patients with large vessel occlusion: reduced mortality despite minimal penumbra. Neuroradiology 2019; 61:1469-1476. [DOI: 10.1007/s00234-019-02280-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 08/12/2019] [Indexed: 02/01/2023]
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Erdener ŞE, Dalkara T. Small Vessels Are a Big Problem in Neurodegeneration and Neuroprotection. Front Neurol 2019; 10:889. [PMID: 31474933 PMCID: PMC6707104 DOI: 10.3389/fneur.2019.00889] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 08/01/2019] [Indexed: 12/11/2022] Open
Abstract
The cerebral microcirculation holds a critical position to match the high metabolic demand by neuronal activity. Functionally, microcirculation is virtually inseparable from other nervous system cells under both physiological and pathological conditions. For successful bench-to-bedside translation of neuroprotection research, the role of microcirculation in acute and chronic neurodegenerative disorders appears to be under-recognized, which may have contributed to clinical trial failures with some neuroprotectants. Increasing data over the last decade suggest that microcirculatory impairments such as endothelial or pericyte dysfunction, morphological irregularities in capillaries or frequent dynamic stalls in blood cell flux resulting in excessive heterogeneity in capillary transit may significantly compromise tissue oxygen availability. We now know that ischemia-induced persistent abnormalities in capillary flow negatively impact restoration of reperfusion after recanalization of occluded cerebral arteries. Similarly, microcirculatory impairments can accompany or even precede neural loss in animal models of several neurodegenerative disorders including Alzheimer's disease. Macrovessels are relatively easy to evaluate with radiological or experimental imaging methods but they cannot faithfully reflect the downstream microcirculatory disturbances, which may be quite heterogeneous across the tissue at microscopic scale and/or happen fast and transiently. The complexity and size of the elements of microcirculation, therefore, require utilization of cutting-edge imaging techniques with high spatiotemporal resolution as well as multidisciplinary team effort to disclose microvascular-neurodegenerative connection and to test treatment approaches to advance the field. Developments in two photon microscopy, ultrafast ultrasound, and optical coherence tomography provide valuable experimental tools to reveal those microscopic events with high resolution. Here, we review the up-to-date advances in understanding of the primary microcirculatory abnormalities that can result in neurodegenerative processes and the combined neurovascular protection approaches that can prevent acute as well as chronic neurodegeneration.
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Affiliation(s)
- Şefik Evren Erdener
- Institute of Neurological Sciences and Psychiatry, Hacettepe University, Ankara, Turkey
| | - Turgay Dalkara
- Institute of Neurological Sciences and Psychiatry, Hacettepe University, Ankara, Turkey.,Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Abstract
PURPOSE OF REVIEW Multimodal CT imaging (non-contrast CT, NCCT; CT angiography, CTA; and CT Perfusion, CTP) is central to acute ischemic stroke diagnosis and treatment. We reviewed the purpose and interpretation of each component of multimodal CT, as well as the evidence for use in routine care. RECENT FINDINGS Acute stroke thrombolysis can be administered immediately following NCCT in acute ischemic stroke patients assessed within 4.5 h of symptom onset. Definitive identification of a large vessel occlusion (LVO) requires vascular imaging, which is easily achieved with CTA. This is critical, as the standard of care for LVO within 6 h of onset is now endovascular thrombectomy (EVT). CTA source images can also be used to estimate the efficacy of collateral flow in LVO patients. The final component (CTP) permits a more accurate assessment of the extent of the ischemic penumbra. Complete multimodal CT, including objective penumbral measurement with CTP, has been used to extend the EVT window to 24 h. There is also randomized controlled trial evidence for extension of the IV thrombolysis window to 9 h with multimodal CT. Although there have been attempts to assess for responders to reperfusion strategies beyond 6 h ("late window") using collateral grades, the only evidence for treatment of this group of patients is based on selection using multimodal CT including CTP. The development of fully automated software providing quantitative ischemic penumbral and core volumes has facilitated the adoption of CTP and complete multimodal CT into routine clinical use. Multimodal CT is a powerful imaging algorithm that is central to current ischemic stroke patient care.
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Zhang XH, Liang HM. Systematic review with network meta-analysis: Diagnostic values of ultrasonography, computed tomography, and magnetic resonance imaging in patients with ischemic stroke. Medicine (Baltimore) 2019; 98:e16360. [PMID: 31348236 PMCID: PMC6709059 DOI: 10.1097/md.0000000000016360] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Ischemic stroke is a foremost cause for disability and death worldwide. This study is conducted in order to compare the diagnostic values between transcranial Doppler ultrasound (ultrasonography), computed tomography (CT), and magnetic resonance imaging (MRI) in patients suffering from ischemic stroke by performing a network meta-analysis. METHODS We made use of Cochrane Library, PubMed, and Embase in order to obtain literature and papers. The combination analysis of both direct and indirect evidence in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy was conducted so as to assess the odds ratios (ORs) and surface under the cumulative ranking curve (SUCRA) values of the seven different imaging methods. These imaging techniques include ultrasonography, computed tomography (traditional CT, computed tomography angiography [CTA], computed tomography perfusion [CTP]), and MRI (traditional MRI, diffusion-weighted imaging [DWI], magnetic resonance angiography), in order to properly diagnose ischemic stroke patients. RESULTS Thirteen eligible diagnostic trials were enrolled into this network meta-analysis. The results of the traditional meta-analysis showed that among CT methods, CTP showed higher sensitivity, NPV, and accuracy; among MRI methods, DWI had relatively higher sensitivity, NPV, and accuracy. The results of network meta-analysis showed that DWI had relatively higher sensitivity, NPV, and accuracy when compared with traditional CT, CTA, magnetic resonance angiography and traditional MRI. CTP showed higher SUCRA among CT methods while DWI showed higher SUCRA among MRI methods. A cluster analysis revealed that DWI had the highest diagnostic value in terms of sensitivity, PPV, NPV, and accuracy amongst the aforementioned seven imaging techniques. CONCLUSION This network meta-analysis provides supporting evidence to the idea that DWI has a higher diagnostic value regarding ischemic stroke among MRI methods, and CTP has a poor diagnostic value among CT methods, which provide therapeutic considerations for Ischemic stroke intervention.
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Affiliation(s)
| | - Hui-Min Liang
- Department of Neurology, Huaihe Hospital of Henan University, Kaifeng, P. R. China
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Yu W, Jiang WJ. A Simple Imaging Guide for Endovascular Thrombectomy in Acute Ischemic Stroke: From Time Window to Perfusion Mismatch and Beyond. Front Neurol 2019; 10:502. [PMID: 31178813 PMCID: PMC6543836 DOI: 10.3389/fneur.2019.00502] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/25/2019] [Indexed: 01/01/2023] Open
Affiliation(s)
- Wengui Yu
- Department of Neurology, University of California Irvine, Irvine, CA, United States
| | - Wei-Jian Jiang
- New Era Stroke Care and Research Institute, The Rocket Force General Hospital, Beijing, China
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Öman O, Mäkelä T, Salli E, Savolainen S, Kangasniemi M. 3D convolutional neural networks applied to CT angiography in the detection of acute ischemic stroke. Eur Radiol Exp 2019; 3:8. [PMID: 30758694 PMCID: PMC6374492 DOI: 10.1186/s41747-019-0085-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 01/04/2019] [Indexed: 12/23/2022] Open
Abstract
Background The aim of this study was to investigate the feasibility of ischemic stroke detection from computed tomography angiography source images (CTA-SI) using three-dimensional convolutional neural networks. Methods CTA-SI of 60 patients with a suspected acute ischemic stroke of the middle cerebral artery were randomly selected for this study; 30 patients were used in the neural network training, and the subsequent testing was performed using the remaining 30 patients. The training and testing were based on manually segmented lesions. Cerebral hemispheric comparison CTA and non-contrast computed tomography (NCCT) were studied as additional input features. Results All ischemic lesions in the testing data were correctly lateralized, and a high correspondence to manual segmentations was achieved. Patients with a diagnosed stroke had clinically relevant regions labeled infarcted with a 0.93 sensitivity and 0.82 specificity. The highest achieved voxel-wise area under receiver operating characteristic curve was 0.93, and the highest Dice similarity coefficient was 0.61. When cerebral hemispheric comparison was used as an input feature, the algorithm performance improved. Only a slight effect was seen when NCCT was included. Conclusion The results support the hypothesis that an acute ischemic stroke lesion can be detected with 3D convolutional neural network-based software from CTA-SI. Utilizing information from the contralateral hemisphere appears to be beneficial for reducing false positive findings.
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Affiliation(s)
- Olli Öman
- HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, P.O. Box 340 (Haartmaninkatu 4), FI-00290, Helsinki, Finland.
| | - Teemu Mäkelä
- HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, P.O. Box 340 (Haartmaninkatu 4), FI-00290, Helsinki, Finland.,Department of Physics, University of Helsinki, P.O. Box 64, FI-00014, Helsinki, Finland
| | - Eero Salli
- HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, P.O. Box 340 (Haartmaninkatu 4), FI-00290, Helsinki, Finland
| | - Sauli Savolainen
- HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, P.O. Box 340 (Haartmaninkatu 4), FI-00290, Helsinki, Finland.,Department of Physics, University of Helsinki, P.O. Box 64, FI-00014, Helsinki, Finland
| | - Marko Kangasniemi
- HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, P.O. Box 340 (Haartmaninkatu 4), FI-00290, Helsinki, Finland
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Ye Z, Ai X, Zheng J, Ma L, Lin S, You C, Li H. The Effect of Cerebrovascular Stenosis on -Peri-Hematoma Cerebral Perfusion and Clinical Outcomes in Patients with Supratentorial Spontaneous Intracerebral Hemorrhage. Med Sci Monit 2018; 24:8647-8654. [PMID: 30496154 PMCID: PMC6282907 DOI: 10.12659/msm.906284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background Many factors are associated with the cerebral hypoperfusion after spontaneous intracerebral hemorrhage (sICH), however, the effect of cerebrovascular stenosis on peri-hematoma cerebral blood flow (CBF) and 90-day poor outcomes in patients with spontaneous intracerebral hemorrhage is still unclear. Material/Methods From September 2016 to March 2017, we prospectively collected data on adults with supratentorial spontaneous intracerebral hemorrhages. Using the Propensity Score model, we compared the peri-hematoma CBF and 90-day poor outcomes (mRS ≥3) in the stenosis group and the control group. Results Before matching, a total of 116 patients were included in this study, 25 patients in the stenosis group and 91 patients in the control group. After matching, the patients in the stenosis group had a higher absolute decrease of CBF (p=0.003), higher relative decrease of CBF (p=0.016), and higher incidence of 90-day poor outcomes (p=0.041) than the control group. With subgroup analysis, the patients with Glasgow Coma Scale from 13 to 15 (p=0.035), hematoma in the cerebral lobe (p=0.003), mean arterial pressure lower than 120 mm Hg (p=0.003), absolute decrease of CBF higher than 15 mL/100 g per minute (p=0.007), and relative decrease of CBF higher than 30% (p=0.020) had poorer outcomes. Conclusions In our series, the stenosis of main cerebral vessels decreased the peri-hematoma CBF and increased the rate of 90-day poor outcomes. Despite higher Glasgow Coma Scale, the evaluation of cerebral perfusion in patients with sICH is needed, especially for the patients with hematoma in the cerebral lobe and lower mean arterial pressure; and treatments to keep adequate cerebral perfusion are needed.
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Affiliation(s)
- Zengpanpan Ye
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Xiaolin Ai
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Jun Zheng
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Lu Ma
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Sen Lin
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Chao You
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Hao Li
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China (mainland)
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Sotoudeh H. Spinal canal meningioma mimicking posterior fossa ischemia on CT perfusion: A CT perfusion pitfall. Radiol Case Rep 2018; 13:1069-1071. [PMID: 30228845 PMCID: PMC6137824 DOI: 10.1016/j.radcr.2018.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 04/10/2018] [Accepted: 04/13/2018] [Indexed: 11/24/2022] Open
Abstract
The recent approach to treat acute stroke is to extend treatment window in patients with salvageable peri-infarct ischemia which increases the application of the perfusion imaging, specifically computed tomography perfusion (CTP). In this paper, I am presenting a case of left middle cerebral artery infarction which was evaluated by CTP under “code stroke.” The patient had an incidental spinal canal meningioma which was out of field of view in CTP but mimicked right cerebellar ischemia on CTP. Although ischemia has been previously reported within the peripheral parenchymal edema surrounding a meningioma, in this patient there was no evidence of edema in the right cerebellum on magnetic resonance imaging. I believe the CTP findings are secondary to steal phenomena at right vertebral artery or compression upon the venous plexus. Recently, by using modern computed tomography scanners, it is common to cover the entire brain in CTP. The emergency radiologist should be aware of this pitfall that spinal canal pathologies which are out of field of view can mimic posterior fossa ischemia.
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Fotakopoulos G, Kotlia P. The Value of Exercise Rehabilitation Program Accompanied by Experiential Music for Recovery of Cognitive and Motor Skills in Stroke Patients. J Stroke Cerebrovasc Dis 2018; 27:2932-2939. [PMID: 30072173 DOI: 10.1016/j.jstrokecerebrovasdis.2018.06.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 06/17/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The aim of this study was to systematically assess the effects of exercise rehabilitation program accompanied by experiential music for clinical recovery. METHODS This was a prospective randomized study with 65 stroke survivor patients. All cases underwent a neuropsychological assessment first as a prescreening test, during the admission at the Rehabilitation center (baseline), and 6 months poststroke. All patients received standard treatment for stroke in terms of medical care and rehabilitation. Additionally, all patients were separated into 2 Groups: a music Group (daily listening to experiential/traditional music), and a control Group (CG) with no experiential/traditional music therapy (standard care only). Computed tomography perfusion and full neurological examination including GCS were assessment. As Recovery was defined the improvement of cognitive and motor skills of the limb in the affected site, with an increase of muscle strength at least by 1/5 and with emotional progress. RESULTS Statistically significant differences were found between the Group CG and the rest of the patients in respect of Lesion size (P = .001) and CBF in affected area (P = .001). Μultivariate analysis revealed that only Group and Lesion size were independent predictors for Recovery (odd ratio [OR][95%confidence interval]) .11(.001-.133) and .798(.668-.954) respectively. CONCLUSION The findings of this study suggest that the music-based exercise program has a positive effect on mood profile in stroke patients and Recovery rate is higher when exercise rehabilitation program was accompanied by an enriched sound environment with experiential music.
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Affiliation(s)
- George Fotakopoulos
- Department of Neurosurgery, University Hospital of Patras, Patra, Greece; Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece
| | - Polikceni Kotlia
- Department of Head of Critical Care, University of Thessaly, University Hospital of Larissa, Biopolis, 41110, Larissa, Thessaly, Greece
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The value of computed tomography perfusion & transcranial Doppler in early diagnosis of cerebral vasospasm in aneurysmal & traumatic subarachnoid hemorrhage. Future Sci OA 2018; 4:FSO313. [PMID: 30057790 PMCID: PMC6060394 DOI: 10.4155/fsoa-2018-0015] [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: 02/05/2018] [Accepted: 05/02/2018] [Indexed: 02/04/2023] Open
Abstract
Early detection and diagnosis of cerebral vasospasm in subarachnoid hemorrhage may be challenging both on clinical and radiographic grounds. In this respect we conducted a pilot study in order to assess the feasibility of the technique in the everyday setting of a tertiary hospital and to evaluate the diagnostic performance of different diagnostic computed tomography perfusion aspects in diagnosing the clinical outcome of patients with subarachnoid hemorrhage. Receiver-operating characteristic analysis showed that a cerebral blood flow value of <24.5 presented 67% sensitivity and 100% specificity to diagnose adverse ischemic events at 1 month (p = 0.041). These case series data provide evidence that computed tomography perfusion-derived cerebral blood flow is a measurable index that may detect the degree of cerebral ischemia in a very early stage. Early detection and diagnosis of cerebral vasospasm in subarachnoid hemorrhage is important but may be challenging both on clinical or radiographic grounds. This article provides evidence that computed tomography perfusion-derived cerebral blood flow is a measurable index that could detect the degree of cerebral ischemia in a very early stage in patients suffering with subarachnoid hemorrhage. Larger studies are needed in order to better define the role of computed tomography perfusion in early diagnosis of cerebral vasospasm.
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