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Huang J, Hao P, Chen Z, Deng K, Liu B, Xu Y. Quantitative assessment of hyperperfusion using arterial spin labeling to predict hemorrhagic transformation in acute ischemic stroke patients with mechanical endovascular therapy. Eur Radiol 2024; 34:579-587. [PMID: 37528300 DOI: 10.1007/s00330-023-10007-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 05/28/2023] [Accepted: 06/05/2023] [Indexed: 08/03/2023]
Abstract
OBJECTIVES This study was aimed to quantitatively assess hyperperfusion using arterial spin labeling (ASL) to predict hemorrhagic transformation (HT) in acute ischemic stroke (AIS) patients. METHODS This study enrolled 98 AIS patients with anterior circulation large vessel occlusion within 24 h of symptom onset. ASL was performed before mechanical endovascular therapy. On pre-treatment ASL maps, a region with relative cerebral blood flow (CBF) ≥ 1.4 was defined as an area of hyperperfusion. The maximum CBF (CBFmax) of hyperperfusion was calculated for each patient. A non-contrast CT scan was performed during the subacute phase for the evaluation of HT. Good clinical outcome was defined as a 90-day modified Rankin scale score of 0-2. RESULTS The CBFmax of hyperperfusion (odds ratio, 1.023; 95% confidence interval [CI], 1.005-1.042; p = 0.012) was an independent risk factor for the status of HT. The CBFmax of hyperperfusion for HT showed an area under the curve of 0.735 (95% CI, 0.588-0.882) with optimal cutoff value, sensitivity, and specificity being 146.5 mL/100 g/min, 76.9%, and 69.6%, respectively. There was a statistically significant relationship between HT grades (from no HT to PH2) and CBFmax of hyperperfusion with a Spearman rank correlation of 0.446 (p = 0.001). In addition, low CBFmax of hyperperfusion were associated with good functional outcome (95% CI, 17.130-73.910; p = 0.002). CONCLUSIONS High CBFmax of hyperperfusion was independently associated with subsequent HT and low CBFmax of hyperperfusion linked to good functional outcome. There was a positive correlation between HT grade and CBFmax. CLINICAL RELEVANCE STATEMENT: Arterial spin labeling is a noninvasive and contrast agent-independent technique, which is sensitive in detecting hyperperfusion. This study shows that the cerebral blood flow of hyperperfusion is associated with clinical prognosis, which will benefit more patients. KEY POINTS • Quantitative assessment of hyperperfusion using pre-treatment arterial spin labeling to predict hemorrhagic transformation and prognosis in acute ischemic stroke patients. • The maximum cerebral blood flow of hyperperfusion was associated with hemorrhagic transformation and clinical prognosis and higher maximum cerebral blood flow of hyperperfusion was associated with higher grade hemorrhagic transformation. • The maximum cerebral blood flow of hyperperfusion can predict hemorrhagic transformation which enables timely intervention to prevent parenchymal hematoma.
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Affiliation(s)
- Jianbin Huang
- Department of Medical Imaging Center, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou Avenue North, Guangzhou, 510515, Guangdong, People's Republic of China
| | - Peng Hao
- Department of Medical Imaging Center, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou Avenue North, Guangzhou, 510515, Guangdong, People's Republic of China
| | - Zelong Chen
- Department of Medical Imaging Center, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou Avenue North, Guangzhou, 510515, Guangdong, People's Republic of China
| | - Kan Deng
- Philips Healthcare, Guangzhou, People's Republic of China
| | - Baoer Liu
- Department of Medical Imaging Center, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou Avenue North, Guangzhou, 510515, Guangdong, People's Republic of China
| | - Yikai Xu
- Department of Medical Imaging Center, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou Avenue North, Guangzhou, 510515, Guangdong, People's Republic of China.
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Li M, Lv Y, Wang M, Zhang Y, Pan Z, Luo Y, Zhang H, Wang J. Magnetic Resonance Perfusion-Weighted Imaging in Predicting Hemorrhagic Transformation of Acute Ischemic Stroke: A Retrospective Study. Diagnostics (Basel) 2023; 13:3404. [PMID: 37998540 PMCID: PMC10670343 DOI: 10.3390/diagnostics13223404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/25/2023] Open
Abstract
Hemorrhagic transformation (HT) is one of the common complications in patients with acute ischemic stroke (AIS). This study aims to investigate the value of different thresholds of Tmax generated from perfusion-weighted MR imaging (PWI) and the apparent diffusion coefficient (ADC) value in the prediction of HT in AIS. A total of 156 AIS patients were enrolled in this study, with 55 patients in the HT group and 101 patients in non-HT group. The clinical baseline data and multi-parametric MRI findings were compared between HT and non-HT groups to identify indicators related to HT. The optimal parameters for predicting HT and the corresponding cutoff values were obtained using the receiver operating characteristic curve analysis of the volumes of ADC < 620 × 10-6 mm2/s and Tmax > 6 s, 8 s, and 10 s. The results showed that the volumes of ADC < 620 × 10-6 mm2/s and Tmax > 6 s, 8 s, and 10 s in the HT group were all significantly larger than that in the non-HT group and were all independent risk factors for HT. Early measurement of the volume of Tmax > 10 s had the highest value, with a cutoff lesion volume of 10.5 mL.
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Affiliation(s)
- Ming Li
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; (M.L.); (Z.P.)
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Yifan Lv
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Mingming Wang
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Yaying Zhang
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Zilai Pan
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; (M.L.); (Z.P.)
| | - Yu Luo
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Haili Zhang
- Southeast University Hospital, Southeast University, Nanjing 210096, China
| | - Jing Wang
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
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Ravi H, Hawkins SH, Stringfield O, Pereira M, Chen DT, Enderling H, Michael Yu HH, Arrington JA, Sahebjam S, Raghunand N. Rules-based Volumetric Segmentation of Multiparametric MRI for Response Assessment in Recurrent High-Grade Glioma. RESEARCH SQUARE 2023:rs.3.rs-3318286. [PMID: 37790451 PMCID: PMC10543497 DOI: 10.21203/rs.3.rs-3318286/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
We report domain knowledge-based rules for assigning voxels in brain multiparametric MRI (mpMRI) to distinct tissuetypes based on their appearance on Apparent Diffusion Coefficient of water (ADC) maps, T1-weighted unenhanced and contrast-enhanced, T2-weighted, and Fluid-Attenuated Inversion Recovery images. The development dataset comprised mpMRI of 18 participants with preoperative high-grade glioma (HGG), recurrent HGG (rHGG), and brain metastases. External validation was performed on mpMRI of 235 HGG participants in the BraTS 2020 training dataset. The treatment dataset comprised serial mpMRI of 32 participants (total 231 scan dates) in a clinical trial of immunoradiotherapy in rHGG (NCT02313272). Pixel intensity-based rules for segmenting contrast-enhancing tumor (CE), hemorrhage, Fluid, non-enhancing tumor (Edema1), and leukoaraiosis (Edema2) were identified on calibrated, co-registered mpMRI images in the development dataset. On validation, rule-based CE and High FLAIR (Edema1 + Edema2) volumes were significantly correlated with ground truth volumes of enhancing tumor (R = 0.85;p < 0.001) and peritumoral edema (R = 0.87;p < 0.001), respectively. In the treatment dataset, a model combining time-on-treatment and rule-based volumes of CE and intratumoral Fluid was 82.5% accurate for predicting progression within 30 days of the scan date. An explainable decision tree applied to brain mpMRI yields validated, consistent, intratumoral tissuetype volumes suitable for quantitative response assessment in clinical trials of rHGG.
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4
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Elsaid AF, Fahmi RM, Shehta N, Ramadan BM. Machine learning approach for hemorrhagic transformation prediction: Capturing predictors' interaction. Front Neurol 2022; 13:951401. [PMID: 36504664 PMCID: PMC9731336 DOI: 10.3389/fneur.2022.951401] [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: 05/24/2022] [Accepted: 10/28/2022] [Indexed: 11/25/2022] Open
Abstract
Background and purpose Patients with ischemic stroke frequently develop hemorrhagic transformation (HT), which could potentially worsen the prognosis. The objectives of the current study were to determine the incidence and predictors of HT, to evaluate predictor interaction, and to identify the optimal predicting models. Methods A prospective study included 360 patients with ischemic stroke, of whom 354 successfully continued the study. Patients were subjected to thorough general and neurological examination and T2 diffusion-weighted MRI, at admission and 1 week later to determine the incidence of HT. HT predictors were selected by a filter-based minimum redundancy maximum relevance (mRMR) algorithm independent of model performance. Several machine learning algorithms including multivariable logistic regression classifier (LRC), support vector classifier (SVC), random forest classifier (RFC), gradient boosting classifier (GBC), and multilayer perceptron classifier (MLPC) were optimized for HT prediction in a randomly selected half of the sample (training set) and tested in the other half of the sample (testing set). The model predictive performance was evaluated using receiver operator characteristic (ROC) and visualized by observing case distribution relative to the models' predicted three-dimensional (3D) hypothesis spaces within the testing dataset true feature space. The interaction between predictors was investigated using generalized additive modeling (GAM). Results The incidence of HT in patients with ischemic stroke was 19.8%. Infarction size, cerebral microbleeds (CMB), and the National Institute of Health stroke scale (NIHSS) were identified as the best HT predictors. RFC (AUC: 0.91, 95% CI: 0.85-0.95) and GBC (AUC: 0.91, 95% CI: 0.86-0.95) demonstrated significantly superior performance compared to LRC (AUC: 0.85, 95% CI: 0.79-0.91) and MLPC (AUC: 0.85, 95% CI: 0.78-0.92). SVC (AUC: 0.90, 95% CI: 0.85-0.94) outperformed LRC and MLPC but did not reach statistical significance. LRC and MLPC did not show significant differences. The best models' 3D hypothesis spaces demonstrated non-linear decision boundaries suggesting an interaction between predictor variables. GAM analysis demonstrated a linear and non-linear significant interaction between NIHSS and CMB and between NIHSS and infarction size, respectively. Conclusion Cerebral microbleeds, NIHSS, and infarction size were identified as HT predictors. The best predicting models were RFC and GBC capable of capturing nonlinear interaction between predictors. Predictor interaction suggests a dynamic, rather than, fixed cutoff risk value for any of these predictors.
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Affiliation(s)
- Ahmed F. Elsaid
- Department of Public Health and Community Medicine, Zagazig University, Zagazig, Egypt,*Correspondence: Ahmed F. Elsaid ;
| | - Rasha M. Fahmi
- Neurology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Nahed Shehta
- Neurology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Bothina M. Ramadan
- Neurology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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5
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ADC measurement relevance to predict hemorrhage transformation after mechanical thrombectomy. J Neurol Sci 2022; 441:120370. [DOI: 10.1016/j.jns.2022.120370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/11/2022] [Accepted: 07/27/2022] [Indexed: 11/20/2022]
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6
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Timing of anticoagulation after acute ischemic stroke in patients with atrial fibrillation. Neurol Sci 2022:1-12. [PMID: 35762354 DOI: 10.1017/cjn.2022.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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7
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Hong JM, Kim DS, Kim M. Hemorrhagic Transformation After Ischemic Stroke: Mechanisms and Management. Front Neurol 2021; 12:703258. [PMID: 34917010 PMCID: PMC8669478 DOI: 10.3389/fneur.2021.703258] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 10/21/2021] [Indexed: 01/01/2023] Open
Abstract
Symptomatic hemorrhagic transformation (HT) is one of the complications most likely to lead to death in patients with acute ischemic stroke. HT after acute ischemic stroke is diagnosed when certain areas of cerebral infarction appear as cerebral hemorrhage on radiological images. Its mechanisms are usually explained by disruption of the blood-brain barrier and reperfusion injury that causes leakage of peripheral blood cells. In ischemic infarction, HT may be a natural progression of acute ischemic stroke and can be facilitated or enhanced by reperfusion therapy. Therefore, to balance risks and benefits, HT occurrence in acute stroke settings is an important factor to be considered by physicians to determine whether recanalization therapy should be performed. This review aims to illustrate the pathophysiological mechanisms of HT, outline most HT-related factors after reperfusion therapy, and describe prevention strategies for the occurrence and enlargement of HT, such as blood pressure control. Finally, we propose a promising therapeutic approach based on biological research studies that would help clinicians treat such catastrophic complications.
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Affiliation(s)
- Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
- Department of Biomedical Science, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
| | - Da Sol Kim
- Department of Biomedical Science, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
| | - Min Kim
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
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8
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Pilgram-Pastor SM, Piechowiak EI, Dobrocky T, Kaesmacher J, Den Hollander J, Gralla J, Mordasini P. Stroke thrombectomy complication management. J Neurointerv Surg 2021; 13:912-917. [PMID: 34158401 PMCID: PMC8458081 DOI: 10.1136/neurintsurg-2021-017349] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/11/2021] [Indexed: 11/04/2022]
Abstract
Endovascular mechanical thrombectomy (EVT) is widely accepted as the first-line treatment for acute ischemic stroke in patients with large vessel occlusion. Being an invasive treatment, this method is associated with various preoperative, perioperative, and postoperative complications. These complications may influence peri-interventional morbidity and mortality and therefore treatment efficacy and clinical outcome. The aim of this review is to discuss the most common types of complications associated with EVT, the probable mechanisms of injury, and effective methods to manage and prevent complications.
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Affiliation(s)
- Sara M Pilgram-Pastor
- Department for Diagnostic and Interventional Neuroradiology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Eike I Piechowiak
- Department for Diagnostic and Interventional Neuroradiology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Tomas Dobrocky
- Department for Diagnostic and Interventional Neuroradiology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Department for Diagnostic and Interventional Neuroradiology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Juergen Den Hollander
- Department for Diagnostic and Interventional Neuroradiology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Jan Gralla
- Department for Diagnostic and Interventional Neuroradiology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department for Diagnostic and Interventional Neuroradiology, Inselspital Universitatsspital Bern, Bern, Switzerland
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9
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Kaesmacher J, Kaesmacher M, Berndt M, Maegerlein C, Mönch S, Wunderlich S, Meinel TR, Fischer U, Zimmer C, Boeckh-Behrens T, Kleine JF. Early Thrombectomy Protects the Internal Capsule in Patients With Proximal Middle Cerebral Artery Occlusion. Stroke 2021; 52:1570-1579. [PMID: 33827247 PMCID: PMC8078129 DOI: 10.1161/strokeaha.120.031977] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Proximal middle cerebral artery (MCA) occlusions impede blood flow to the noncollateralized lenticulostriate artery territory. Previous work has shown that this almost inevitably leads to infarction of the dependent gray matter territories in the striate even if perfusion is restored by mechanical thrombectomy. Purpose of this analysis was to evaluate potential sparing of neighboring fiber tracts, ie, the internal capsule. METHODS An observational single-center study of patients with proximal MCA occlusions treated with mechanical thrombectomy and receiving postinterventional high-resolution diffusion-weighted imaging was conducted. Patients were classified according to internal capsule ischemia (IC+ versus IC-) at the postero-superior level of the MCA lenticulostriate artery territory (corticospinal tract correlate). Associations of IC+ versus IC- with baseline variables as well as its clinical impact were evaluated using multivariable logistic or linear regression analyses adjusting for potential confounders. RESULTS Of 92 included patients with proximal MCA territory infarctions, 45 (48.9%) had an IC+ pattern. Longer time from symptom-onset to groin-puncture (adjusted odds ratio, 2.12 [95% CI, 1.19-3.76] per hour), female sex and more severe strokes were associated with IC+. Patients with IC+ had lower rates of substantial neurological improvement and functional independence (adjusted odds ratio, 0.26 [95% CI, 0.09-0.81] and adjusted odds ratio, 0.25 [95% CI, 0.07-0.86]) after adjustment for confounders. These associations remained unchanged when confining analyses to patients without ischemia in the corona radiata or the motor cortex and here, IC+ was associated with higher National Institutes of Health Stroke Scale motor item scores (β, +2.8 [95% CI, 1.5 to 4.1]) without a significant increase in nonmotor items (β, +0.8 [95% CI, -0.2 to 1.9). CONCLUSIONS Rapid mechanical thrombectomy with successful reperfusion of the lenticulostriate arteries often protects the internal capsule from subsequent ischemia despite early basal ganglia damage. Salvage of this eloquent white matter tract within the MCA lenticulostriate artery territory seems strongly time-dependent, which has clinical and pathophysiological implications.
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Affiliation(s)
- Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Germany (J.K., M.K., M.B., C.M., S.M., C.Z., T.B.-B., J.F.K.).,University Institute of Diagnostic and Interventional Neuroradiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland.,University Institute of Diagnostic and Interventional and Pediatric Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Mirjam Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Germany (J.K., M.K., M.B., C.M., S.M., C.Z., T.B.-B., J.F.K.)
| | - Maria Berndt
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Germany (J.K., M.K., M.B., C.M., S.M., C.Z., T.B.-B., J.F.K.).,Department of Radiology, DONAUISAR Hospital, Deggendorf, Germany (M.B.)
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Germany (J.K., M.K., M.B., C.M., S.M., C.Z., T.B.-B., J.F.K.)
| | - Sebastian Mönch
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Germany (J.K., M.K., M.B., C.M., S.M., C.Z., T.B.-B., J.F.K.)
| | - Silke Wunderlich
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Germany (S.W.)
| | - Thomas R Meinel
- Department of Neurology (T.R.M., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Urs Fischer
- Department of Neurology (T.R.M., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Germany (J.K., M.K., M.B., C.M., S.M., C.Z., T.B.-B., J.F.K.)
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Germany (J.K., M.K., M.B., C.M., S.M., C.Z., T.B.-B., J.F.K.)
| | - Justus F Kleine
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Germany (J.K., M.K., M.B., C.M., S.M., C.Z., T.B.-B., J.F.K.).,Department of Neuroradiology, Charité Universitätsmedizin Berlin, Germany (J.F.K.)
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10
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Yu S, Ma SJ, Liebeskind DS, Qiao XJ, Yan L, Saver JL, Salamon N, Wang DJJ. Reperfusion Into Severely Damaged Brain Tissue Is Associated With Occurrence of Parenchymal Hemorrhage for Acute Ischemic Stroke. Front Neurol 2020; 11:586. [PMID: 32670187 PMCID: PMC7332705 DOI: 10.3389/fneur.2020.00586] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 05/22/2020] [Indexed: 12/27/2022] Open
Abstract
Background and Purpose: This study aims to quantify the reperfusion status within severely damaged brain tissue and to evaluate its relationship with high grade of hemorrhagic transformation (HT). Methods: Pseudo-continuous ASL was performed along with DWI in 102 patients within 24 h post-treatments. The infarction core was identified using ADC values <550 × 10−6 mm2/s. CBF within the infarction core and its contralateral counterpart were acquired. CBF at the 25th, median, and 75th percentiles of the contralateral counterpart were used as thresholds and the ASL reperfusion volume above the threshold was labeled as vol-25, -50, and -75, respectively. Recanalization was defined according to Thrombolysis in Myocardial Infarction (TIMI) criteria. Results: Quantified reperfusion within the infarction core differed significantly in patients with complete and incomplete recanalization. In the ROC analysis for the prediction of parenchymal hematoma (PH), ASL reperfusion vol-25 had the highest area under the curve (AUC) when compared with ASL vol-50 and ASL vol-75. ASL reperfusion vol-25 had significantly higher AUC compared with ADC threshold volume in the prediction of PH (0.783 vs. 0.685, P = 0.0036) and PH-2 (0.844 vs. 0.754, P = 0.0035). In stepwise multivariate logistic regression analysis, only ASL reperfusion vol-25 emerged as an independent predictor of PH (OR = 3.51, 95% CI: 1.65–7.45, P < 0.001) and PH-2 (OR = 2.32, 95% CI: 1.13–4.76, P = 0.022). Conclusions: Increased reperfusion volume within severely damaged brain tissue is associated with the occurrence of higher grade of HT.
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Affiliation(s)
- Songlin Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Neurovascular Imaging Research Core and UCLA Stroke Center, Department of Neurology, UCLA, Los Angeles, CA, United States.,CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, China
| | - Samantha J Ma
- Department of Neurology, USC Stevens Neuroimaging and Informatics Institute, USC, Los Angeles, CA, United States
| | - David S Liebeskind
- Neurovascular Imaging Research Core and UCLA Stroke Center, Department of Neurology, UCLA, Los Angeles, CA, United States
| | - Xin J Qiao
- Department of Radiology, UCLA, Los Angeles, CA, United States
| | - Lirong Yan
- Department of Neurology, USC Stevens Neuroimaging and Informatics Institute, USC, Los Angeles, CA, United States
| | - Jeffrey L Saver
- Neurovascular Imaging Research Core and UCLA Stroke Center, Department of Neurology, UCLA, Los Angeles, CA, United States
| | - Noriko Salamon
- Department of Radiology, UCLA, Los Angeles, CA, United States
| | - Danny J J Wang
- Department of Neurology, USC Stevens Neuroimaging and Informatics Institute, USC, Los Angeles, CA, United States
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11
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Xu J, Li Y, Pu J. Two cases of successful recanalization for acute cerebral artery embolism during perioperative period of radiofrequency ablation for atrial fibrillation. Ann Noninvasive Electrocardiol 2020; 25:e12754. [PMID: 32277556 PMCID: PMC7507426 DOI: 10.1111/anec.12754] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 02/18/2020] [Indexed: 12/26/2022] Open
Abstract
To explore the strategy of acute cerebral artery embolism after radiofrequency catheter ablation (RFA) for atrial fibrillation (AF). Reporting two cases with acute cerebral infarction after RFA for AF. Two patients were both with AF, and intracardiac thrombus was excluded through transesophageal echocardiogram (TEE) before procedure. Approach of ablation: circumferential pulmonary vein ablation in left atrium to isolate pulmonary vein plus linear ablation in the top and bottom of left atrium (BOX procedure). They both received Dabigatran Etexilate 110 mg twice daily, starting 6 hr after ablation. Symptoms of major stroke appeared 30 hr after ablation in Case 1. Occlusion was detected in M1 segment of the left middle cerebral artery by MRI 2 hr after symptoms onset. Intravenous thrombolysis was given immediately. In Case 2, the patient presented symptoms of major stroke 34 hr after ablation and occlusion in the basilar artery was confirmed by MRI 4.5 hr after symptoms onset. Although it was beyond the thrombolysis time window, mechanical thrombectomy was taken 7 hr after the symptoms onset. The culprit artery was successfully revascularized in both cases. In Case 1, NIHSS score was reduced from 8 (before thrombolysis) to 0 (24 hr after thrombolysis). In Case 2, NIHSS score decreased from 18 (before embolectomy) to 3 (24 hr after embolectomy). Both of the patients live a normal life without brain function impairment and hemorrhage until the last follow‐up. Timely recanalization could attained a good cure effect when acute stoke was happened after RFA for AF.
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Affiliation(s)
- Jin Xu
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yana Li
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jun Pu
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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12
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Elsaid N, Mustafa W, Saied A. Radiological predictors of hemorrhagic transformation after acute ischemic stroke: An evidence-based analysis. Neuroradiol J 2020; 33:118-133. [PMID: 31971093 PMCID: PMC7140299 DOI: 10.1177/1971400919900275] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Hemorrhagic transformation (HT) is one of the most common adverse events related to acute ischemic stroke (AIS) that affects the treatment plan and clinical outcome. Identification of a sensitive radiological marker may influence the controversial thrombolytic decision in the setting of AIS and may at a minimum indicate more intensive monitoring or further prophylactic interventions. In this article we summarize possible radiological biomarkers and the role of different radiological modalities including computed tomography (CT), magnetic resonance imaging, angiography, and ultrasound in predicting HT. Different radiological indices of early ischemic changes, large ischemic lesion volume, severe blood flow restriction, blood-brain barrier disruption, poor collaterals and high blood flow velocities have been reported to be associated with higher risk of HT. The current levels of evidence of the available studies highlight the role of the different CT perfusion parameters in predicting HT. Further large standardized studies are recommended to compare the sensitivity and specificity of the different radiological markers combined and delineate the most reliable predictor.
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Affiliation(s)
- Nada Elsaid
- Department of Neurology, University of Mansoura
Faculty of Medicine, Egypt
| | - Wessam Mustafa
- Department of Neurology, University of Mansoura
Faculty of Medicine, Egypt
| | - Ahmed Saied
- Department of Neurology, University of Mansoura
Faculty of Medicine, Egypt
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Kaesmacher J, Chaloulos-Iakovidis P, Panos L, Mordasini P, Michel P, Hajdu SD, Ribo M, Requena M, Maegerlein C, Friedrich B, Costalat V, Benali A, Pierot L, Gawlitza M, Schaafsma J, Mendes Pereira V, Gralla J, Fischer U. Mechanical Thrombectomy in Ischemic Stroke Patients With Alberta Stroke Program Early Computed Tomography Score 0-5. Stroke 2020; 50:880-888. [PMID: 30827193 PMCID: PMC6430594 DOI: 10.1161/strokeaha.118.023465] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— If anterior circulation large vessel occlusion acute ischemic stroke patients presenting with ASPECTS 0–5 (Alberta Stroke Program Early CT Score) should be treated with mechanical thrombectomy remains unclear. Purpose of this study was to report on the outcome of patients with ASPECTS 0–5 treated with mechanical thrombectomy and to provide data regarding the effect of successful reperfusion on clinical outcomes and safety measures in these patients. Methods— Multicenter, pooled analysis of 7 institutional prospective registries: Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the SOLITAIRE FR With the Intention for Thrombectomy (Clinical Trial Registration—URL: https://www.clinicaltrials.gov. Unique identifier: NCT03496064). Primary outcome was defined as modified Rankin Scale 0–3 at day 90 (favorable outcome). Secondary outcomes included rates of day 90 modified Rankin Scale 0–2 (functional independence), day 90 mortality and occurrence of symptomatic intracerebral hemorrhage. Multivariable logistic regression analyses were performed to assess the association of successful reperfusion with clinical outcomes. Outputs are displayed as adjusted Odds Ratios (aOR) and 95% CI. Results— Two hundred thirty-seven of 2046 patients included in this registry presented with anterior circulation large vessel occlusion and ASPECTS 0–5. In this subgroup, the overall rates of favorable outcome and mortality at day 90 were 40.1% and 40.9%. Achieving successful reperfusion was independently associated with favorable outcome (aOR, 5.534; 95% CI, 2.363–12.961), functional independence (aOR, 5.583; 95% CI, 1.964–15.873), reduced mortality (aOR, 0.180; 95% CI, 0.083–0.390), and lower rates of symptomatic intracerebral hemorrhage (aOR, 0.235; 95% CI, 0.062–0.887). The mortality-reducing effect remained in patients with ASPECTS 0–4 (aOR, 0.167; 95% CI, 0.056–0.499). Sensitivity analyses did not change the primary results. Conclusions— In patients presenting with ASPECTS 0–5, who were treated with mechanical thrombectomy, successful reperfusion was beneficial without increasing the risk of symptomatic intracerebral hemorrhage. Although the results do not allow for general treatment recommendations, formal testing of mechanical thrombectomy versus best medical treatment in these patients in a randomized controlled trial is warranted.
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Affiliation(s)
- Johannes Kaesmacher
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., P. Mordasini, J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland.,Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland.,University Institute of Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Panagiotis Chaloulos-Iakovidis
- Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Leonidas Panos
- Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Pasquale Mordasini
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., P. Mordasini, J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Patrik Michel
- Department of Neurology (P. Michel) and Department of Radiology (S.D.H.), CHUV Lausanne, Switzerland
| | - Steven D Hajdu
- Department of Neurology (P. Michel) and Department of Radiology (S.D.H.), CHUV Lausanne, Switzerland
| | - Marc Ribo
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (M. Ribo, M. Requena)
| | - Manuel Requena
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (M. Ribo, M. Requena)
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (C.M., B.F.)
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (C.M., B.F.)
| | - Vincent Costalat
- Department of Neuroradiology, CHU Montpellier, France (V.C., A.B.), Toronto Western Hospital, ON
| | - Amel Benali
- Department of Neuroradiology, CHU Montpellier, France (V.C., A.B.), Toronto Western Hospital, ON
| | - Laurent Pierot
- Department of Neuroradiology, CHU Reims, France (L.P., M.G.), Toronto Western Hospital, ON
| | - Matthias Gawlitza
- Department of Neuroradiology, CHU Reims, France (L.P., M.G.), Toronto Western Hospital, ON
| | | | | | - Jan Gralla
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., P. Mordasini, J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Urs Fischer
- Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
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14
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Adebayo OD, Culpan G. Diagnostic accuracy of computed tomography perfusion in the prediction of haemorrhagic transformation and patient outcome in acute ischaemic stroke: A systematic review and meta-analysis. Eur Stroke J 2019; 5:4-16. [PMID: 32232165 DOI: 10.1177/2396987319883461] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 09/23/2019] [Indexed: 01/23/2023] Open
Abstract
Purpose The aim of this systematic review and meta-analysis is to determine the diagnostic accuracy of computed tomography brain perfusion in the prediction of haemorrhagic transformation and patient outcome in acute ischaemic stroke. Method Electronic databases and grey literature published over the last 10 years related to healthcare and radiology were searched using the key terms: 'computed tomography perfusion', 'haemorrhagic transformation', 'acute ischaemic stroke', 'functional outcome' and their synonyms using both UK and American spellings. Inclusion criteria were: sample size at least 30 patients, original research, evaluate ability of computed tomography perfusion to predict haemorrhagic transformation, reports diagnostic accuracy or provide relevant data for a 2 × 2 contingency table, use follow-up non-contrast computed tomography (NCCT) or magnetic resonance imaging as reference standard. Findings Twelve studies were included in the review; studies cover a total of 808 patients. Haemorrhagic transformation occurred in 30.2% of patients. Pooled sensitivity and specificity were 85.9% (95% CI; 65-97%), 73.9% (95% CI; 45-92%) and accuracy of 79.1% (95% CI; 57-98%). Pooled NPV was 92.9% with a high false positive rate (19.8%), which could be explained in terms of outcome classification, acquisition artefact and computed tomography perfusion processing algorithms. Discussion This review evaluated the importance of using pre-defined threshold measurement for optimal prediction of HT, the relevance of patient pre-treatment clinical parameters to HT occurrence, the CTP parameters and the measurements that are independent predictors of HT, the significance of rtPA rather as an exacerbator of HT and the impact of both minor and major HT/PH on patient 20 functional outcome. Conclusion Computed tomography perfusion has a high sensitivity and moderately high specificity for prediction of haemorrhagic transformation in acute ischaemic stroke. Pre-treatment clinical decision making requires consideration of clinical factors in addition to imaging findings. This systematic review and meta-analysis highlights that pre-treatment computed tomography perfusion adds to clinical confidence by predicting potential for haemorrhage, both in thrombolysed and un-thrombolysed patients, and also influences decisions about alternative treatments for acute ischaemic stroke patients.
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Affiliation(s)
- Olushola D Adebayo
- Mercy University Hospital Cork, Cork, Republic of Ireland
- Faculty of Health Sciences, University of Bradford, Bradford, UK
| | - Gary Culpan
- Faculty of Health Sciences, University of Bradford, Bradford, UK
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15
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Kaesmacher J, Kaesmacher M, Maegerlein C, Zimmer C, Gersing AS, Wunderlich S, Friedrich B, Boeckh-Behrens T, Kleine JF. Hemorrhagic Transformations after Thrombectomy: Risk Factors and Clinical Relevance. Cerebrovasc Dis 2017; 43:294-304. [PMID: 28343220 DOI: 10.1159/000460265] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/28/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hemorrhagic transformation (HT) is a major complication of acute ischemic stroke, potentially associated with clinical deterioration. We attempted to identify risk factors and evaluated clinical relevance of minor and major HTs following endovascular thrombectomy (ET) in isolated middle cerebral artery (MCA) occlusions. METHODS This is a retrospective single-center analysis of 409 patients with isolated MCA occlusion treated with ET. Patients' and procedural characteristics, severity of HT according to the European Cooperative Acute Stroke Study criteria, and clinical outcomes were analyzed. Multivariate logistic regression models with standard retention criteria (p < 0.1) were used to determine risk factors and clinical relevance of HT. Results are shown as adjusted OR (aOR) and respective 95% CIs. Good neurologic short-term outcome was defined as National Institutes of Health Stroke Scale (NIHSS) score <5 at the day of discharge. RESULTS Of 299 patients included, hemorrhagic infarction (HI) was detected in 87 patients, while 13 patients developed parenchymal hematoma (PH). Higher age (aOR 0.970, 95% CI 0.947-0.993, p = 0.012), eligibility for intravenous recombinant tissue plasminogen activator (IV rtPA; aOR 0.512, 95% CI 0.267-0.982, p = 0.044), and complete recanalization (TICI 3, aOR 0.408, 95% CI 0.210-0.789, p = 0.008) were associated with a lower risk of HI. Risk factors for HI included higher admission NIHSS score (aOR 1.080, 95% CI 1.010-1.153, p = 0.024) and higher admission glucose levels (aOR 1.493, 95% CI 1.170-1.904, p = 0.001). Further, female sex tended to be associated with a lower risk of HI (aOR 0.601, 95% CI 0.316-1.143, p = 0.121), while a statistical trend was observable for proximal MCA occlusion (aOR 1.856, 95% CI 0.945-3.646, p = 0.073) and a history of hypertension (aOR 2.176, 95% CI 0.932-5.080, p = 0.072) to increase risk of HI. Longer intervals from symptom onset to first digital subtraction angiography runs (aOR 1.013, 95% CI 1.003-1.022, p = 0.009), lower preinterventional Alberta Stroke Program Early CT score (aOR 0.536, 95% CI 0.307-0.936, p = 0.028) and wake-up stroke (aOR 18.540, 95% CI 1.352-254.276, p = 0.029) were associated with PH. Both, PH and HI were independently associated with lower rates of good neurologic outcome (aOR 0.086, 95% CI 0.008-0.902, p = 0.041 and aOR 0.282, 95% CI 0.131-0.606, p = 0.001). CONCLUSION Risk of HI following MCA occlusion and subsequent ET is mainly determined by factors influencing infarct severity. Good recanalization results seem to be protective against subsequent HI. Our results support the notion that occurrence of PH after ET is time dependent and risk increases with more extensive early ischemic damage. Both, HI and PH do not seem to be facilitated by bridging therapy with IV rtPA or the use of oral anticoagulants, but were independently associated with more severe neurologic disability. These results support the notion that HI is not a "benign" imaging sign.
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Affiliation(s)
- Johannes Kaesmacher
- Department of Neuroradiology, Klinikum rechts der Isar, TU München, Munich, Germany
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16
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Nael K, Knitter JR, Jahan R, Gornbein J, Ajani Z, Feng L, Meyer BC, Schwamm LH, Yoo AJ, Marshall RS, Meyers PM, Yavagal DR, Wintermark M, Liebeskind DS, Guzy J, Starkman S, Saver JL, Kidwell CS. Multiparametric Magnetic Resonance Imaging for Prediction of Parenchymal Hemorrhage in Acute Ischemic Stroke After Reperfusion Therapy. Stroke 2017; 48:664-670. [PMID: 28138001 PMCID: PMC5325250 DOI: 10.1161/strokeaha.116.014343] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 12/05/2016] [Accepted: 12/07/2016] [Indexed: 12/31/2022]
Abstract
Background and Purpose— Patients with acute ischemic stroke are at increased risk of developing parenchymal hemorrhage (PH), particularly in the setting of reperfusion therapies. We have developed a predictive model to examine the risk of PH using combined magnetic resonance perfusion and diffusion parameters, including cerebral blood volume (CBV), apparent diffusion coefficient, and microvascular permeability (K2). Methods— Voxel-based values of CBV, K2, and apparent diffusion coefficient from the ischemic core were obtained using pretreatment magnetic resonance imaging data from patients enrolled in the MR RESCUE clinical trial (Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy). The associations between PH and extreme values of imaging parameters were assessed in univariate and multivariate analyses. Receiver-operating characteristic curve analysis was performed to determine the optimal parameter(s) and threshold for predicting PH. Results— In 83 patients included in this analysis, 20 developed PH. Univariate analysis showed significantly lower 10th percentile CBV and 10th percentile apparent diffusion coefficient values and significantly higher 90th percentile K2 values within the infarction core of patients with PH. Using classification tree analysis, the 10th percentile CBV at threshold of 0.47 and 90th percentile K2 at threshold of 0.28 resulted in overall predictive accuracy of 88.7%, sensitivity of 90.0%, and specificity of 87.3%, which was superior to any individual or combination of other classifiers. Conclusions— Our results suggest that combined 10th percentile CBV and 90th percentile K2 is an independent predictor of PH in patients with acute ischemic stroke with diagnostic accuracy superior to individual classifiers alone. This approach may allow risk stratification for patients undergoing reperfusion therapies. Clinical Trial Registration— URL: https://www.clinicaltrials.gov. Unique identifier: NCT00389467.
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Affiliation(s)
- Kambiz Nael
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.).
| | - James R Knitter
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.)
| | - Reza Jahan
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.)
| | - Jeffery Gornbein
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.)
| | - Zahra Ajani
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.)
| | - Lei Feng
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.)
| | - Brett C Meyer
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.)
| | - Lee H Schwamm
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.)
| | - Albert J Yoo
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.)
| | - Randolph S Marshall
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.)
| | - Philip M Meyers
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.)
| | - Dileep R Yavagal
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.)
| | - Max Wintermark
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.)
| | - David S Liebeskind
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.)
| | - Judy Guzy
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.)
| | - Sidney Starkman
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.)
| | - Jeffrey L Saver
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.)
| | - Chelsea S Kidwell
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.)
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Liu D, Scalzo F, Rao NM, Hinman JD, Kim D, Ali LK, Saver JL, Sun W, Dai Q, Liu X, Liebeskind DS. Fluid-Attenuated Inversion Recovery Vascular Hyperintensity Topography, Novel Imaging Marker for Revascularization in Middle Cerebral Artery Occlusion. Stroke 2016; 47:2763-2769. [PMID: 27659851 DOI: 10.1161/strokeaha.116.013953] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 08/12/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In acute arterial occlusion, fluid-attenuated inversion recovery vascular hyperintensity (FVH) has been linked to slow flow in leptomeningeal collaterals and cerebral hypoperfusion, but the impact on clinical outcome is still controversial. In this study, we aimed to investigate the association between FVH topography or FVH-Alberta Stroke Program Early CT Score (ASPECTS) pattern and outcome in acute M1-middle cerebral artery occlusion patients with endovascular treatment. METHODS We included acute M1-middle cerebral artery occlusion patients treated with endovascular therapy (ET). All patients had diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery before ET. Distal FVH-ASPECTS was evaluated according to distal middle cerebral artery-ASPECT area (M1-M6) and acute DWI lesion was also reviewed. The presence of FVH inside and outside DWI-positive lesions was separately analyzed. Clinical outcome after ET was analyzed with respect to different distal FVH-ASPECTS topography. RESULTS Among 101 patients who met inclusion criteria for the study, mean age was 66.2±17.8 years and median National Institutes of Health Stroke Scale was 17.0 (interquartile range, 12.0-21.0). FVH-ASPECTS measured outside of the DWI lesion was significantly higher in patients with good outcome (modified Rankin Scale [mRS] score of 0-2; 8.0 versus 4.0, P<0.001). Logistic regression demonstrated that FVH-ASPECTS outside of the DWI lesion was independently associated with clinical outcome of these patients (odds ratio, 1.3; 95% confidence interval, 1.06-1.68; P=0.013). FVH-ASPECTS inside the DWI lesion was associated with hemorrhagic transformation (odds ratio, 1.3; 95% confidence interval, 1.04-1.51; P=0.019). CONCLUSIONS Higher FVH-ASPECTS measured outside the DWI lesion is associated with good clinical outcomes in patients undergoing ET. FVH-ASPECTS measured inside the DWI lesion was predictive of hemorrhagic transformation. The FVH pattern, not number, can serve as an imaging selection marker for ET in acute middle cerebral artery occlusion.
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Affiliation(s)
- Dezhi Liu
- From the Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China (D.L., W.S., Q.D., X.L.); and Department of Neurology, Neurovascular Imaging Research Core (D.L., F.S., D.S.L.) and Department of Neurology, UCLA Stroke Center (D.L., F.S., N.M.R., J.D.H., D.K., L.K.A., J.L.S., D.S.L.), University of California Los Angeles
| | - Fabien Scalzo
- From the Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China (D.L., W.S., Q.D., X.L.); and Department of Neurology, Neurovascular Imaging Research Core (D.L., F.S., D.S.L.) and Department of Neurology, UCLA Stroke Center (D.L., F.S., N.M.R., J.D.H., D.K., L.K.A., J.L.S., D.S.L.), University of California Los Angeles
| | - Neal M Rao
- From the Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China (D.L., W.S., Q.D., X.L.); and Department of Neurology, Neurovascular Imaging Research Core (D.L., F.S., D.S.L.) and Department of Neurology, UCLA Stroke Center (D.L., F.S., N.M.R., J.D.H., D.K., L.K.A., J.L.S., D.S.L.), University of California Los Angeles
| | - Jason D Hinman
- From the Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China (D.L., W.S., Q.D., X.L.); and Department of Neurology, Neurovascular Imaging Research Core (D.L., F.S., D.S.L.) and Department of Neurology, UCLA Stroke Center (D.L., F.S., N.M.R., J.D.H., D.K., L.K.A., J.L.S., D.S.L.), University of California Los Angeles
| | - Doojin Kim
- From the Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China (D.L., W.S., Q.D., X.L.); and Department of Neurology, Neurovascular Imaging Research Core (D.L., F.S., D.S.L.) and Department of Neurology, UCLA Stroke Center (D.L., F.S., N.M.R., J.D.H., D.K., L.K.A., J.L.S., D.S.L.), University of California Los Angeles
| | - Latisha K Ali
- From the Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China (D.L., W.S., Q.D., X.L.); and Department of Neurology, Neurovascular Imaging Research Core (D.L., F.S., D.S.L.) and Department of Neurology, UCLA Stroke Center (D.L., F.S., N.M.R., J.D.H., D.K., L.K.A., J.L.S., D.S.L.), University of California Los Angeles
| | - Jeffrey L Saver
- From the Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China (D.L., W.S., Q.D., X.L.); and Department of Neurology, Neurovascular Imaging Research Core (D.L., F.S., D.S.L.) and Department of Neurology, UCLA Stroke Center (D.L., F.S., N.M.R., J.D.H., D.K., L.K.A., J.L.S., D.S.L.), University of California Los Angeles
| | - Wen Sun
- From the Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China (D.L., W.S., Q.D., X.L.); and Department of Neurology, Neurovascular Imaging Research Core (D.L., F.S., D.S.L.) and Department of Neurology, UCLA Stroke Center (D.L., F.S., N.M.R., J.D.H., D.K., L.K.A., J.L.S., D.S.L.), University of California Los Angeles
| | - Qiliang Dai
- From the Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China (D.L., W.S., Q.D., X.L.); and Department of Neurology, Neurovascular Imaging Research Core (D.L., F.S., D.S.L.) and Department of Neurology, UCLA Stroke Center (D.L., F.S., N.M.R., J.D.H., D.K., L.K.A., J.L.S., D.S.L.), University of California Los Angeles
| | - Xinfeng Liu
- From the Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China (D.L., W.S., Q.D., X.L.); and Department of Neurology, Neurovascular Imaging Research Core (D.L., F.S., D.S.L.) and Department of Neurology, UCLA Stroke Center (D.L., F.S., N.M.R., J.D.H., D.K., L.K.A., J.L.S., D.S.L.), University of California Los Angeles
| | - David S Liebeskind
- From the Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China (D.L., W.S., Q.D., X.L.); and Department of Neurology, Neurovascular Imaging Research Core (D.L., F.S., D.S.L.) and Department of Neurology, UCLA Stroke Center (D.L., F.S., N.M.R., J.D.H., D.K., L.K.A., J.L.S., D.S.L.), University of California Los Angeles.
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Krieger DA, Dehkharghani S. Magnetic Resonance Imaging in Ischemic Stroke and Cerebral Venous Thrombosis. Top Magn Reson Imaging 2015; 24:331-352. [PMID: 26636639 DOI: 10.1097/rmr.0000000000000067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Imaging is indispensable in the evaluation of patients presenting with central nervous system emergencies. Although computed tomography (CT) is the mainstay of initial assessment and triage, magnetic resonance imaging (MRI) has become vital in expanding diagnostic capabilities, refining management strategies, and developing our understanding of disease processes. Ischemic stroke and cerebral venous thrombosis are 2 areas wherein MRI is actively revolutionizing patient care. Familiarity with the imaging manifestations of these 2 disease processes is crucial for any radiologist reading brain MR studies. In this review, the fundamentals of image interpretation will be addressed in-depth. Furthermore, advanced imaging techniques which are redefining the role of emergency MRI will be outlined, with a focus on the pathophysiological mechanisms that underlie image interpretation. In particular, emerging data surrounding the use of MR perfusion imaging in acute stroke management portend dramatic shifts in neurointerventional management. To this end, a review of the recent stroke literature will hopefully enhance the radiologist's role in both meaningful reporting and multidisciplinary teamwork.
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Affiliation(s)
- Daniel A Krieger
- Emory University School of Medicine, Department of Radiology and Imaging Sciences, Division of Neuroradiology, Atlanta, Georgia
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Parameterization of the Age-Dependent Whole Brain Apparent Diffusion Coefficient Histogram. BIOMED RESEARCH INTERNATIONAL 2015; 2015:373716. [PMID: 26609526 PMCID: PMC4644831 DOI: 10.1155/2015/373716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 09/04/2015] [Accepted: 09/10/2015] [Indexed: 12/03/2022]
Abstract
Purpose. The distribution of apparent diffusion coefficient (ADC) values in the brain can be used to characterize age effects and pathological changes of the brain tissue. The aim of this study was the parameterization of the whole brain ADC histogram by an advanced model with influence of age considered. Methods. Whole brain ADC histograms were calculated for all data and for seven age groups between 10 and 80 years. Modeling of the histograms was performed for two parts of the histogram separately: the brain tissue part was modeled by two Gaussian curves, while the remaining part was fitted by the sum of a Gaussian curve, a biexponential decay, and a straight line. Results. A consistent fitting of the histograms of all age groups was possible with the proposed model. Conclusions. This study confirms the strong dependence of the whole brain ADC histograms on the age of the examined subjects. The proposed model can be used to characterize changes of the whole brain ADC histogram in certain diseases under consideration of age effects.
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Ibatullin MM, Kalinin MN, Curado AT, Khasanova DR. [Neurovisualisation predictors of malignant cerebral infarction and hemorrhagic transformation]. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:3-11. [PMID: 26120991 DOI: 10.17116/jnevro2015115323-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neuroimaging plays a central role in the assessment of patients with acute ischemic stroke. Within a few minutes, modern multimodal imaging protocols can provide one with comprehensive information about prognosis, management, and outcome of the disease, and may detect changes in the intracranial structures reflecting severity of the ischemic injury depicted by four Ps: parenchyma (of the brain), pipes (i.e., the cerebral blood vessels), penumbra, and permeability (of the blood brain barrier). In this article, we have reviewed neuroradiological predictors of malignant middle cerebral artery infarction and hemorrhagic transformation in light of the aforementioned four Ps.
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Affiliation(s)
| | | | - A T Curado
- Interregional Clinical Diagnostic Center, Kazan
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21
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Mishra NK, Christensen S, Wouters A, Campbell BCV, Straka M, Mlynash M, Kemp S, Cereda CW, Bammer R, Marks MP, Albers GW, Lansberg MG. Reperfusion of very low cerebral blood volume lesion predicts parenchymal hematoma after endovascular therapy. Stroke 2015; 46:1245-9. [PMID: 25828235 DOI: 10.1161/strokeaha.114.008171] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 02/27/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND PURPOSE Ischemic stroke patients with regional very low cerebral blood volume (VLCBV) on baseline imaging have increased risk of parenchymal hemorrhage (PH) after intravenous alteplase-induced reperfusion. We developed a method for automated detection of VLCBV and examined whether patients with reperfused-VLCBV are at increased risk of PH after endovascular reperfusion therapy. METHODS Receiver operating characteristic analysis was performed to optimize a relative CBV threshold associated with PH in patients from the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution 2 (DEFUSE 2) study. Regional reperfused-VLCBV was defined as regions with low relative CBV on baseline imaging that demonstrated normal perfusion (Tmax <6 s) on coregistered early follow-up magnetic resonance imaging. The association between VLCBV, regional reperfused-VLCBV and PH was assessed in univariate and multivariate analyses. RESULTS In 91 patients, the greatest area under the curve for predicting PH occurred at an relative CBV threshold of <0.42 (area under the curve, 0.77). At this threshold, VLCBV lesion volume ≥3.55 mL optimally predicted PH with 94% sensitivity and 63% specificity. Reperfused-VLCBV lesion volume was more specific (0.74) and equally sensitive (0.94). In total, 18 patients developed PH, of whom 17 presented with VLCBV (39% versus 2%; P=0.001), all of them had regional reperfusion (47% versus 0%; P=0.01), and 71% received intravenous alteplase. VLCBV lesion (odds ratio, 33) and bridging with intravenous alteplase (odds ratio, 3.8) were independently associated with PH. In a separate model, reperfused-VLCBV remained the single independent predictor of PH (odds ratio, 53). CONCLUSIONS These results suggest that VLCBV can be used for risk stratification of patients scheduled to undergo endovascular therapy in trials and routine clinical practice.
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Affiliation(s)
- Nishant K Mishra
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Søren Christensen
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Anke Wouters
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Bruce C V Campbell
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Matus Straka
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Michael Mlynash
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Stephanie Kemp
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Carlo W Cereda
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Roland Bammer
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Michael P Marks
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Gregory W Albers
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Maarten G Lansberg
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.).
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Hakma Z, Stofko DL, Binning MJ, Liebman K, Veznedaroglu E. Retrospective study of Heparin Administration for Ischemic Stroke when there is an IV-tPA Contraindication. Surg Neurol Int 2014; 5:62. [PMID: 24991465 PMCID: PMC4078448 DOI: 10.4103/2152-7806.132032] [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: 11/14/2013] [Accepted: 03/11/2014] [Indexed: 11/25/2022] Open
Abstract
Background: The majority of patients presenting with an ischemic stroke arrive after the 3-4.5 h time window allowed for intravenous tissue plasminogen activator (IV tPA) administration. Most of the literature on heparin use in acute ischemic stroke does not describe dose-adjusted intravenous unfractionated heparin (IV UFH) without bolus, a common method of administration. This study was designed to test whether an anticoagulation regimen of intravenous dose-adjusted UFH with no bolus, in patients with a contraindication to IV TPA, administered within 24 h of an acute ischemic stroke could be effective and safe. Methods: We conducted a retrospective study of 273 patients over two consecutive years with acute ischemic stroke, who were outside the window for IV tPA. All patients had imaging studies on admission. The primary outcome measure of the study was to evaluate the safety of dose-adjusted IV UFH use in the setting of acute stroke. We looked at duration of heparin infusion, average partial thromboplastin time (PTT) value, and the incidence of new hemorrhagic events. Results: A total of 273 patients met the inclusion criteria. These patients received heparin infusion within 24 h of symptom onset. The duration of intravenous heparin infusion ranged from 1 to 18 days with a mean of 4 days. Mean PTT value was 72.4. Hemorrhagic complications occurred in 26 patients (9.5%), and included 12 asymptomatic petechial or hemorrhagic conversion (4.3%), 2 symptomatic intracranial hemorrhages (0.7%), 5 gastrointestinal bleeds (2 requiring transfusion and interventions), 2 patients experienced benign hematuria, 4 patients with groin hematomas, and one neck hematoma. Conclusion: This study suggests that intravenous dose-adjusted UFH with no bolus can be administered to patients with acute ischemic stroke with relative safety.
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Affiliation(s)
- Zakaria Hakma
- Department of Neurosurgery, Stroke and Cerebrovascular Center of New Jersey at Capital Health, Two Capital Way, Suite 456, Pennington, NJ 08534, USA
| | - Douglas L Stofko
- Department of Neurosurgery, Stroke and Cerebrovascular Center of New Jersey at Capital Health, Two Capital Way, Suite 456, Pennington, NJ 08534, USA
| | - Mandy Jo Binning
- Department of Neurosurgery, Stroke and Cerebrovascular Center of New Jersey at Capital Health, Two Capital Way, Suite 456, Pennington, NJ 08534, USA
| | - Kenneth Liebman
- Department of Neurosurgery, Stroke and Cerebrovascular Center of New Jersey at Capital Health, Two Capital Way, Suite 456, Pennington, NJ 08534, USA
| | - Erol Veznedaroglu
- Department of Neurosurgery, Stroke and Cerebrovascular Center of New Jersey at Capital Health, Two Capital Way, Suite 456, Pennington, NJ 08534, USA
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Hemorrhagic transformation after ischemic stroke in animals and humans. J Cereb Blood Flow Metab 2014; 34:185-99. [PMID: 24281743 PMCID: PMC3915212 DOI: 10.1038/jcbfm.2013.203] [Citation(s) in RCA: 360] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 10/10/2013] [Accepted: 10/28/2013] [Indexed: 01/12/2023]
Abstract
Hemorrhagic transformation (HT) is a common complication of ischemic stroke that is exacerbated by thrombolytic therapy. Methods to better prevent, predict, and treat HT are needed. In this review, we summarize studies of HT in both animals and humans. We propose that early HT (<18 to 24 hours after stroke onset) relates to leukocyte-derived matrix metalloproteinase-9 (MMP-9) and brain-derived MMP-2 that damage the neurovascular unit and promote blood-brain barrier (BBB) disruption. This contrasts to delayed HT (>18 to 24 hours after stroke) that relates to ischemia activation of brain proteases (MMP-2, MMP-3, MMP-9, and endogenous tissue plasminogen activator), neuroinflammation, and factors that promote vascular remodeling (vascular endothelial growth factor and high-moblity-group-box-1). Processes that mediate BBB repair and reduce HT risk are discussed, including transforming growth factor beta signaling in monocytes, Src kinase signaling, MMP inhibitors, and inhibitors of reactive oxygen species. Finally, clinical features associated with HT in patients with stroke are reviewed, including approaches to predict HT by clinical factors, brain imaging, and blood biomarkers. Though remarkable advances in our understanding of HT have been made, additional efforts are needed to translate these discoveries to the clinic and reduce the impact of HT on patients with ischemic stroke.
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Padma V, Fisher M, Moonis M. Role of heparin and low-molecular-weight heparins in the management of acute ischemic stroke. Expert Rev Cardiovasc Ther 2014; 4:405-15. [PMID: 16716101 DOI: 10.1586/14779072.4.3.405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The numerous large-scale randomized clinical trials performed during the last decade on either unfractionated heparin, or low molecular weight heparin have not been able to demonstrate undisputed benefits in patients with acute ischemic stroke, compared with no treatment or aspirin. However, a large number of these trials, including the International Stroke Trial and Chinese Acute Stroke Trial, exhibit severe methodological limitations and need to be interpreted with caution. Knowledge of thromboembolism pathophysiology and clinical experience leads to the theory that heparins will prevent red thrombus formation, propagation and embolism. Heparins effectively prevent venous thrombosis and pulmonary embolism. More trials are needed to test heparins in patients whose cardiocerebrovascular lesions are better defined by newer neuroimaging techniques. The efficacy of heparins has not been adequately tested in patients with defined stroke subtypes and occlusive vascular lesions. Heparins should not be indiscriminately given to all patients with acute ischemic stroke. High-quality, randomized trials that adequately study heparin use in patients using modern technology for vascular lesions and stroke subtypes are lacking, and need to be performed.
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Cerebral blood volume affects blood-brain barrier integrity in an acute transient stroke model. J Cereb Blood Flow Metab 2013; 33:898-905. [PMID: 23462571 PMCID: PMC3677109 DOI: 10.1038/jcbfm.2013.27] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Insufficient vascular reserve after an ischemic stroke may induce biochemical cascades that subsequently deteriorate the blood-brain barrier (BBB) function. However, the direct relationship between poor cerebral blood volume (CBV) restoration and BBB disruption has not been examined in acute stroke. To quantify BBB integrity at acute stages of transient stroke, in particular for cases in which extravasation of the standard contrast agent (Gd-DTPA) is not observed, we adopted the water exchange index (WEI), a novel magnetic resonance image-derived parameter to estimate the water permeability across the BBB. The apparent diffusion coefficient (ADC) and R2 relaxation rate constant were also measured for outlining the tissue abnormality, while fractional CBV and WEI were quantified for assessing vascular alterations. The significantly decreased ADC and R2 in the ischemic cortices did not correlate with the changes in CBV or WEI. In contrast, a strong negative correlation between the ipsilesional WEI and CBV was found, in which stroke mice were clustered into two groups: (1) high WEI and low CBV and (2) normal WEI and CBV. The low CBV observed for mice with a disrupted BBB, characterized by a high WEI, indicates the importance of CBV restoration for maintaining BBB stability in acute stroke.
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Abstract
Stroke is a major cause of morbidity and mortality in children and long-term neurological deficits. Although cerebrovascular disorders occur less often in children than in adults, recognition of stroke in children has probably increased because of the widespread application of noninvasive diagnostic studies such as magnetic resonance imaging and computed tomography.Computed tomography (CT) should be the first imaging choice in the emergency setting when stroke is suspected. It will show the presence of hemorrhage (eg, bleeding from arteriovenous malformation). It is often normal within the first hours in arterial ischemic stroke. As in adults, magnetic resonance imaging is the neuroimaging modality to confirm the clinical diagnosis of ischemic stroke. In children, however, magnetic resonance imaging requires sedation and may not be as readily available as CT. Perfusion imaging demonstrates flow within the brain and can detect areas that are at risk of ischemia; however, further studies in the pediatric population need to be validated for this technique in children. Angiography detects arterial disease (eg, aneurysm); however, its use has been largely superseded by better magnetic resonance angiography, which is sensitive enough to visualize lesions in the proximal anterior cerebral artery, middle cerebral artery, and distal internal carotid artery (ICA). Magnetic resonance imaging using diffusion- weighted imaging is the most versatile and sensitive imaging technique for identifying ischemic lesions. In the future, we need to identify the pediatric patient presenting to the emergency department with an acute stroke and develop a pathway for the use of particular imaging techniques (eg, CT vs magnetic resonance imaging).
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Michel P, Ntaios G, Reichhart M, Schindler C, Bogousslavsky J, Maeder P, Meuli R, Wintermark M. Perfusion-CT guided intravenous thrombolysis in patients with unknown-onset stroke: a randomized, double-blind, placebo-controlled, pilot feasibility trial. Neuroradiology 2011; 54:579-88. [PMID: 21808985 DOI: 10.1007/s00234-011-0944-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Accepted: 07/25/2011] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Patients with unknown stroke onset are generally excluded from acute recanalisation treatments. We designed a pilot study to assess feasibility of a trial of perfusion computed tomography (PCT)-guided thrombolysis in patients with ischemic tissue at risk of infarction and unknown stroke onset. METHODS Patients with a supratentorial stroke of unknown onset in the middle cerebral artery territory and significant volume of at-risk tissue on PCT were randomized to intravenous thrombolysis with alteplase (0.9 mg/kg) or placebo. Feasibility endpoints were randomization and blinded treatment of patients within 2 h after hospital arrival, and the correct application (estimation) of the perfusion imaging criteria. RESULTS At baseline, there was a trend towards older age [69.5 (57-78) vs. 49 (44-78) years] in the thrombolysis group (n = 6) compared to placebo (n = 6). Regarding feasibility, hospital arrival to treatment delay was above the allowed 2 h in three patients (25%). There were two protocol violations (17%) regarding PCT, both underestimating the predicted infarct in patients randomized in the placebo group. No symptomatic hemorrhage or death occurred during the first 7 days. Three of the four (75%) and one of the five (20%) patients were recanalized in the thrombolysis and placebo group respectively. The volume of non-infarcted at-risk tissue was 84 (44-206) cm(3) in the treatment arm and 29 (8-105) cm(3) in the placebo arm. CONCLUSIONS This pilot study shows that a randomized PCT-guided thrombolysis trial in patients with stroke of unknown onset may be feasible if issues such as treatment delays and reliable identification of tissue at risk of infarction tissue are resolved. Safety and efficiency of such an approach need to be established.
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Affiliation(s)
- Patrik Michel
- Department of Neurology Service, Center Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland.
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Abstract
Stroke is a leading cause of death and adult morbidity worldwide. By defining stroke symptom onset by the time the patient was last known to be well, many patients whose onsets are unwitnessed are automatically ineligible for thrombolytic therapy. Advanced brain imaging may serve as a substitute witness to estimate stroke onset and duration in those patients who do not have a human witness. This article reviews and compares some of these imaging-based approaches to thrombolysis eligibility, which can potentially expand the use of thrombolytic therapy to a broader population of acute stroke patients.
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Affiliation(s)
- Ona Wu
- Department of Radiology, MGH/MIT/HMS Athinoula A. Martinos Center for Biomedical Imaging, MGH, 149 Thirteenth Street Suite 2301, Charlestown, MA 02129, USA.
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Zhang JB, Ding ZY, Yang Y, Sun W, Hai F, Sui XN, Li XY, Wang HZ, Wang XT, Zheng JL. Thrombolysis with alteplase for acute ischemic stroke patients with atrial fibrillation. Neurol Res 2010; 32:353-8. [PMID: 20483000 DOI: 10.1179/016164110x12656393665206] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Intravenous administration of recombinant tissue plasminogen activator (rtPA) is known as the only approved treatment for acute ischemic stroke. However, it is still controversial whether acute ischemic stroke patients with atrial fibrillation should receive rtPA therapy. METHODS We studied 99 patients altogether who belonged to three different groups based on the patient characteristics: (1) atrial fibrillation rtPA-treated group consisting of 22 ischemic stroke patients with atrial fibrillation treated with rtPA within 4.5 hours after the onset of stroke; (2) atrial fibrillation non-rtPA-treated group consisting of 44 acute ischemic stroke patients with atrial fibrillation matching in age and baseline National Institutes of Health Stroke Scale (NIHSS); (3) the non-atrial fibrillation rtPA-treated group consisting of 33 patients without atrial fibrillation treated with rtPA. RESULTS The median time for the administration of rtPA was 199.6 +/- 50.0 minutes. More patients had favorable outcomes (90 day modified Rankin Scale 0-1) in the atrial fibrillation rtPA-treated group than the atrial fibrillation non-rtPA-treated group (36.4 versus 13.6%; odds ratio=2.667; 95% confidence interval: 1.056-6.735; p=0.033). The mortality at day 90 was lower in the rtPA-treated group than the non-rtPA-treated group (18.2 versus 20.5%; p=0.827), although the incidence of symptomatic intracranial hemorrhage was higher (18.2 versus 6.8%; p=0.184). Patients in the atrial fibrillation rtPA-treated group had fewer favorable outcomes than non-atrial fibrillation rtPA-treated group (36.4 versus 51.6%; p=0.076), but their baseline NIHSS was higher (12.0 +/- 7.1 versus 9.1 +/- 7.3; p=0.161). CONCLUSION As compared with non-rtPA-treated patients, rtPA treated within 4.5 hours after the onset of stroke significantly improved clinical outcomes in atrial fibrillation patients. Thrombolytic treatment increases intracranial hemorrhage rate but does not increase mortality.
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Affiliation(s)
- Jing-Bo Zhang
- Department of Neurology, The Third People's Hospital of Dalian, Dalian, China.
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Abstract
The treatment of acute ischaemic stroke is based on the principle that there is ischaemic but still potentially salvageable tissue that could be rescued if blood flow could be restored quickly. It is assumed that salvage might only be possible in the first few hours, and that infarct expansion is a direct result of failed recanalization of the main artery. This concept arose from experimental work in the 1970s, supported more recently by studies using imaging to identify penumbral tissue. However, although magnetic resonance diffusion and perfusion imaging is a way of imaging penumbral tissue and has been around for over a decade, it is not an easy technique to apply in practice and its use has produced conflicting results. Computed tomography perfusion, and any other tissue perfusion imaging technique, is likely to encounter the same difficulties. Indeed many factors, other than the presence of a diffusion-perfusion mismatch acutely, may determine or influence ultimate tissue fate even days after the stroke, and in turn, clinical outcome. Many of these potential influences are beginning to emerge from studies using different forms of imaging at later times after stroke. This review will explore the information now emerging from imaging studies in large artery ischaemic stroke to summarize knowledge to date and indicate unresolved issues for the future.
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Affiliation(s)
- J M Wardlaw
- SINAPSE Collaboration, SFC Brain Imaging Research Centre, Division of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Edinburgh EH4 2EX, UK.
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Derex L, Nighoghossian N. Thrombolysis, stroke-unit admission and early rehabilitation in elderly patients. Nat Rev Neurol 2009; 5:506-11. [DOI: 10.1038/nrneurol.2009.127] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Aviv RI, d'Esterre CD, Murphy BD, Hopyan JJ, Buck B, Mallia G, Li V, Zhang L, Symons SP, Lee TY. Hemorrhagic transformation of ischemic stroke: prediction with CT perfusion. Radiology 2009; 250:867-77. [PMID: 19244051 DOI: 10.1148/radiol.2503080257] [Citation(s) in RCA: 126] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To determine whether admission computed tomography (CT) perfusion-derived permeability-surface area product (PS) maps differ between patients with hemorrhagic acute stroke and those with nonhemorrhagic acute stroke. MATERIALS AND METHODS This prospective study was institutional review board approved, and all participants gave written informed consent. Forty-one patients who presented with acute stroke within 3 hours after stroke symptom onset underwent two-phase CT perfusion imaging, which enabled PS measurement. Patients were assigned to groups according to whether they had hemorrhage transformation (HT) at follow-up magnetic resonance (MR) imaging and CT and/or whether they received tissue plasminogen activator (TPA) treatment. Clinical, demographic, and CT perfusion variables were compared between the HT and non-HT patient groups. Associations between PS and HT were tested at univariate and multivariate logistic regression analyses and receiver operating characteristic (ROC) analysis. RESULTS HT developed in 23 (56%) patients. Patients with HT had higher National Institutes of Health Stroke Scale (NIHSS) scores (P = .005), poorer outcomes (P = .001), and a higher likelihood of having received TPA (P = .005) compared with patients without HT. Baseline blood flow (P = .17) and blood volume (P = .11) defects and extent of flow reduction (P = .27) were comparable between the two groups. The mean PS for the HT group, 0.49 mL x min(-1) x (100 g)(-1), was significantly higher than that for the non-HT group, 0.09 mL x min(-1) x (100 g)(-1) (P < .0001). PS (odds ratio, 3.5; 95% confidence interval [CI]: 1.69, 7.06; P = .0007) and size of hypoattenuating area at nonenhanced admission CT (odds ratio, 0.4; 95% CI: 0.2, 0.7; P = .002) were the only independent variables associated with HT at stepwise multivariate analysis. The mean area under the ROC curve was 0.918 (95% CI: 0.828, 1.00). The PS threshold of 0.23 mL x min(-1) x (100 g)(-1) had 77% sensitivity and 94% specificity for detection of HT. CONCLUSION Admission PS measurement appears promising for distinguishing patients with acute stroke who are likely from those who are not likely to develop HT. SUPPLEMENTAL MATERIAL http://radiology.rsnajnls.org/cgi/content/full/250/3/867/DC1.
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Affiliation(s)
- Richard I Aviv
- Division of Neuroradiology, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
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Mechanisms and markers for hemorrhagic transformation after stroke. ACTA NEUROCHIRURGICA. SUPPLEMENT 2009; 105:173-8. [PMID: 19066105 DOI: 10.1007/978-3-211-09469-3_34] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Intracerebral hemorrhagic transformation is a multifactorial phenomenon in which ischemic brain tissue converts into a hemorrhagic lesion with blood vessel leakage. Hemorrhagic transformation can significantly contribute to additional brain injury after stroke. Especially threatening are the thrombolytic-induced hemorrhages after reperfusion therapy with tissue plasminogen activator (tPA), the only treatment available for ischemic stroke. In this context, it is important to understand its underlying mechanisms and identify early markers of hemorrhagic transformation, so that we can both search for new treatments as well as predict clinical outcomes in patients. In this review, we discuss the emerging mechanisms for hemorrhagic transformation after stroke, and briefly survey potential molecular, genetic, and neuroimaging markers that might be used for early detection of this challenging clinical problem.
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Schlaganfall-MRT zur Abschätzung des Blutungsrisikos bei thrombolytischer Therapie. DER NERVENARZT 2009; 80:130, 132-6. [DOI: 10.1007/s00115-008-2593-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Cho TH, Pialat JB, Hermier M, Derex L, Nighoghossian N. Risonanza magnetica multimodale nel trattamento in urgenza degli ictus cerebrali ischemici. Neurologia 2009. [DOI: 10.1016/s1634-7072(09)70512-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Affiliation(s)
- Carlos A Molina
- Neurovascular Unit, Hospital Vall D'HebronPasseig Vall D'Hebron 119-129,08035, Barcelona, Spain.
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Singer OC, Humpich MC, Fiehler J, Albers GW, Lansberg MG, Kastrup A, Rovira A, Liebeskind DS, Gass A, Rosso C, Derex L, Kim JS, Neumann-Haefelin T. Risk for symptomatic intracerebral hemorrhage after thrombolysis assessed by diffusion-weighted magnetic resonance imaging. Ann Neurol 2008; 63:52-60. [PMID: 17880020 DOI: 10.1002/ana.21222] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The risk for symptomatic intracerebral hemorrhage (sICH) associated with thrombolytic treatment has not been evaluated in large studies using diffusion-weighted imaging (DWI). Here, we investigated the relation between pretreatment DWI lesion size and the risk for sICH after thrombolysis. METHODS In this retrospective multicenter study, prospectively collected data from 645 patients with anterior circulation stroke treated with intravenous or intraarterial thrombolysis within 6 hours (<3 hours: n = 320) after symptom onset were pooled. Patients were categorized according to the pretreatment DWI lesion size into three prespecified groups: small (< or =10 ml; n = 218), moderate (10-100 ml; n = 371), and large (>100 ml; n = 56) DWI lesions. RESULTS In total, 44 (6.8%) patients experienced development of sICH. The sICH rate was significantly different between subgroups: 2.8, 7.8, and 16.1% in patients with small, moderate, and large DWI lesions, respectively (p < 0.05). This translates to a 5.8 (2.8)-fold greater sICH risk for patients with large DWI lesions as compared with patients with small (or moderate) DWI lesions. The results were similar in the large subgroup (n = 536) of patients treated with intravenous tissue plasminogen activator. DWI lesion size remained an independent risk factor when including National Institutes of Health Stroke Scale, age, time to thrombolysis, and leukoariosis in a logistic regression analysis. INTERPRETATION This multicenter study provides estimates of sICH risk in potential candidates for thrombolysis. The sICH risk increases gradually with increasing DWI lesion size, indicating that the potential benefit of therapy needs to be balanced carefully against the risk for sICH, especially in patients with large DWI lesions.
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Affiliation(s)
- Oliver C Singer
- Klinik für Neurologie, Universitätsklinik, Johann Wolfgang von Goethe-Universität, Frankfurt, Germany.
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Chapter 56 General principles of acute stroke management. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/s0072-9752(08)94056-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Abstract
PURPOSE OF REVIEW MRI is increasingly used as the primary imaging modality in acute stroke, since it allows treatment based on individual pathophysiology rather than strict time windows. RECENT FINDINGS PET studies have confirmed that regions with disturbed diffusion frequently indicate irreversible tissue damage, although they may in part be viable. The mismatch between a larger perfusion deficit and a smaller diffusion abnormality contains both critically hypoperfused regions as well as oligemic regions. Although mismatch is thus not perfect, recent prospective trials have convincingly shown that mismatch patients treated with revascularization therapies benefit from reperfusion, while patients without mismatch do not. This is particularly important for patients presenting beyond the first three hours. In addition, several studies have investigated MRI as a tool to assess the risk of thrombolytic treatment. Parameters reflecting severe ischemia, blood-brain barrier damage and preexisting small-vessel disease emerge as risk factors for intracerebral hemorrhage, while microbleeds are not clearly associated with an increased risk. SUMMARY Based on data from prospective trials, the mismatch concept is an acceptable method to identify patients who benefit from recanalization therapies. The concept, however, still needs to be further improved and standard definitions are required before widespread use can be recommended.
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Lansberg MG, Thijs VN, Bammer R, Kemp S, Wijman CAC, Marks MP, Albers GW. Risk factors of symptomatic intracerebral hemorrhage after tPA therapy for acute stroke. Stroke 2007; 38:2275-8. [PMID: 17569874 PMCID: PMC3985814 DOI: 10.1161/strokeaha.106.480475] [Citation(s) in RCA: 153] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Studies evaluating predictors of tPA-associated symptomatic intracerebral hemorrhage (SICH) have typically focused on clinical and CT-based variables. MRI-based variables have generally not been included in predictive models, and little is known about the influence of reperfusion on SICH risk. METHODS Seventy-four patients were prospectively enrolled in an open-label study of intravenous tPA administered between 3 and 6 hours after symptom onset. An MRI was obtained before and 3 to 6 hours after tPA administration. The association between several clinical and MRI-based variables and tPA-associated SICH was determined using multivariate logistic regression analysis. SICH was defined as a > or = 2 point change in National Institutes of Health Stroke Scale Score (NIHSSS) associated with any degree of hemorrhage on CT or MRI. Reperfusion was defined as a decrease in PWI lesion volume of at least 30% between baseline and the early follow-up MRI. RESULTS SICH occurred in 7 of 74 (9.5%) patients. In univariate analysis, NIHSSS, DWI lesion volume, PWI lesion volume, and reperfusion status were associated with an increased risk of SICH (P<0.05). In multivariate analysis, DWI lesion volume was the single independent baseline predictor of SICH (odds ratio 1.42; 95% CI 1.13 to 1.78 per 10 mL increase in DWI lesion volume). When early reperfusion status was included in the predictive model, the interaction between DWI lesion volume and reperfusion status was the only independent predictor of SICH (odds ratio 1.77; 95% CI 1.25 to 2.50 per 10 mL increase in DWI lesion volume). CONCLUSIONS Patients with large baseline DWI lesion volumes who achieve early reperfusion appear to be at greatest risk of SICH after tPA therapy.
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Affiliation(s)
- Maarten G Lansberg
- Stanford University, Stanford Stroke Center, Palo Alto, California 94304, USA.
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Fan JS, Chang FC, Hu HH, Hsu LC. Hemorrhagic transformation of stroke secondary to spontaneous internal carotid artery dissection. J Chin Med Assoc 2006; 69:585-8. [PMID: 17182353 DOI: 10.1016/s1726-4901(09)70334-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The clinical course of patients with hemorrhagic transformation in stroke secondary to spontaneous cervical internal carotid artery dissection (ICAD) has not been elucidated. We report a 36-year-old man with presentation of headache and subsequent left hemiparesis. Magnetic resonance imaging disclosed right ICAD with nearly complete occlusion of the right distal internal carotid artery and infarction over the right basal ganglion with hemorrhagic transformation in its central area. Hemorrhagic transformation can develop early in ICAD patients without preceding treatment with antithrombotic agents. Clinicians are urged to use antithrombotic agents with caution in patients with spontaneous ICAD with ischemic stroke because early hemorrhagic transformation may also be present. Possible pathomechanisms and treatment strategies are also discussed.
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Affiliation(s)
- Ju-Sing Fan
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, R.O.C
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Bammer R, Skare S, Newbould R, Liu C, Thijs V, Ropele S, Clayton DB, Krueger G, Moseley ME, Glover GH. Foundations of advanced magnetic resonance imaging. NeuroRx 2005; 2:167-96. [PMID: 15897944 PMCID: PMC1064985 DOI: 10.1602/neurorx.2.2.167] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
During the past decade, major breakthroughs in magnetic resonance imaging (MRI) quality were made by means of quantum leaps in scanner hardware and pulse sequences. Some advanced MRI techniques have truly revolutionized the detection of disease states and MRI can now-within a few minutes-acquire important quantitative information noninvasively from an individual in any plane or volume at comparatively high resolution. This article provides an overview of the most common advanced MRI methods including diffusion MRI, perfusion MRI, functional MRI, and the strengths and weaknesses of MRI at high magnetic field strengths.
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Affiliation(s)
- Roland Bammer
- Lucas MRS/I Center, Department of Radiology, Stanford University, California, USA.
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Bammer R, Skare S, Newbould R, Liu C, Thijs V, Ropele S, Clayton DB, Krueger G, Moseley ME, Glover GH. Foundations of advanced magnetic resonance imaging. Neurotherapeutics 2005. [DOI: 10.1007/bf03206665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Fiehler J, Remmele C, Kucinski T, Rosenkranz M, Thomalla G, Weiller C, Zeumer H, Röther J. Reperfusion after Severe Local Perfusion Deficit Precedes Hemorrhagic Transformation: An MRI Study in Acute Stroke Patients. Cerebrovasc Dis 2005; 19:117-24. [PMID: 15640606 DOI: 10.1159/000083180] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2003] [Accepted: 07/24/2004] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We applied magnetic resonance imaging to analyze the degree of local diffusion and perfusion abnormalities and the status of reperfusion in regions with subsequent hemorrhagic transformation (HT). METHODS 51 patients with acute ischemic stroke were studied by diffusion- and perfusion-weighted imaging within 3.0 +/- 0.8 h, on day 1 and days 5-8. After realignment of the image data sets, the parameter maps of the apparent diffusion coefficient (ADC), cerebral blood flow (CBF) and cerebral blood volume (CBV), and mean transit time were analyzed in the area of subsequent HT. The degree of local diffusion and perfusion impairment in the HT area was compared with the entire diffusion and perfusion abnormality. Reperfusion status was separately assessed for the entire perfusion abnormality and the HT area. RESULTS HT was observed in 19/51 patients (37.2%) within 8 days after symptom onset. Areas destined for HT revealed a more severe decrease in ADC (to 70 +/- 13%; p < 0.01), CBV (to 31 +/- 26%; p < 0.001) and CBF (to 28 +/- 19%; p < 0.001) compared to the entire perfusion abnormality. Local reperfusion in the HT area was seen in 18/19 patients. The presence of HT did not coincide with a worse clinical outcome. DISCUSSION HT is the result of reperfusion in the region with the most severe local perfusion impairment and does not influence the neurological outcome.
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Affiliation(s)
- Jens Fiehler
- Department of Neuroradiology, University Hospital Eppendorf, University of Hamburg, Hamburg, Germany.
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Derex L, Hermier M, Adeleine P, Pialat JB, Wiart M, Berthezène Y, Philippeau F, Honnorat J, Froment JC, Trouillas P, Nighoghossian N. Clinical and imaging predictors of intracerebral haemorrhage in stroke patients treated with intravenous tissue plasminogen activator. J Neurol Neurosurg Psychiatry 2005; 76:70-5. [PMID: 15607998 PMCID: PMC1739325 DOI: 10.1136/jnnp.2004.038158] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate clinical, biological, and pretreatment imaging variables for predictors of tissue plasminogen activator (tPA) related intracerebral haemorrhage (ICH) in stroke patients. METHODS 48 consecutive patients with hemispheric stroke were given intravenous tPA within seven hours of symptom onset, after computed tomography (CT) and magnetic resonance imaging (MRI) of the brain. Baseline diffusion weighted (DWI) and perfusion weighted (PWI) imaging volumes, time to peak, mean transit time, regional cerebral blood flow index, and regional cerebral blood volume were evaluated. The distribution of apparent diffusion coefficient (ADC) values was determined within each DWI lesion. RESULTS The symptomatic ICH rate was 8.3% (four of 48); the rate for any ICH was 43.8% (21 of 48). Univariate analysis showed that age, weight, history of hyperlipidaemia, baseline NIHSS score, glucose level, red blood cell count, and lacunar state on MRI were associated with ICH. However, mean 24 hour systolic blood pressure and a hyperdense artery sign on pretreatment CT were the only independent predictors of ICH. Patients with a hyperdense artery sign had larger pretreatment PWI and DWI lesion volumes and a higher NIHSS score. Analysis of the distribution of ADC values within DWI lesions showed that a greater percentage of pixels had lower ADCs (< 400 x 10(-6) mm(2)/s) in patients who experienced ICH than in those who did not. CONCLUSION Key clinical and biological variables, pretreatment CT signs, and MRI indices are associated with tPA related intracerebral haemorrhage.
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Affiliation(s)
- L Derex
- Service d'Urgences Neurovasculaires, Hôpital Neurologique, 59 boulevard Pinel, 69003 Lyon, France.
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Ozsunar Y, Koseoglu K, Huisman TAGM, Koroshetz W, Sorensen AG. MRI measurements of water diffusion: impact of region of interest selection on ischemic quantification. Eur J Radiol 2004; 51:195-201. [PMID: 15294325 DOI: 10.1016/j.ejrad.2003.09.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2003] [Revised: 09/19/2003] [Accepted: 09/22/2003] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To investigate the effect of ADC heterogeneity on region of interest (ROI) measurement of isotropic and anisotropic water diffusion in acute (< 12 h) cerebral infarctions. METHODS AND MATERIALS Full diffusion tensor images were retrospectively analyzed in 32 patients with acute cerebral infarction. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were measured in ischemic lesions and in the corresponding contralateral, normal appearing brain by using four ROIs for each patient. The 2 x 2 pixel square ROIs were placed in the center, the lateral rim and the medial rim of the infarction. In addition, the whole volume of the infarction was measured using a free hand method. Each ROI value obtained from the ischemic lesion was normalized using contralateral normal ROI values. RESULTS The localization of the ROIs in relation to the ischemic lesion significantly affected ADC measurement (P < 0.01, using Friedman test), but not FA measurement (P = 0.25). Significant differences were found between ADC values of the center of the infarction versus whole volume (P < 0.01), and medial rim versus whole volume of infarction (P < 0.001) with variation of relative ADC values up to 11%. The differences of absolute ADC for these groups were 22 and 23%, respectively. The lowest ADC was found in the center, followed by medial rim, lateral rim and whole volume of infarction. CONCLUSION ADC quantification may provide variable results depending on ROI method. The ADC and FA values, obtained from the center of infarction tend to be lower compared to the periphery. The researchers who try to compare studies or work on ischemic quantification should be aware of these differences and effects.
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Affiliation(s)
- Yelda Ozsunar
- Department of Radiology, School of Medicine, Adnan Menderes University, Aydin 09100, Turkey.
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Liu Y, Karonen JO, Vanninen RL, Nuutinen J, Koskela A, Soimakallio S, Aronen HJ. Acute Ischemic Stroke: Predictive Value of 2D Phase-Contrast MR Angiography—Serial Study with Combined Diffusion and Perfusion MR Imaging. Radiology 2004; 231:517-27. [PMID: 15044743 DOI: 10.1148/radiol.2312030565] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To evaluate phase-contrast magnetic resonance (MR) angiography and diffusion- and perfusion-weighted imaging in predicting evolution of infarction and clinical outcome. MATERIALS AND METHODS Phase-contrast angiographic and diffusion-weighted images obtained 1 and 2 days after acute middle cerebral artery (MCA) stroke were assessed in 43 patients; 39 underwent perfusion-weighted imaging on day 1. Follow-up phase-contrast angiographic and T2-weighted images (n = 38) were obtained on day 8. Clinical outcome was assessed at 3 months. Patients were assigned to three groups according to angiographic findings on day 1: group 1, absence of flow in proximal MCA (M1 segment); group 2, internal carotid artery (ICA) occlusion with collateral M1 flow; group 3, flow in ICA and M1. Differences in lesion volumes on diffusion- and perfusion-weighted maps among groups were compared with one-way analysis of variance with Tukey post hoc multiple comparisons. RESULTS Patients in group 1 had significantly larger infarct growth, volumes of hypoperfusion on relative cerebral blood volume (rCBV) and relative cerebral blood flow maps, and initial and final infarct volumes than did other patients (P <.05). Initial perfusion deficits on mean transit time maps were significantly (P =.002) larger in group 2 than in group 3, but there were no significant differences in infarct growth (P =.977), final infarct volume on day 8 (P =.947), and clinical outcome (P =.969). Absence of M1 flow on day 1 was significantly associated with unfavorable clinical outcome (modified Rankin score > or = 3) at 3 months (P =.010, chi(2) test). Discriminant analysis revealed that rCBV maps alone and combination of diffusion-weighted imaging and MR angiography yielded the highest accuracy in predicting an unfavorable clinical outcome. CONCLUSION Phase-contrast MR angiography can provide complementary information to that with diffusion- and perfusion- weighted imaging in predicting the outcome of patients with acute stroke.
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Affiliation(s)
- Yawu Liu
- Department of Clinical Radiology, Kuopio University Hospital, PO Box 1777, FIN-70211 Kuopio, Finland.
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Hermier M, Nighoghossian N, Derex L, Adeleine P, Wiart M, Berthezène Y, Cotton F, Pialat JB, Dardel P, Honnorat J, Trouillas P, Froment JC. Hypointense transcerebral veins at T2*-weighted MRI: a marker of hemorrhagic transformation risk in patients treated with intravenous tissue plasminogen activator. J Cereb Blood Flow Metab 2003; 23:1362-70. [PMID: 14600444 DOI: 10.1097/01.wcb.0000091764.61714.79] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Prediction of hemorrhagic transformation (HT) in patients treated by intravenous recombinant tissue-type plasminogen activator (rt-PA) is a challenging issue in acute stroke management. HT may be correlated with severe hypoperfusion. Signal changes may be observed at susceptibility-weighted magnetic resonance imaging (MRI) within large perfusion defects. A signal drop within cerebral veins at T2*-weighted gradient-echo MRI may be expected in severe ischemia, and may indicate subsequent risk of HT. The authors prospectively searched for an abnormal visibility of transcerebral veins (AVV) within the ischemic area in patients with hemispheric ischemic stroke, before they were treated with intravenous rt-PA therapy. Any correlation between AVV and baseline clinical or MRI findings, or further HT, was noted. An AVV was present in 23 of 49 patients (obvious, n = 8; moderate, n = 15), and was supported by severe hemodynamic changes at baseline MRI. The AVV was correlated with the occurrence of parenchymal hematoma type 2 at computed tomography during the first week (r = 0.44, P = 0.002). Five of six type 2 parenchymal hematomas occurred in association with obvious AVV. At multiple regression analysis, two baseline MRI factors had an independent predictive value for HT risk during the first week: the AVV and the cerebral blood volume ratio (Nagelkerke R2 = 0.48).
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Affiliation(s)
- Marc Hermier
- Department of Radiology and MRI, Hôpital Neurologique, Hospices Civils de Lyon, Lyon, France.
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