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Mansour M. Reperfusion Therapies in Acute Ischemic Stroke Beyond the Conventional Time Window: A Narrative Review. Cureus 2023; 15:e45864. [PMID: 37881372 PMCID: PMC10597672 DOI: 10.7759/cureus.45864] [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] [Accepted: 09/24/2023] [Indexed: 10/27/2023] Open
Abstract
Stroke is the second most common cause of death worldwide, with 50% of survivors experiencing long-term disability. For more than two decades, treatment with intravenous thrombolysis (IVT) and mechanical endovascular thrombectomy (MET), the only approved stroke reperfusion therapies, was restricted to patients within the 4.5-6 hour time window, respectively. Therefore, patients who presented with acute ischemic stroke (AIS) beyond the conventional time window were excluded from reperfusion treatment. This narrative review aims to review the scientific literature on the possibilities of reperfusion therapies for patients who present with an unknown time of stroke onset, and those with stroke onset beyond the conventional 4.5-6 hour time window. Beyond the conventional time window, the eligibility of patients for IVT or MET, the two main therapeutic procedures, is decided based on the concept of penumbral imaging. Penumbral imaging identifies patients with hypoperfused but viable brain tissue, who could benefit from reperfusion. On the other hand, clock-based DWI-fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) can detect stroke that has occurred within 4.5 hours in patients with an unknown time of onset, including patients who awaken with stroke. The introduction of penumbral imaging and MRI-based tissue clocking as imaging biomarkers for stroke has revolutionized stroke therapy, potentially allowing for personalized treatment of eligible stroke patients.
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Affiliation(s)
- Mohammad Mansour
- Department of General Medicine, University of Debrecen, Debrecen, HUN
- Department of General Medicine, Jordan University Hospital, Amman, JOR
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2
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Hasan KM, Haque ME. Editorial for "Predicting the Onset of Ischemic Stroke With Fast High-Resolution 3D MR Spectroscopic Imaging". J Magn Reson Imaging 2023; 58:848-849. [PMID: 36607155 DOI: 10.1002/jmri.28592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 01/07/2023] Open
Affiliation(s)
- Khader M Hasan
- Department of Interventional Diagnostic Radiology, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Muhammad E Haque
- McGovern Medical School, Institute for Stroke and Cerebrovascular Diseases and Department of Neurology, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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Li YH, Lin SC, Chung HW, Chang CC, Peng HH, Huang TY, Shen WC, Tsai CH, Lo YC, Lee TY, Juan CH, Juan CE, Chang HC, Liu YJ, Juan CJ. The role of input imaging combination and ADC threshold on segmentation of acute ischemic stroke lesion using U-Net. Eur Radiol 2023; 33:6157-6167. [PMID: 37095361 DOI: 10.1007/s00330-023-09622-z] [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: 08/24/2022] [Revised: 02/11/2023] [Accepted: 02/17/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND To evaluate the effect of the weighting of input imaging combo and ADC threshold on the performance of the U-Net and to find an optimized input imaging combo and ADC threshold in segmenting acute ischemic stroke (AIS) lesion. METHODS This study retrospectively enrolled a total of 212 patients having AIS. Four combos, including ADC-ADC-ADC (AAA), DWI-ADC-ADC (DAA), DWI-DWI-ADC (DDA), and DWI-DWI-DWI (DDD), were used as input images, respectively. Three ADC thresholds including 0.6, 0.8 and 1.8 × 10-3 mm2/s were applied. Dice similarity coefficient (DSC) was used to evaluate the segmentation performance of U-Nets. Nonparametric Kruskal-Wallis test with Tukey-Kramer post-hoc tests were used for comparison. A p < .05 was considered statistically significant. RESULTS The DSC significantly varied among different combos of images and different ADC thresholds. Hybrid U-Nets outperformed uniform U-Nets at ADC thresholds of 0.6 × 10-3 mm2/s and 0.8 × 10-3 mm2/s (p < .001). The U-Net with imaging combo of DDD had segmentation performance similar to hybrid U-Nets at an ADC threshold of 1.8 × 10-3 mm2/s (p = .062 to 1). The U-Net using the imaging combo of DAA at the ADC threshold of 0.6 × 10-3 mm2/s achieved the highest DSC in the segmentation of AIS lesion. CONCLUSIONS The segmentation performance of U-Net for AIS varies among the input imaging combos and ADC thresholds. The U-Net is optimized by choosing the imaging combo of DAA at an ADC threshold of 0.6 × 10-3 mm2/s in segmentating AIS lesion with highest DSC. KEY POINTS • Segmentation performance of U-Net for AIS differs among input imaging combos. • Segmentation performance of U-Net for AIS differs among ADC thresholds. • U-Net is optimized using DAA with ADC = 0.6 × 10-3 mm2/s.
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Affiliation(s)
- Ya-Hui Li
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan, Republic of China
- Department of Medical Imaging, China Medical University Hsinchu Hospital, No. 199, Sec. 1, Xinglong Rd., Zhubei City, Hsinchu County 302, Hsinchu, Taiwan, Republic of China
| | - Shao-Chieh Lin
- Department of Medical Imaging, China Medical University Hsinchu Hospital, No. 199, Sec. 1, Xinglong Rd., Zhubei City, Hsinchu County 302, Hsinchu, Taiwan, Republic of China
- Ph.D. Program in Electrical and Communication Engineering, Feng Chia University, Taichung, Taiwan, Republic of China
| | - Hsiao-Wen Chung
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan, Republic of China
- Department of Electrical Engineering, National Taiwan University, Taipei, Taiwan, Republic of China
| | - Chia-Ching Chang
- Department of Medical Imaging, China Medical University Hsinchu Hospital, No. 199, Sec. 1, Xinglong Rd., Zhubei City, Hsinchu County 302, Hsinchu, Taiwan, Republic of China
- Department of Management Science, National Yang Ming Chiao Tung University, Hsinchu, Taiwan, Republic of China
| | - Hsu-Hsia Peng
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan, Republic of China
| | - Teng-Yi Huang
- Department of Electrical Engineering, National Taiwan University of Science and Technology, Taipei, Taiwan, Republic of China
| | - Wu-Chung Shen
- Department of Radiology, School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan, Republic of China
- Department of Medical Imaging, Medical University Hospital, Taichung, Taiwan, Republic of China
| | - Chon-Haw Tsai
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan, Republic of China
| | - Yu-Chien Lo
- Department of Medical Imaging, Medical University Hospital, Taichung, Taiwan, Republic of China
| | - Tung-Yang Lee
- Cheng Ching Hospital, Taichung, Taiwan, Republic of China
- Master's Program of Biomedical Informatics and Biomedical Engineering, Feng Chia University, Taichung, Taiwan, Republic of China
| | - Cheng-Hsuan Juan
- Cheng Ching Hospital, Taichung, Taiwan, Republic of China
- Master's Program of Biomedical Informatics and Biomedical Engineering, Feng Chia University, Taichung, Taiwan, Republic of China
| | - Cheng-En Juan
- Master's Program of Biomedical Informatics and Biomedical Engineering, Feng Chia University, Taichung, Taiwan, Republic of China
| | - Hing-Chiu Chang
- Department of Biomedical Engineering, The Chinese University of Hong Kong, ERB1112, 11/F, William M.W. Mong Engineering Building, Shatin, N.T, Hong Kong.
- Multi-Scale Medical Robotics Center, The Chinese University of Hong Kong, Shatin, N.T, Hong Kong.
| | - Yi-Jui Liu
- Department of Automatic Control Engineering, Feng Chia University, No. 100 Wenhwa Rd., Seatwen, 40724, Taichung, Taiwan, Republic of China.
| | - Chun-Jung Juan
- Department of Medical Imaging, China Medical University Hsinchu Hospital, No. 199, Sec. 1, Xinglong Rd., Zhubei City, Hsinchu County 302, Hsinchu, Taiwan, Republic of China.
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan, Republic of China.
- Department of Radiology, School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan, Republic of China.
- Department of Medical Imaging, Medical University Hospital, Taichung, Taiwan, Republic of China.
- Department of Biomedical Engineering, National Defense Medical Center, Taipei, Taiwan, Republic of China.
- Department of Computer Science and Information Engineering, National Taiwan University, Taipei, Taiwan, Republic of China.
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Tani T, Imai S, Inoue N, Kanazawa N, Fushimi K. Association between volume of patients undergoing stroke rehabilitation at acute care hospitals and improvement in activities of daily living. J Stroke Cerebrovasc Dis 2023; 32:106872. [PMID: 36450184 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 10/23/2022] [Accepted: 10/31/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND This study aimed to determine the relationship between the annual volume of patients undergoing rehabilitation per hospital and the outcomes of patients admitted for acute stroke. METHODS This observational study used nationwide administrative data. Data on stroke patients aged ≥ 20 years who underwent rehabilitation were extracted from 1,182 acute care hospitals in Japan. The exclusion criteria were extended hospital stay exceeding 180 days and death during hospitalization. Hospital volumes were divided into four quartiles of total patients per hospital. The primary outcome was an improvement in activities of daily living from admission to discharge measured using the Barthel index. Poisson regression analysis of activities of daily living improvement was performed using inverse probability of treatment weighting. RESULTS High rehabilitation volume was significantly correlated with improvements in activities of daily living using the "very low group" as a reference (risk ratio [95% confidence interval]): 1.06 [1.05-1.08], P<0.001). Low volume was also significantly associated with activities of daily living improvement (risk ratio [95% confidence interval]: 1.04 [1.03-1.06], P<0.001). CONCLUSIONS The annual volume of stroke patients undergoing multidisciplinary rehabilitation at a specific hospital may be a factor in the degree of patient improvement in activities of daily living.
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Affiliation(s)
- Takuaki Tani
- Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8510, Japan; Clinical Research Center National Hospital Organization, 2-21 Higashigaoka, Meguro-ku, Tokyo, 152-8621, Japan
| | - Shinobu Imai
- Clinical Research Center National Hospital Organization, 2-21 Higashigaoka, Meguro-ku, Tokyo, 152-8621, Japan; Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji-shi, Tokyo, 192-0392, Japan
| | - Norihiko Inoue
- Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8510, Japan; Clinical Research Center National Hospital Organization, 2-21 Higashigaoka, Meguro-ku, Tokyo, 152-8621, Japan
| | - Natsuko Kanazawa
- Clinical Research Center National Hospital Organization, 2-21 Higashigaoka, Meguro-ku, Tokyo, 152-8621, Japan
| | - Kiyohide Fushimi
- Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8510, Japan; Clinical Research Center National Hospital Organization, 2-21 Higashigaoka, Meguro-ku, Tokyo, 152-8621, Japan.
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5
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Nazari-Farsani S, Yu Y, Duarte Armindo R, Lansberg M, Liebeskind DS, Albers G, Christensen S, Levin CS, Zaharchuk G. Predicting final ischemic stroke lesions from initial diffusion-weighted images using a deep neural network. Neuroimage Clin 2022; 37:103278. [PMID: 36481696 PMCID: PMC9727698 DOI: 10.1016/j.nicl.2022.103278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/20/2022] [Accepted: 11/30/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND For prognosis of stroke, measurement of the diffusion-perfusion mismatch is a common practice for estimating tissue at risk of infarction in the absence of timely reperfusion. However, perfusion-weighted imaging (PWI) adds time and expense to the acute stroke imaging workup. We explored whether a deep convolutional neural network (DCNN) model trained with diffusion-weighted imaging obtained at admission could predict final infarct volume and location in acute stroke patients. METHODS In 445 patients, we trained and validated an attention-gated (AG) DCNN to predict final infarcts as delineated on follow-up studies obtained 3 to 7 days after stroke. The input channels consisted of MR diffusion-weighted imaging (DWI), apparent diffusion coefficients (ADC) maps, and thresholded ADC maps with values less than 620 × 10-6 mm2/s, while the output was a voxel-by-voxel probability map of tissue infarction. We evaluated performance of the model using the area under the receiver-operator characteristic curve (AUC), the Dice similarity coefficient (DSC), absolute lesion volume error, and the concordance correlation coefficient (ρc) of the predicted and true infarct volumes. RESULTS The model obtained a median AUC of 0.91 (IQR: 0.84-0.96). After thresholding at an infarction probability of 0.5, the median sensitivity and specificity were 0.60 (IQR: 0.16-0.84) and 0.97 (IQR: 0.93-0.99), respectively, while the median DSC and absolute volume error were 0.50 (IQR: 0.17-0.66) and 27 ml (IQR: 7-60 ml), respectively. The model's predicted lesion volumes showed high correlation with ground truth volumes (ρc = 0.73, p < 0.01). CONCLUSION An AG-DCNN using diffusion information alone upon admission was able to predict infarct volumes at 3-7 days after stroke onset with comparable accuracy to models that consider both DWI and PWI. This may enable treatment decisions to be made with shorter stroke imaging protocols.
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Affiliation(s)
| | - Yannan Yu
- Department of Radiology, Stanford University, CA, USA; Internal Medicine Department, University of Massachusetts Memorial Medical Center, University of Massachusetts, Boston, USA
| | - Rui Duarte Armindo
- Department of Radiology, Stanford University, CA, USA; Department of Neuroradiology, Hospital Beatriz Ângelo, Loures, Lisbon, Portugal
| | | | - David S Liebeskind
- Department of Neurology, University of California Los Angeles, Los Angeles, CA, USA
| | | | | | - Craig S Levin
- Department of Radiology, Stanford University, CA, USA
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Juan CJ, Lin SC, Li YH, Chang CC, Jeng YH, Peng HH, Huang TY, Chung HW, Shen WC, Tsai CH, Chang RF, Liu YJ. Improving interobserver agreement and performance of deep learning models for segmenting acute ischemic stroke by combining DWI with optimized ADC thresholds. Eur Radiol 2022; 32:5371-5381. [PMID: 35201408 DOI: 10.1007/s00330-022-08633-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/26/2021] [Accepted: 01/31/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine the role of ADC threshold on agreement across observers and deep learning models (DLMs) plus segmentation performance of DLMs for acute ischemic stroke (AIS). METHODS Twelve DLMs, which were trained on DWI-ADC-ADC combination from 76 patients with AIS using 6 different ADC thresholds with ground truth manually contoured by 2 observers, were tested by additional 67 patients in the same hospital and another 78 patients in another hospital. Agreement between observers and DLMs were evaluated by Bland-Altman plot and intraclass correlation coefficient (ICC). The similarity between ground truth (GT) defined by observers and between automatic segmentation performed by DLMs was evaluated by Dice similarity coefficient (DSC). Group comparison was performed using the Mann-Whitney U test. The relationship between the DSC and ADC threshold as well as AIS lesion size was evaluated by linear regression analysis. A p < .05 was considered statistically significant. RESULTS Excellent interobserver agreement and intraobserver repeatability in the manual segmentation (all ICC > 0.98, p < .001) were achieved. The 95% limit of agreement was reduced from 11.23 cm2 for GT on DWI to 0.59 cm2 for prediction at an ADC threshold of 0.6 × 10-3 mm2/s combined with DWI. The segmentation performance of DLMs was improved with an overall DSC from 0.738 ± 0.214 on DWI to 0.971 ± 0.021 on an ADC threshold of 0.6 × 10-3 mm2/s combined with DWI. CONCLUSIONS Combining an ADC threshold of 0.6 × 10-3 mm2/s with DWI reduces interobserver and inter-DLM difference and achieves best segmentation performance of AIS lesions using DLMs. KEY POINTS • Higher Dice similarity coefficient (DSC) in predicting acute ischemic stroke lesions was achieved by ADC thresholds combined with DWI than by DWI alone (all p < .05). • DSC had a negative association with the ADC threshold in most sizes, both hospitals, and both observers (most p < .05) and a positive association with the stroke size in all ADC thresholds, both hospitals, and both observers (all p < .001). • An ADC threshold of 0.6 × 10-3 mm2/s eliminated the difference of DSC at any stroke size between observers or between hospitals (p = .07 to > .99).
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Affiliation(s)
- Chun-Jung Juan
- Department of Computer Science and Information Engineering, National Taiwan University, Taipei, Taiwan, Republic of China.,Department of Medical Imaging, China Medical University Hsinchu Hospital, Hsinchu, Taiwan, Republic of China.,Department of Radiology, School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan, Republic of China.,Department of Medical Imaging, China Medical University Hospital, Taichung, Taiwan, Republic of China.,Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan, Republic of China
| | - Shao-Chieh Lin
- Department of Medical Imaging, China Medical University Hsinchu Hospital, Hsinchu, Taiwan, Republic of China.,Ph.D. Program in Electrical and Communication Engineering, Feng Chia University, Taichung, Taiwan, Republic of China
| | - Ya-Hui Li
- Department of Medical Imaging, China Medical University Hsinchu Hospital, Hsinchu, Taiwan, Republic of China.,Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan, Republic of China
| | - Chia-Ching Chang
- Department of Medical Imaging, China Medical University Hsinchu Hospital, Hsinchu, Taiwan, Republic of China.,Department of Management Science, National Chiao-Tung University, Hsinchu, Taiwan, Republic of China
| | - Yi-Hung Jeng
- Department of Medical Imaging, China Medical University Hsinchu Hospital, Hsinchu, Taiwan, Republic of China.,Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan, Republic of China
| | - Hsu-Hsia Peng
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan, Republic of China
| | - Teng-Yi Huang
- Department of Electrical Engineering, National Taiwan University of Science and Technology, Taipei, Taiwan, Republic of China
| | - Hsiao-Wen Chung
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan, Republic of China.,Department of Electrical Engineering, National Taiwan University, Taipei, Taiwan, Republic of China
| | - Wu-Chung Shen
- Department of Medical Imaging, China Medical University Hsinchu Hospital, Hsinchu, Taiwan, Republic of China.,Department of Radiology, School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan, Republic of China
| | - Chon-Haw Tsai
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan, Republic of China
| | - Ruey-Feng Chang
- Department of Computer Science and Information Engineering, National Taiwan University, Taipei, Taiwan, Republic of China. .,Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan, Republic of China.
| | - Yi-Jui Liu
- Department of Automatic Control Engineering, Feng Chia University, No. 100 Wenhwa Rd., Seatwen, 40724, Taichung, Taiwan, Republic of China.
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7
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Fawaz AM, Wu S, Viswanathan D, Kaur K, Nuoman R, Nuoaman H, Adnan YA, Gandhi CD, Kurian C, Sahni R. Time to Wake-Up: Extending the Window for Management of Unknown-Onset Strokes. Cardiol Rev 2021; 29:26-32. [PMID: 32769626 DOI: 10.1097/crd.0000000000000336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The term "Wake-Up Stroke" is applied to a patient who displays no symptoms before sleep, but wakes with neurologic deficits suggestive of stroke. The current guidelines for acute ischemic stroke limit intravenous tissue plasminogen activator use to stroke patients in whom symptom onset or last known well is less than 4.5 hours. Approximately one-third of acute ischemic stroke patients present with unknown time of symptom onset and are often not eligible for intravenous reperfusion therapy in clinical practice. This review provides an overview of several earlier trials that used advanced neuroimaging to determine eligibility for reperfusion therapy in patients with unknown stroke onset. The reassuring results of these earlier trials that led to recent thrombolysis trials specifically targeted at "wake-up stroke" patients are discussed in this review. Ongoing studies aim to expand our knowledge regarding the safety and efficacy of thrombolysis in these patients.
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Affiliation(s)
- Al-Mufti Fawaz
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Sarah Wu
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Divya Viswanathan
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Kavneet Kaur
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Rolla Nuoman
- Department of Neurology, Maria Fareri Children's Hospital-Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Halla Nuoaman
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Yasir Ammar Adnan
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Chirag D Gandhi
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Christeena Kurian
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Ramandeep Sahni
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
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Grøan M, Ospel J, Ajmi S, Sandset EC, Kurz MW, Skjelland M, Advani R. Time-Based Decision Making for Reperfusion in Acute Ischemic Stroke. Front Neurol 2021; 12:728012. [PMID: 34790159 PMCID: PMC8591257 DOI: 10.3389/fneur.2021.728012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 09/16/2021] [Indexed: 11/13/2022] Open
Abstract
Decision making in the extended time windows for acute ischemic stroke can be a complex and time-consuming process. The process of making the clinical decision to treat has been compounded by the availability of different imaging modalities. In the setting of acute ischemic stroke, time is of the essence and chances of a good outcome diminish by each passing minute. Navigating the plethora of advanced imaging modalities means that treatment in some cases can be inefficaciously delayed. Time delays and individually based non-programmed decision making can prove challenging for clinicians. Visual aids can assist such decision making aimed at simplifying the use of advanced imaging. Flow charts are one such visual tool that can expedite treatment in this setting. A systematic review of existing literature around imaging modalities based on site of occlusion and time from onset can be used to aid decision making; a more program-based thought process. The use of an acute reperfusion flow chart helping navigate the myriad of imaging modalities can aid the effective treatment of patients.
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Affiliation(s)
- Mathias Grøan
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Johanna Ospel
- Department of Radiology, Basel University Hospital, Basel, Switzerland.,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Soffien Ajmi
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway.,University of Stavanger, Stavanger, Norway
| | - Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway.,Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Martin W Kurz
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway.,Neuroscience Research Group, Stavanger University Hospital, Stavanger, Norway
| | - Mona Skjelland
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Rajiv Advani
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway.,Neuroscience Research Group, Stavanger University Hospital, Stavanger, Norway
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9
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The Frequency and Associated Factors of Asymmetrical Prominent Veins: A Predictor of Unfavorable Outcomes in Patients with Acute Ischemic Stroke. Neural Plast 2021; 2021:9733926. [PMID: 34567108 PMCID: PMC8463180 DOI: 10.1155/2021/9733926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives The present study is aimed at investigating the frequency and associated factors of asymmetrical prominent veins (APV) in patients with acute ischemic stroke (AIS). Methods Consecutive patients with AIS admitted to the Comprehensive Stroke Center of Shanghai Fourth People's Hospital between January 2013 and December 2017 were enrolled. MRI including diffusion-weighted imaging (DWI), perfusion-weighted imaging (PWI), and susceptibility-weighted imaging (SWI) was performed within 12 hours of symptom onset. The volume of asymmetrical prominent veins (APV) was evaluated using the Signal Processing In nuclear magnetic resonance software (SPIN, Detroit, Michigan, USA). Multivariate analysis was used to assess relationships between APV findings and medical history, clinical variables as well as cardio-metabolic indices. Results Seventy-six patients met the inclusion criteria. The frequency of APV ≥ 10 mL was 46.05% (35/76). Multivariate analyses showed that proximal artery stenosis or occlusion (≥50%) (P < 0.001, adjusted odds ratio (OR) = 660.0, 95%CI = 57.28-7604.88) and history of atrial fibrillation (P < 0.001, adjusted OR = 10.48, 95%CI = 1.78-61.68) were independent factors associated with high APV (≥10 mL). Conclusion Our findings suggest that the frequency of APV ≥ 10 mL is high in patients with AIS within 12 hours of symptom onset. History of atrial fibrillation and severe proximal artery stenosis or occlusion are strong predictors of high APV as calculated by SPIN on the SWI map.
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10
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Berge E, Whiteley W, Audebert H, De Marchis GM, Fonseca AC, Padiglioni C, de la Ossa NP, Strbian D, Tsivgoulis G, Turc G. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J 2021; 6:I-LXII. [PMID: 33817340 DOI: 10.1177/2396987321989865] [Citation(s) in RCA: 437] [Impact Index Per Article: 145.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/27/2020] [Indexed: 02/06/2023] Open
Abstract
Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.
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Affiliation(s)
- Eivind Berge
- Department of Internal Medicine and Cardiology, Oslo University Hospital, Oslo, Norway
| | - William Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Heinrich Audebert
- Klinik und Hochschulambulanz für Neurologie, Charité Universitätsmedizin Berlin & Center for Stroke Research Berlin, Berlin, Germany
| | - Gian Marco De Marchis
- University Hospital of Basel & University of Basel, Department for Neurology & Stroke Center, Basel, Switzerland
| | - Ana Catarina Fonseca
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Chiara Padiglioni
- Neurology Unit-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hopital Sainte-Anne, Université de Paris, Paris, France.,INSERM U1266.,FHU NeuroVasc
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11
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Toyoda K, Inoue M, Yoshimura S, Yamagami H, Sasaki M, Fukuda-Doi M, Kimura K, Asakura K, Miwa K, Kanzawa T, Ihara M, Kondo R, Shiozawa M, Ohtaki M, Kamiyama K, Itabashi R, Iwama T, Aoki J, Minematsu K, Yamamoto H, Koga M. Magnetic Resonance Imaging-Guided Thrombolysis (0.6 mg/kg) Was Beneficial for Unknown Onset Stroke Above a Certain Core Size: THAWS RCT Substudy. Stroke 2020; 52:12-19. [PMID: 33297866 DOI: 10.1161/strokeaha.120.030848] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We determined to identify patients with unknown onset stroke who could have favorable 90-day outcomes after low-dose thrombolysis from the THAWS (Thrombolysis for Acute Wake-Up and Unclear-Onset Strokes With Alteplase at 0.6 mg/kg) database. METHODS This was a subanalysis of an investigator-initiated, multicenter, randomized, open-label, blinded-end point trial. Patients with stroke with a time last-known-well >4.5 hours who showed a mismatch between diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery were randomly assigned (1:1) to receive alteplase at 0.6 mg/kg intravenously or standard medical treatment. The patients were dichotomized by ischemic core size or National Institutes of Health Stroke Scale score, and the effects of assigned treatments were compared in each group. The efficacy outcome was favorable outcome at 90 days, defined as a modified Rankin Scale score of 0 to 1. RESULTS The median DWI-Alberta Stroke Program Early CT Score (ASPECTS) was 9, and the median ischemic core volume was 2.5 mL. Both favorable outcome (47.1% versus 48.3%) and any intracranial hemorrhage (26% versus 14%) at 22 to 36 hours were comparable between the 68 thrombolyzed patients and the 58 control patients. There was a significant treatment-by-cohort interaction for favorable outcome between dichotomized patients by ASPECTS on DWI (P=0.026) and core volume (P=0.035). Favorable outcome was more common in the alteplase group than in the control group in patients with DWI-ASPECTS 5 to 8 (RR, 4.75 [95% CI, 1.33-30.2]), although not in patients with DWI-ASPECTS 9 to 10. Favorable outcome tended to be more common in the alteplase group than in the control group in patients with core volume >6.4 mL (RR, 6.15 [95% CI, 0.87-43.64]), although not in patients with volume ≤6.4 mL. The frequency of any intracranial hemorrhage did not differ significantly between the 2 treatment groups in any dichotomized patients. CONCLUSIONS Patients developing unknown onset stroke with DWI-ASPECTS 5 to 8 showed favorable outcomes more commonly after low-dose thrombolysis than after standard treatment. Registration: URL: https://www.clinicaltrials.gov; Unique Identifier: NCT02002325. URL: https://www.umin.ac.jp/ctr; Unique Identifier: UMIN000011630.
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Affiliation(s)
- Kazunori Toyoda
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Japan (H. Yamagami)
| | - Makoto Sasaki
- Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Japan (M. Sasaki, H. Yamamoto)
| | - Mayumi Fukuda-Doi
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan.,Center for Advancing Clinical and Translational Sciences (M.F.-D., K.A.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan (K. Kimura, J.A.)
| | - Koko Asakura
- Center for Advancing Clinical and Translational Sciences (M.F.-D., K.A.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takao Kanzawa
- Department of Stroke Medicine, Institute of Brain and Blood Vessels, Mihara Memorial Hospital, Isesaki, Japan (T.K.)
| | - Masafumi Ihara
- Department of Neurology (M. Ihara), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Rei Kondo
- Department of Neurosurgery, Yamagata City Hospital Saiseikan, Japan (R.K.)
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masafumi Ohtaki
- Department of Neurosurgery, Obihiro Kosei Hospital, Japan (M.O.)
| | - Kenji Kamiyama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama)
| | - Ryo Itabashi
- Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (R.I.)
| | - Toru Iwama
- Department of Neurosurgery, Gifu University School of Medicine, Japan (T.I.)
| | - Junya Aoki
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan (K. Kimura, J.A.)
| | - Kazuo Minematsu
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Haruko Yamamoto
- Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Japan (M. Sasaki, H. Yamamoto)
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
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12
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Woo I, Lee A, Jung SC, Lee H, Kim N, Cho SJ, Kim D, Lee J, Sunwoo L, Kang DW. Fully Automatic Segmentation of Acute Ischemic Lesions on Diffusion-Weighted Imaging Using Convolutional Neural Networks: Comparison with Conventional Algorithms. Korean J Radiol 2020; 20:1275-1284. [PMID: 31339015 PMCID: PMC6658883 DOI: 10.3348/kjr.2018.0615] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 03/16/2019] [Indexed: 01/03/2023] Open
Abstract
Objective To develop algorithms using convolutional neural networks (CNNs) for automatic segmentation of acute ischemic lesions on diffusion-weighted imaging (DWI) and compare them with conventional algorithms, including a thresholding-based segmentation. Materials and Methods Between September 2005 and August 2015, 429 patients presenting with acute cerebral ischemia (training:validation:test set = 246:89:94) were retrospectively enrolled in this study, which was performed under Institutional Review Board approval. Ground truth segmentations for acute ischemic lesions on DWI were manually drawn under the consensus of two expert radiologists. CNN algorithms were developed using two-dimensional U-Net with squeeze-and-excitation blocks (U-Net) and a DenseNet with squeeze-and-excitation blocks (DenseNet) with squeeze-and-excitation operations for automatic segmentation of acute ischemic lesions on DWI. The CNN algorithms were compared with conventional algorithms based on DWI and the apparent diffusion coefficient (ADC) signal intensity. The performances of the algorithms were assessed using the Dice index with 5-fold cross-validation. The Dice indices were analyzed according to infarct volumes (< 10 mL, ≥ 10 mL), number of infarcts (≤ 5, 6–10, ≥ 11), and b-value of 1000 (b1000) signal intensities (< 50, 50–100, > 100), time intervals to DWI, and DWI protocols. Results The CNN algorithms were significantly superior to conventional algorithms (p < 0.001). Dice indices for the CNN algorithms were 0.85 for U-Net and DenseNet and 0.86 for an ensemble of U-Net and DenseNet, while the indices were 0.58 for ADC-b1000 and b1000-ADC and 0.52 for the commercial ADC algorithm. The Dice indices for small and large lesions, respectively, were 0.81 and 0.88 with U-Net, 0.80 and 0.88 with DenseNet, and 0.82 and 0.89 with the ensemble of U-Net and DenseNet. The CNN algorithms showed significant differences in Dice indices according to infarct volumes (p < 0.001). Conclusion The CNN algorithm for automatic segmentation of acute ischemic lesions on DWI achieved Dice indices greater than or equal to 0.85 and showed superior performance to conventional algorithms.
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Affiliation(s)
- Ilsang Woo
- Department of Convergence Medicine, Biomedical Engineering Research Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Areum Lee
- Department of Convergence Medicine, Biomedical Engineering Research Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seung Chai Jung
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Hyunna Lee
- Department of Convergence Medicine, Biomedical Engineering Research Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Namkug Kim
- Department of Convergence Medicine, Biomedical Engineering Research Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Se Jin Cho
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Donghyun Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jungbin Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Leonard Sunwoo
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong Wha Kang
- Department of Neurology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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13
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Boese AC, Eckert A, Hamblin MH, Lee JP. Human neural stem cells improve early stage stroke outcome in delayed tissue plasminogen activator-treated aged stroke brains. Exp Neurol 2020; 329:113275. [PMID: 32147438 PMCID: PMC7609039 DOI: 10.1016/j.expneurol.2020.113275] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/26/2020] [Accepted: 03/03/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Clinically, significant stroke injury results from ischemia-reperfusion (IR), which induces a deleterious biphasic opening of the blood-brain barrier (BBB). Tissue plasminogen activator (tPA) remains the sole pharmacological agent to treat ischemic stroke. However, major limitations of tPA treatment include a narrow effective therapeutic window of 4.5 h in most patients after initial stroke onset and off-target non-thrombolytic effects (e.g., the risk of increased IR injury). We hypothesized that ameliorating BBB damage with exogenous human neural stem cells (hNSCs) would improve stroke outcome to a greater extent than treatment with delayed tPA alone in aged stroke mice. METHODS We employed middle cerebral artery occlusion to produce focal ischemia with subsequent reperfusion (MCAO/R) in aged mice and administered tPA at a delayed time point (6 h post-stroke) via tail vein. We transplanted hNSCs intracranially in the subacute phase of stroke (24 h post-stroke). We assessed the outcomes of hNSC transplantation on pathophysiological markers of stroke 48 h post-stroke (24 h post-transplant). RESULTS Delayed tPA treatment resulted in more extensive BBB damage and inflammation relative to MCAO controls. Notably, transplantation of hNSCs ameliorated delayed tPA-induced escalated stroke damage; decreased expression of proinflammatory factors (tumor necrosis factor-alpha (TNF-α) and interleukin (IL)-6), decreased the level of matrix metalloprotease-9 (MMP-9), increased the level of brain-derived neurotrophic factor (BDNF), and reduced BBB damage. CONCLUSIONS Aged stroke mice that received delayed tPA treatment in combination with hNSC transplantation exhibited reduced stroke pathophysiology in comparison to non-transplanted stroke mice with delayed tPA. This suggests that hNSC transplantation may synergize with already existing stroke therapies to benefit a larger stroke patient population.
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Affiliation(s)
- Austin C Boese
- Department of Physiology, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Auston Eckert
- Department of Physiology, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Milton H Hamblin
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Jean-Pyo Lee
- Department of Physiology, Tulane University School of Medicine, New Orleans, LA 70112, USA; Tulane Brain Institute, Tulane University, New Orleans, LA 70112, USA.
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14
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Heidari P, Blayney S, Butler J, Hitomi E, Luby M, Leigh R. Frequency of thrombolytic targets in stroke patients presenting in an extended time window. Brain Circ 2020; 6:163-168. [PMID: 33210039 PMCID: PMC7646384 DOI: 10.4103/bc.bc_12_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/04/2020] [Accepted: 07/01/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE: The objective of this study was to determine the proportion of stroke patients presenting in an extended time window who have a thrombolytic treatment target. BACKGROUND: Patients presenting up to 24 h after stroke onset have been found to have penumbral tissue on multimodal imaging. Stroke patients presenting in this extended time window without a large vessel occlusion (LVO) may benefit from reperfusion therapy using thrombolysis. METHODS: Patients seen at our institutions from 2011 through 2015 were reviewed to identify those who presented >4 h and <24 h from last seen normal (LSN) and did not receive acute treatment. Magnetic resonance imaging (MRI) scans were used to dichotomize patients using a diffusion–perfusion mismatch ratio of 1.2. RESULTS: During the study period, 3469 patients were evaluated by our stroke service, with 893 seen 4–24 h from LSN who were not treated. MRI was performed with diffusion and perfusion imaging in 439 patients, of whom 26 were excluded due to hemorrhage and 37 were excluded due to LVO. This left 376 patients who potentially could have been treated with thrombolysis in an extended time window and were included in the analysis. Of these, 156 (42%) demonstrated a mismatch ratio >1.2. Patients with a mismatch presented earlier (P = 0.012), were more likely to be female (P = 0.03), and had higher National Institutes of Health Stroke Scale (P < 0.001). CONCLUSIONS: Almost half of the patients presenting 4–24 h from LSN had a target for thrombolysis in our study. Multimodal imaging may be able to expand the population of treatable stroke patients given the results of recent clinical trials.
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Affiliation(s)
- Parisa Heidari
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Sarah Blayney
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Jarrhett Butler
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Emi Hitomi
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Marie Luby
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Richard Leigh
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
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15
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Yu Y, Xie Y, Thamm T, Gong E, Ouyang J, Huang C, Christensen S, Marks MP, Lansberg MG, Albers GW, Zaharchuk G. Use of Deep Learning to Predict Final Ischemic Stroke Lesions From Initial Magnetic Resonance Imaging. JAMA Netw Open 2020; 3:e200772. [PMID: 32163165 PMCID: PMC7068232 DOI: 10.1001/jamanetworkopen.2020.0772] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
IMPORTANCE Predicting infarct size and location is important for decision-making and prognosis in patients with acute stroke. OBJECTIVES To determine whether a deep learning model can predict final infarct lesions using magnetic resonance images (MRIs) acquired at initial presentation (baseline) and to compare the model with current clinical prediction methods. DESIGN, SETTING, AND PARTICIPANTS In this multicenter prognostic study, a specific type of neural network for image segmentation (U-net) was trained, validated, and tested using patients from the Imaging Collaterals in Acute Stroke (iCAS) study from April 14, 2014, to April 15, 2018, and the Diffusion Weighted Imaging Evaluation for Understanding Stroke Evolution Study-2 (DEFUSE-2) study from July 14, 2008, to September 17, 2011 (reported in October 2012). Patients underwent baseline perfusion-weighted and diffusion-weighted imaging and MRI at 3 to 7 days after baseline. Patients were grouped into unknown, minimal, partial, and major reperfusion status based on 24-hour imaging results. Baseline images acquired at presentation were inputs, and the final true infarct lesion at 3 to 7 days was considered the ground truth for the model. The model calculated the probability of infarction for every voxel, which can be thresholded to produce a prediction. Data were analyzed from July 1, 2018, to March 7, 2019. MAIN OUTCOMES AND MEASURES Area under the curve, Dice score coefficient (DSC) (a metric from 0-1 indicating the extent of overlap between the prediction and the ground truth; a DSC of ≥0.5 represents significant overlap), and volume error. Current clinical methods were compared with model performance in subgroups of patients with minimal or major reperfusion. RESULTS Among the 182 patients included in the model (97 women [53.3%]; mean [SD] age, 65 [16] years), the deep learning model achieved a median area under the curve of 0.92 (interquartile range [IQR], 0.87-0.96), DSC of 0.53 (IQR, 0.31-0.68), and volume error of 9 (IQR, -14 to 29) mL. In subgroups with minimal (DSC, 0.58 [IQR, 0.31-0.67] vs 0.55 [IQR, 0.40-0.65]; P = .37) or major (DSC, 0.48 [IQR, 0.29-0.65] vs 0.45 [IQR, 0.15-0.54]; P = .002) reperfusion for which comparison with existing clinical methods was possible, the deep learning model had comparable or better performance. CONCLUSIONS AND RELEVANCE The deep learning model appears to have successfully predicted infarct lesions from baseline imaging without reperfusion information and achieved comparable performance to existing clinical methods. Predicting the subacute infarct lesion may help clinicians prepare for decompression treatment and aid in patient selection for neuroprotective clinical trials.
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Affiliation(s)
- Yannan Yu
- Department of Radiology, Stanford University, Stanford, California
| | - Yuan Xie
- Department of Radiology, Stanford University, Stanford, California
| | - Thoralf Thamm
- Department of Radiology, Stanford University, Stanford, California
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Enhao Gong
- Department of Electrical Engineering, Stanford University, Stanford, California
| | - Jiahong Ouyang
- Department of Electrical Engineering, Stanford University, Stanford, California
| | - Charles Huang
- Department of Electrical Engineering, Stanford University, Stanford, California
| | | | - Michael P. Marks
- Department of Radiology, Stanford University, Stanford, California
| | | | | | - Greg Zaharchuk
- Department of Radiology, Stanford University, Stanford, California
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16
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Francillard I, Grangeon L, Cornillot A, Houivet E, Ozkul-Wermester O, Triquenot-Bagan A, Hebant B, Maltete D, Gerardin E, Guegan-Massardier E. Is there a timing for sensitivity to acute cerebral ischemia in migraine patients? J Neurol Sci 2020; 408:116528. [PMID: 31677557 DOI: 10.1016/j.jns.2019.116528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 10/05/2019] [Accepted: 10/08/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Migraine may be a factor of increased cerebral sensitivity to ischemia. Previous studies were conducted within 6 to 72 after stroke onset. We aimed to determine if an accelerated infarct growth exists in migraine patients within the first 4.5 h. METHOD A retrospective case-control study was conducted where all patients admitted for acute stroke started <4.5 h before and who underwent perfusion CT were assessed. The hypoperfusion and necrosis volumes on initial CT perfusion were analyzed, as well as the final infarct volume on MRI performed within 72 h after admission. A no-mismatch pattern was defined as a ratio necrosis/hypoperfusion volume > 83%. RESULTS 24 patients with personal history of migraine were identified, 8 of them with aura. The control cohort included 51 patients. No difference was found between groups in terms of demographics, initial severity or outcome or presumed cause of stroke. Mean time to CT scan was 125 min in migraine patients and 127 min in the control group. A no-mismatch pattern was equally found in migraine patients and controls, even after adjustment for age, sex and presence of proximal occlusion (p = .22). The final infarct volume was also similar in both groups. CONCLUSIONS Migraine patients did not display more no-mismatch pattern than controls within the 4.5 h of stroke onset. This deviates from previous studies and may be due to our earlier time from stroke onset to CT scan. A history of migraine may lead to malignant progression of ischemia but occurring only after several hours.
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Affiliation(s)
| | - Lou Grangeon
- Department of Neurology, Rouen University Hospital, 76031 Rouen, France.
| | - Agathe Cornillot
- Department of Radiology, Rouen University Hospital, 76031, Rouen, France
| | - Estelle Houivet
- Department of Biostatistics and Clinical Research, INSERM U 1219, Rouen University Hospital, University of Rouen, Rouen, France
| | | | | | - Benjamin Hebant
- Department of Neurology, Rouen University Hospital, 76031 Rouen, France
| | - David Maltete
- Department of Neurology, Rouen University Hospital, 76031 Rouen, France
| | - Emmanuel Gerardin
- Department of Radiology, Rouen University Hospital, 76031, Rouen, France
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17
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Yang Y, Sun W, Li D, Li XY, Wang XT, Li SC, Zhao HJ, Zhang JB. Multimode Computed-Tomography-Guided Thrombolysis under a Prolonged Time Window in Acute Ischemic Stroke Patients with Atrial Fibrillation. Int Heart J 2019; 60:822-829. [PMID: 31257338 DOI: 10.1536/ihj.18-636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Atrial fibrillation (AF) is an independent risk factor for intracranial hemorrhage in patients receiving recombinant-tissue-type plasminogen activator (rt-PA) thrombolytic therapy. Research showed that patients with acute ischemic stroke (AIS) could benefit from multimode computed-tomography- (CT-) guided intravenous thrombolysis over 4.5 hours. The medical data of patients with AIS in our center were retrospectively reviewed, and the data of the multimode CT-guided thrombolytic therapy or nonthrombolytic therapy within different time windows (3-9 hours) were evaluated. 134 AIS cases were selected successfully and divided into three groups: patients with AF treated by rt-PA (AF rt-PA), patients with AF not treated by rt-PA (AF non-rt-PA), and patients without AF treated by rt-PA (non-AF rt-PA). After correcting for the baseline NIH Stroke Scale (NIHSS), sex, age, and hypertension data, the comparison results showed that the NIHSS improved significantly at hospital discharge for rt-PA-treated patients (n = 47) compared to non-rt-PA-treated patients with AIS (n = 31) with AF (P = 0.0156). The NIHSS evaluation at 90 days of follow-up also improved in rt-PA-treated patients (P = 0.0157). The NIHSS at hospital discharge was higher in AF rt-PA-treated patients compared to non-AF rt-PA-treated patients (P = 0.0167) after correction; the difference was not statistically significant at 90 days of follow-up (P = 0.091). Our research showed that the neural function improved after 3-9 hours of thrombolytic therapy with rt-PA in patients with AIS and AF. If there is no thrombolytic taboo, the patients could benefit from the thrombolytic therapy, although the onset time window has been extended to 9 hours.
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Affiliation(s)
- Ying Yang
- The Third Peoples Hospital of Dalian
| | - Wei Sun
- The Third Peoples Hospital of Dalian
| | - Dan Li
- Chongqing Changshou District Hospital of Traditional Chinese Medicine
| | | | | | | | | | - Jing-Bo Zhang
- The Third Peoples Hospital of Dalian.,Affiliated Brain Hospital of Shanghai Tongji University
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18
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Reduced Ischemic Lesion Growth with Heparin in Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2019; 28:1500-1508. [PMID: 30935810 DOI: 10.1016/j.jstrokecerebrovasdis.2019.03.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/19/2019] [Accepted: 03/05/2019] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE The role of heparin in acute ischemic stroke is controversial. We investigated the effect of heparin on ischemic lesion growth. METHODS Data were analyzed on nonthrombolyzed ischemic stroke patients in whom diffusion-weighted imaging (DWI)/perfusion-weighted imaging (PWI) MRI was performed less than 12 hours of last known well and showed a PWI-DWI lesion mismatch, and who underwent follow-up neuroimaging at least 4 days after admission. Lesion growth was assessed by (1) absolute lesion growth and (2) percentage mismatch lost (PML). Univariate and multivariate regression analysis, and propensity score matching, were used to determine the effects of heparin on ischemic lesion growth. RESULTS Of the 113 patients meeting study criteria, 59 received heparin within 24 hours. Heparin use was associated with ∼5-fold reductions in PML (3.5% versus 19.2%, P = .002) and absolute lesion growth (4.7 versus 20.5 mL, P = .009). In multivariate regression models, heparin independently predicted reduced PML (P = .04) and absolute lesion growth (P = .04) in the entire cohort, and in multiple subgroups (patients with and without proximal artery occlusion; DWI volume greater than 5 mL; cardio-embolic mechanism; DEFUSE-3 target mismatch). In propensity score matching analysis where patients were matched by admission NIHSS, DWI volume and proximal artery occlusion, heparin remained an independent predictor of PML (P = .048) and tended to predict absolute lesion growth (P = .06). Heparin treatment did not predict functional outcome at discharge or 90 days. CONCLUSION Early heparin treatment in acute ischemic stroke patients with PWI-DWI mismatch attenuates ischemic lesion growth. Clinical trials with careful patient selection are warranted to investigate the potential ischemic protective effects of heparin.
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Si Z, Liu J, Hu K, Lin Y, Liu J, Wang A. Effects of thrombolysis within 6 hours on acute cerebral infarction in an improved rat embolic middle cerebral artery occlusion model for ischaemic stroke. J Cell Mol Med 2019; 23:2468-2474. [PMID: 30697923 PMCID: PMC6433693 DOI: 10.1111/jcmm.14120] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 11/20/2018] [Accepted: 12/05/2018] [Indexed: 01/05/2023] Open
Abstract
Recombinant tissue plasminogen activator (rt-PA) is the first-line drug for revascularization in acute cerebral infarction (ACI) treatment. In this study, an improved rat embolic middle cerebral artery occlusion model for ischaemic stroke was used and the rats were killed on the first, third and seventh day after model establishment. Increases in infarct volume were significantly less in the thrombolytic group than in the conventional group at every time-point. The microvascular density (MVD) in the thrombolytic group was significantly higher than that in the conventional group at every time-point, especially on the seventh day. Increases in the expressions of neuronal nitric-oxide synthase (NOS) and caspase-3 in the ischaemic region and in the nitric oxide contents, malondialdehyde contents, and inducible NOS activities in the cortex of infarct side were significantly less in the thrombolytic group than in the conventional group. Furthermore, decreases in the superoxide dismutase activities in the thrombolytic group were significantly less than those in the conventional group. In conclusion, thrombolytic rt-PA therapy within a broadened therapeutic window (6 hours) could significantly decrease the infarct volume after ACI, possibly by increasing MVD in the ischaemic region, decreasing apoptotic molecule expression, and alleviating the oxidative stress response.
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Affiliation(s)
- Zhihua Si
- Department of Neurology, Shandong Provincial Qianfoshan Hospital, Affiliated to Shandong University, Jinan, Shandong, China
| | - Jinzhi Liu
- Department of Neurology, Shandong Provincial Qianfoshan Hospital, Affiliated to Shandong University, Jinan, Shandong, China
| | - Ke Hu
- Department of Emergency, Qianfoshan Hospital Affiliated to Shandong University, Jinan, China
| | - Yan Lin
- Department of Internal Medicine, Shandong Provincial Police General Hospital, Jinan, Shandong, China
| | - Jie Liu
- Department of Neurology, People's Hospital of Rizhao, Rizhao, Shandong, China
| | - Aihua Wang
- Department of Neurology, Shandong Provincial Qianfoshan Hospital, Affiliated to Shandong University, Jinan, Shandong, China
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20
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Majidi S, Simpkins AN, Leigh R. The Efficacy of IV Tissue Plasminogen Activator for Restoring Cerebral Blood Flow in the Hours Immediately after Administration in Patients with Acute Stroke. J Neuroimaging 2018; 29:206-210. [PMID: 30508260 DOI: 10.1111/jon.12587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 11/18/2018] [Accepted: 11/19/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND PURPOSE Timely restoration of tissue-level cerebral blood flow is the goal of thrombolytic therapy in patients presenting with an acute ischemic stroke. We aimed to identify the incidence and predictors of reperfusion immediately following treatment with intravenous recombinant tissue plasminogen activator (IV rt-PA). METHODS This study included patients with acute ischemic stroke triaged using magnetic resonance imaging (MRI) with perfusion-weighted imaging (PWI) and treated with IV rt-PA who were subsequently enrolled in our natural history study and underwent repeat MRI with PWI approximately 2 hours posttreatment. Early reperfusion was defined as >80% decrease in the size of initial perfusion deficit on the 2 hours follow-up MRI. Demographics, stroke risk factors, presenting National Institutes of Health Stroke Scale score, and location of the thrombosis were compared between patients with and without early reperfusion. RESULTS Of the 49 patients included in this study, 21 (43%) had early reperfusion. The mean age for patients with early reperfusion was significantly lower in comparison to the patients without early reperfusion (64 vs. 76, P = .01). The prevalence of hyperlipidemia was significantly lower among patients with early reperfusion (24% vs. 54%, P = .036). Patients with early reperfusion were less likely to have large-vessel occlusion (LVO) (internal carotid artery terminus or proximal middle cerebral artery) (24% vs. 50%, P = .06). In a multivariate analysis, the presence of an LVO was an independent predictor of lack of early reperfusion (OR [95%Cl]: .13 [.019-.89], P = .038). CONCLUSION Early reperfusion was found in a substantial percentage of the patients treated with IV rt-PA. It was more common in patients without LVO.
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Affiliation(s)
- Shahram Majidi
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD.,Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexis N Simpkins
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Richard Leigh
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
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- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
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21
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Ghandehari K, Shahedi S, Valipour Z, Sobhani MR, Salehian H, Nazemian S, Rezae M. Review Study: Intravenous Thrombolysis, Time Window, Dosage, and Off-Label. CASPIAN JOURNAL OF NEUROLOGICAL SCIENCES 2018. [DOI: 10.29252/cjns.4.15.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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22
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Smith AG, Rowland Hill C. Imaging assessment of acute ischaemic stroke: a review of radiological methods. Br J Radiol 2017; 91:20170573. [PMID: 29144166 DOI: 10.1259/bjr.20170573] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Acute ischaemic stroke is the second largest cause of death worldwide and a cause of major physical and psychological morbidity. Current evidence based treatment includes intravenous thrombolysis (IVT) and mechanical thrombectomy (MT), both requiring careful patient selection and to be administered as quickly as possible within a limited time window from symptom onset. Imaging plays a crucial role identifying patients who may benefit from MT or IVT whilst excluding those that may be harmed. For IVT, imaging must as a minimum exclude haemorrhage, stroke mimics and provide an estimate of non-viable brain. For MT, imaging must in addition detect and characterize intra-arterial thrombus and assess the intra and extracranial arterial architecture. More advanced imaging techniques may be used to assess more accurately the volume of non-viable and potentially salvageable brain tissue. It is highly likely that further research will identify patients who would benefit from treatment beyond currently accepted time windows for IVT (4.5 h) and MT (6 h) and patients with an unknown time of symptom onset. Current evidence indicates that best outcomes are achieved when treatment is instituted as soon as possible after symptom onset. A rapid, efficient imaging pathway including interpretation is fundamental to achieving the best outcomes. This review summarizes current techniques for imaging assessment of acute stroke, highlighting strengths and limitations of each. The optimum pathway is a balance between diagnostic information, local resources, specialization and the time taken to acquire, process and interpret the data. As new evidence emerges, it is likely that the minimum required imaging data will change.
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23
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Thirugnanachandran T, Ma H, Singhal S, Slater LA, Davis SM, Donnan GA, Phan T. Refining the ischemic penumbra with topography. Int J Stroke 2017; 13:277-284. [DOI: 10.1177/1747493017743056] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
It has been 40 years since the ischemic penumbra was first conceptualized through work on animal models. The topography of penumbra has been portrayed as an infarcted core surrounded by penumbral tissue and an extreme rim of oligemic tissue. This picture has been used in many review articles and textbooks before the advent of modern imaging. In this paper, we review our understanding of the topography of the ischemic penumbra from the initial experimental animal models to current developments with neuroimaging which have helped to further define the temporal and spatial evolution of the penumbra and refine our knowledge. The concept of the penumbra has been successfully applied in clinical trials of endovascular therapies with a time window as long as 24 h from onset. Further, there are reports of “good” outcome even in patients with a large ischemic core. This latter observation of good outcome despite having a large core requires an understanding of the topography of the penumbra and the function of the infarcted regions. It is proposed that future research in this area takes departure from a time-dependent approach to a more individualized tissue and location-based approach.
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Affiliation(s)
- Tharani Thirugnanachandran
- Stroke & Ageing Research (STARC), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Henry Ma
- Stroke & Ageing Research (STARC), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Shaloo Singhal
- Stroke & Ageing Research (STARC), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Lee-Anne Slater
- Diagnostic Imaging, Monash Health, The Royal Melbourne Hospital and the University of Melbourne, Parkville, VIC, Australia
| | - Stephen M Davis
- Melbourne Brain Centre, The Royal Melbourne Hospital and the University of Melbourne, Parkville, VIC, Australia
| | - Geoffrey A Donnan
- Florey Neuroscience Institute, The Royal Melbourne Hospital and the University of Melbourne, Parkville, VIC, Australia
| | - Thanh Phan
- Stroke & Ageing Research (STARC), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
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24
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Mackay MT, Monagle P, Babl FE. Improving diagnosis of childhood arterial ischaemic stroke. Expert Rev Neurother 2017; 17:1157-1165. [DOI: 10.1080/14737175.2017.1395699] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Mark T. Mackay
- Department of Neurology, Royal Children’s Hospital, Parkville, Australia
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Florey Institute of Neurosciences and Mental Health, Parkville, Australia
| | - Paul Monagle
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Department of Haematology, Royal Children’s Hospital, Parkville, Australia
| | - Franz E. Babl
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Emergency Department, Royal Children’s Hospital Melbourne, Parkville, Australia
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25
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Unknown onset ischemic strokes in patients last-seen-well >4.5 h: differences between wake-up and daytime-unwitnessed strokes. Acta Neurol Belg 2017; 117:637-642. [PMID: 28803427 PMCID: PMC5565646 DOI: 10.1007/s13760-017-0830-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 08/01/2017] [Indexed: 01/22/2023]
Abstract
Patients with unknown time of stroke onset (UOS) represent around one-third of ischemic stroke patients. These are patients with wake-up stroke (WUS) or daytime-unwitnessed stroke (DUS), often presenting outside the time-window for reperfusion therapy. UOS patients presenting between 4.5 and 12 h after time of last-seen-well were included. Clinical and imaging characteristics were compared between WUS and DUS patients. Good functional outcome was defined as a modified Rankin scale of ≤2 at follow-up. Sixty-one UOS patients were included: 42 WUS and 19 DUS patients. Stroke severity at presentation was mild to moderate with a median National Institutes of Health Stroke Scale of 5 in WUS and 6 in DUS patients. Time between last-seen-well and presentation at the hospital was shorter in patients with DUS compared to WUS (506 vs 362 min, p < 0.01). CT imaging results were similar, with a median Alberta Stroke Program Early CT Score of 10 for both WUS and DUS patients. After correction for age and NIHSS at presentation, no difference in good functional outcome was found between WUS (52%) and DUS (22%). In patients with unknown onset ischemic strokes presenting between 4.5 and 12 h after time of last-seen-well, clinical and radiological features were in large part similar between WUS and DUS. The outcome in the overall cohort was rather poor despite a favorable neuroimaging profile at presentation. These findings underscore the need for clinical trials in patients in whom stroke onset time is unknown.
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26
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Abstract
Patients with wake-up strokes account for approximately 1 in 5 individuals presenting with an acute ischemic stroke. However, they are commonly excluded from acute stroke treatment. This article reviews the current understanding of wake-up strokes. A comparison of wake-up and awake-onset strokes demonstrated that they are physiologically, clinically, and radiologically similar. Use of advanced CT and MRI techniques may help extend acute stroke treatment options to patients with wake-up stroke.
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Affiliation(s)
- Jenny P Tsai
- Department of Neurology and Neurological Sciences, Stanford University Medical Centre, Stanford, CA
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27
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Abstract
In recent years, several landmark trials have transformed acute ischemic stroke care. The most dramatic results from the field of acute endovascular intervention demonstrate unequivocal benefit for a select group of patients with moderate to severe deficits presenting within 7 hours from onset and with occlusions of proximal arteries in the anterior circulation. In addition, technological advances and workflow efficiencies have facilitated more rapid delivery of acute stroke interventions. This review provides an overview of recent advances in the management of acute ischemic stroke.
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Affiliation(s)
- Philip Chang
- Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Ward 12-140, Chicago, USA
| | - Shyam Prabhakaran
- Northwestern University Feinberg School of Medicine, Abbott Hall Suite 1123, 710 N Lake Shore Drive, Chicago, USA
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28
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Ni L, Li J, Li W, Zhou F, Wang F, Schwarz CG, Liu R, Zhao H, Wu W, Zhang X, Li M, Yu H, Zhu B, Villringer A, Zang Y, Zhang B, Lv Y, Xu Y. The value of resting-state functional MRI in subacute ischemic stroke: comparison with dynamic susceptibility contrast-enhanced perfusion MRI. Sci Rep 2017; 7:41586. [PMID: 28139701 PMCID: PMC5282488 DOI: 10.1038/srep41586] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 12/21/2016] [Indexed: 11/09/2022] Open
Abstract
To evaluate the potential clinical value of the time-shift analysis (TSA) approach for resting-state fMRI (rs-fMRI) blood oxygenation level-dependent (BOLD) data in detecting hypoperfusion of subacute stroke patients through comparison with dynamic susceptibility contrast perfusion weighted imaging (DSC-PWI). Forty patients with subacute stroke (3–14 days after neurological symptom onset) underwent MRI examination. Cohort A: 31 patients had MRA, DSC-PWI and BOLD data. Cohort B: 9 patients had BOLD and MRA data. The time delay between the BOLD time course in each voxel and the mean signal of global and contralateral hemisphere was calculated using TSA. Time to peak (TTP) was employed to detect hypoperfusion. Among cohort A, 14 patients who had intracranial large-vessel occlusion/stenosis with sparse collaterals showed hypoperfusion by both of the two approaches, one with abundant collaterals showed neither TTP nor TSA time delay. The remaining 16 patients without obvious MRA lesions showed neither TTP nor TSA time delay. Among cohort B, eight patients showed time delay areas. The TSA approach was a promising alternative to DSC-PWI for detecting hypoperfusion in subacute stroke patients who had obvious MRA lesions with sparse collaterals, those with abundant collaterals would keep intact local perfusion.
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Affiliation(s)
- Ling Ni
- Department of Radiology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, University of Nanjing, Nanjing, China
| | - Jingwei Li
- Department of Neurology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Weiping Li
- Department of Radiology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, University of Nanjing, Nanjing, China
| | - Fei Zhou
- Department of Radiology, The Affiliated Drum Tower Hospital of Nanjing Medical University, Nanjing, China
| | - Fangfang Wang
- Department of Radiology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, University of Nanjing, Nanjing, China
| | | | - Renyuan Liu
- Department of Neurology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Hui Zhao
- Department of Neurology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Wenbo Wu
- Department of Radiology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, University of Nanjing, Nanjing, China
| | - Xin Zhang
- Department of Radiology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, University of Nanjing, Nanjing, China
| | - Ming Li
- Department of Radiology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, University of Nanjing, Nanjing, China
| | - Haiping Yu
- Department of Radiology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, University of Nanjing, Nanjing, China
| | - Bin Zhu
- Department of Radiology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, University of Nanjing, Nanjing, China
| | - Arno Villringer
- Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Yufeng Zang
- Center for Cognition and Brain Disorders, Affiliated Hospital, Hangzhou Normal University, Hangzhou, Zhejiang, China.,Zhejiang Key Laboratory for Research in Assessment of Cognitive Impairments, Hangzhou, Zhejiang, China
| | - Bing Zhang
- Department of Radiology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, University of Nanjing, Nanjing, China
| | - Yating Lv
- Center for Cognition and Brain Disorders, Affiliated Hospital, Hangzhou Normal University, Hangzhou, Zhejiang, China.,Zhejiang Key Laboratory for Research in Assessment of Cognitive Impairments, Hangzhou, Zhejiang, China
| | - Yun Xu
- Department of Neurology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
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29
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Tateishi Y, Hamabe J, Kanamoto T, Nakaoka K, Morofuji Y, Horie N, Izumo T, Morikawa M, Tsujino A. Subacute lesion volume as a potential prognostic biomarker for acute ischemic stroke after intravenous thrombolysis. J Neurol Sci 2016; 369:77-81. [DOI: 10.1016/j.jns.2016.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/30/2016] [Accepted: 08/02/2016] [Indexed: 10/21/2022]
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30
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The pros and cons of intravenous thrombolysis in stroke. Lancet Neurol 2016; 15:997-8. [DOI: 10.1016/s1474-4422(16)30159-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 06/29/2016] [Indexed: 11/19/2022]
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31
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Sagnier S, Galli P, Poli M, Debruxelles S, Renou P, Olindo S, Rouanet F, Sibon I. The impact of intravenous thrombolysis on outcome of patients with acute ischemic stroke after 90 years old. BMC Geriatr 2016; 16:156. [PMID: 27562122 PMCID: PMC5000473 DOI: 10.1186/s12877-016-0331-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 08/20/2016] [Indexed: 12/24/2022] Open
Abstract
Background Age increases the risk of mortality and poor prognosis following stroke. The benefit of intravenous thrombolysis in very old patients remains uncertain. The purpose of the study was to evaluate the efficacy and safety of thrombolysis in very old patients considering their perfusion-imaging profile. Methods We conducted a retrospective study including patients older than 90 y.o. admitted for an acute ischemic stroke. A computed tomography perfusion-imaging (CTP) was performed in patients who received thrombolysis. Primary outcome was the functional status at 3 months, assessed by the modified Rankin scale (mRS). Secondary outcomes were the rate of hemorrhagic transformations, duration of hospitalization and the rate of death in the first 7 days. Patients receiving thrombolysis were compared with an age-matched group of non-thrombolysed patients. Results 78 patients were included (31 % male, aged 92 ± 1.7 y.o). 37 patients received thrombolysis and among them, 30 had CTP with a mismatch. The three months mRS was not significantly different in the two groups (mRS 0–2: 5 % and 7 % in the thrombolysed and non-thrombolysed group, respectively). Hemorrhagic transformations were more frequent in the thrombolysed group (54 % versus 12 %, p = 0.002) and symptomatic intracranial hemorrhage tended to be associated with mRS at three months and death in the first 7 days. Duration of hospitalization was longer in the thrombolysed group (10 days ± 12 versus 7 days ± 9, p = 0.046). Conclusions Patients who received thrombolysis did not have a better functional prognosis than non-thrombolysed patients. Electronic supplementary material The online version of this article (doi:10.1186/s12877-016-0331-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- S Sagnier
- Unité Neuro-vasculaire, Pôle de Neurosciences Cliniques, Hôpital Pellegrin, CHU Bordeaux, UnitéBordeaux Segalen, 33076, Bordeaux, France
| | - P Galli
- Unité Neuro-vasculaire, Pôle de Neurosciences Cliniques, Hôpital Pellegrin, CHU Bordeaux, UnitéBordeaux Segalen, 33076, Bordeaux, France.,Université Bordeaux Segalen, Bordeaux, France
| | - M Poli
- Unité Neuro-vasculaire, Pôle de Neurosciences Cliniques, Hôpital Pellegrin, CHU Bordeaux, UnitéBordeaux Segalen, 33076, Bordeaux, France
| | - S Debruxelles
- Unité Neuro-vasculaire, Pôle de Neurosciences Cliniques, Hôpital Pellegrin, CHU Bordeaux, UnitéBordeaux Segalen, 33076, Bordeaux, France
| | - P Renou
- Unité Neuro-vasculaire, Pôle de Neurosciences Cliniques, Hôpital Pellegrin, CHU Bordeaux, UnitéBordeaux Segalen, 33076, Bordeaux, France
| | - S Olindo
- Unité Neuro-vasculaire, Pôle de Neurosciences Cliniques, Hôpital Pellegrin, CHU Bordeaux, UnitéBordeaux Segalen, 33076, Bordeaux, France
| | - F Rouanet
- Unité Neuro-vasculaire, Pôle de Neurosciences Cliniques, Hôpital Pellegrin, CHU Bordeaux, UnitéBordeaux Segalen, 33076, Bordeaux, France
| | - I Sibon
- Unité Neuro-vasculaire, Pôle de Neurosciences Cliniques, Hôpital Pellegrin, CHU Bordeaux, UnitéBordeaux Segalen, 33076, Bordeaux, France. .,Université Bordeaux Segalen, Bordeaux, France.
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32
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Bivard A, Lou M, Levi CR, Krishnamurthy V, Cheng X, Aviv RI, McElduff P, Lin L, Kleinig T, O'Brien B, Butcher K, Jingfen Z, Jannes J, Dong Q, Parsons MW. Too good to treat? ischemic stroke patients with small computed tomography perfusion lesions may not benefit from thrombolysis. Ann Neurol 2016; 80:286-93. [PMID: 27352245 DOI: 10.1002/ana.24714] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 06/05/2016] [Accepted: 06/26/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Although commonly used in clinical practice, there remains much uncertainty about whether perfusion computed tomography (CTP) should be used to select stroke patients for acute reperfusion therapy. In this study, we tested the hypothesis that a small acute perfusion lesion predicts good clinical outcome regardless of thrombolysis administration. METHODS We used a prospectively collected cohort of acute ischemic stroke patients being assessed for treatment with IV-alteplase, who had CTP before a treatment decision. Volumetric CTP was retrospectively analyded to identify patients with a small perfusion lesion (<15ml in volume). The primary analysis was excellent 3-month outcome in patients with a small perfusion lesion who were treated with alteplase compared to those who were not treated. RESULTS Of 1526 patients, 366 had a perfusion lesion <15ml and were clinically eligible for alteplase (212 being treated and 154 not treated). Median acute National Institutes of Health Stroke Scale score was 8 in each group. Of the 366 patients with a small perfusion lesion, 227 (62%) were modified Rankin Scale (mRS) 0 to 1 at day 90. Alteplase-treated patients were less likely to achieve 90-day mRS 0 to 1 (57%) than untreated patients (69%; relative risk [RR] = 0.83; 95% confidence interval [CI], 0.71-0.97; p = 0.022) and did not have different rates of mRS 0 to 2 (72% treated patients vs 77% untreated; RR, 0.93; 95% CI, 0.82-1.95; p = 0.23). INTERPRETATION This large observational cohort suggests that a portion of ischemic stroke patients clinically eligible for alteplase therapy with a small perfusion lesion have a good natural history and may not benefit from treatment. Ann Neurol 2016;80:286-293.
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Affiliation(s)
- Andrew Bivard
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Min Lou
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Christopher R Levi
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Venkatesh Krishnamurthy
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Xin Cheng
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Richard I Aviv
- Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Patrick McElduff
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Longting Lin
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Tim Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
| | - Billy O'Brien
- Department of Neurology, Gosford Hospital, Gosford, Australia
| | - Kenneth Butcher
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Zhang Jingfen
- Department of Neurology, Baotou Central Hospital, Baotou, China
| | - Jim Jannes
- Department of Neurology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Mark W Parsons
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
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33
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Eligibility and Predictors for Acute Revascularization Procedures in a Stroke Center. Stroke 2016; 47:1844-9. [DOI: 10.1161/strokeaha.115.012577] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 05/17/2016] [Indexed: 01/19/2023]
Abstract
Background and Purpose—
Endovascular treatment (EVT) is a new standard of care for selected, large vessel occlusive strokes. We aimed to determine frequency of potentially eligible patients for intravenous thrombolysis (IVT) and EVT in comprehensive stroke centers. In addition, predictors of EVT eligibility were derived.
Methods—
Patients from a stroke center–based registry (2003–2014), admitted within 24 hours of last proof of usual health, were selected if they had all data to determine IVT and EVT eligibility according to American Heart Association/American Stroke Association (AHA/ASA) guidelines (class I–IIa recommendations). Moreover, less restrictive criteria adapted from randomized controlled trials and clinical practice were tested. Maximum onset-to-door time windows for IVT eligibility were 3.5 hours (allowing door-to-needle delay of ≤60 minutes) and 4.5 hours for EVT eligibility (door-to-groin delay ≤90 minutes). Demographic and clinical information were used in logistic regression analysis to derive variables associated with EVT eligibility.
Results—
A total of 2704 patients with acute ischemic stroke were included, of which 26.8% were transfers. Of all patients with stroke arriving at our comprehensive stroke center, a total proportion of 12.4% patients was eligible for IVT. Frequency of EVT eligibility differed between AHA/ASA guidelines and less restrictive approach: 2.9% versus 4.9%, respectively, of all patients with acute ischemic stroke and 10.5% versus 17.7%, respectively, of all patients arriving within <6 hours. Predictors for AHA–EVT eligibility were younger, shorter onset-to-admission delays, higher National Institutes of Health Stroke Scale (NIHSS), decreased vigilance, hemineglect, absent cerebellar signs, atrial fibrillation, smoking, and decreasing glucose levels (area under the curve=0.86).
Conclusions—
Of patients arriving within 6 hours at a comprehensive stroke center, 10.5% are EVT eligible according to AHA/ASA criteria, 17.7% according to criteria resembling randomized controlled trials, and twice as many patients are IVT eligible (36.2%).
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Hassen WB, Tisserand M, Turc G, Charron S, Seners P, Edjlali M, Legrand L, Lion S, Calvet D, Naggara O, Mas JL, Meder JF, Baron JC, Oppenheim C. Comparison between voxel-based and subtraction methods for measuring diffusion-weighted imaging lesion growth after thrombolysis. Int J Stroke 2016; 11:221-8. [DOI: 10.1177/1747493015616636] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Infarct growth (IG) is used as surrogate end-point in therapeutic trials. For practical reasons, infarct growth is commonly assessed using simple subtraction of acute from follow-up diffusion-weighted imaging (DWI) lesion volumes. However, the volume subtraction method will underestimate true infarct growth in case of diffusion-weighted imaging lesion reversal. Aim To measure the size of the difference between true infarct growth on voxel-based coregistration and infarct growth approximated with simple volume subtraction. Methods We retrospectively analyzed 322 consecutive stroke patients (median (IQR) age: 70 years (57–80), National Institute of Health Stroke Score at admission 14 (8–19)), who underwent a magnetic resonance imaging before (DWI1) and ≈24 h (DWI2) after IV-thrombolysis. IGvoxel-based was defined as the volume of signal changes on DWI2 that did not overlap with that on coregistered DWI1. This was compared with simply subtracting DWI1 from DWI2 lesion volume (IGsubtracted). We also compared these two metrics for the prediction of three-month unfavorable outcome (mRS ≥ 2) using c-statistics of multivariable models, adjusted for age, and National Institute of Health Stroke Score. Results Infarct growth volume metrics were strongly correlated (ρ = 0.94), but IGsubtracted substantially underestimated IGvoxel-based (median (IQR): 9.52 (0.23–38.9) vs. 16.98 (4.4–45.4) mL). Of the 75 patients with shrinking or stable diffusion-weighted imaging lesion using volume subtraction, IGvoxel-based was ≥5 mL in 20 (27% of the subset, 6.2% of the whole population). Moreover, IGvoxel-based better predicted unfavorable outcome than IGsubtracted (c-statistics = 0.86 (95% CI, 0.82–0.90) vs. 0.82 (0.78–0.87), P = 0.003). Conclusion At early post-thrombolysis time points, the simple subtraction of lesion volumes masked substantial diffusion-weighted imaging lesion growth in 6.2% of patients. Although more time-consuming, the voxel-based method may impact results of trials that use infarct growth attenuation as an end-point.
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Affiliation(s)
- Wajih Ben Hassen
- Department of Radiology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Paris, France
- Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Paris, France
| | - Marie Tisserand
- Department of Radiology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Paris, France
- Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Paris, France
| | - Guillaume Turc
- Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Paris, France
- Department of Neurology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Paris, France
| | - Sylvain Charron
- Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Paris, France
| | - Pierre Seners
- Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Paris, France
- Department of Neurology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Paris, France
| | - Myriam Edjlali
- Department of Radiology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Paris, France
- Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Paris, France
| | - Laurence Legrand
- Department of Radiology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Paris, France
- Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Paris, France
| | - Stéphanie Lion
- Department of Radiology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Paris, France
| | - David Calvet
- Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Paris, France
- Department of Neurology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Paris, France
| | - Olivier Naggara
- Department of Radiology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Paris, France
- Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Paris, France
| | - Jean-Louis Mas
- Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Paris, France
- Department of Neurology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Paris, France
| | - Jean-François Meder
- Department of Radiology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Paris, France
- Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Paris, France
| | - Jean-Claude Baron
- Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Paris, France
- Department of Neurology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Paris, France
| | - Catherine Oppenheim
- Department of Radiology, Centre Hospitalier Sainte-Anne, Université Paris Descartes, Paris, France
- Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Paris, France
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Moretti A, Ferrari F, Villa RF. Pharmacological therapy of acute ischaemic stroke: Achievements and problems. Pharmacol Ther 2015; 153:79-89. [DOI: 10.1016/j.pharmthera.2015.06.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 06/03/2015] [Indexed: 01/04/2023]
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Vanacker P, Lambrou D, Eskandari A, Ntaios G, Cras P, Maeder P, Meuli R, Michel P. Improving the Prediction of Spontaneous and Post-thrombolytic Recanalization in Ischemic Stroke Patients. J Stroke Cerebrovasc Dis 2015; 24:1781-6. [PMID: 26015095 DOI: 10.1016/j.jstrokecerebrovasdis.2015.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 03/17/2015] [Accepted: 04/01/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Endovascular treatment for acute ischemic stroke patients was recently shown to improve recanalization rates and clinical outcome in a well-defined study population. Intravenous thrombolysis (IVT) alone is insufficiently effective to recanalize in certain patients or of little value in others. Accordingly, we aimed at identifying predictors of recanalization in patients treated with or without IVT. METHODS In the observational Acute Stroke Registry and Analysis of Lausanne (ASTRAL) registry, we selected those stroke patients (1) with an arterial occlusion on computed tomography angiography (CTA) imaging, (2) who had an arterial patency assessment at 24 hours (CTA/magnetic resonance angiography/transcranial Doppler), and (3) who were treated with IVT or had no revascularization treatment. Based on 2 separate logistic regression analyses, predictors of spontaneous and post-thrombolytic recanalization were generated. RESULTS Partial or complete recanalization was achieved in 121 of 210 (58%) thrombolyzed patients. Recanalization was associated with atrial fibrillation (odds ratio , 1.6; 95% confidence interval, 1.2-3.0) and absence of early ischemic changes on CT (1.1, 1.1-1.2) and inversely correlated with the presence of a significant extracranial (EC) stenosis or occlusion (.6, .3-.9). In nonthrombolyzed patients, partial or complete recanalization was significantly less frequent (37%, P < .01). The recanalization was independently associated with a history of hypercholesterolemia (2.6, 1.2-5.6) and the proximal site of the intracranial occlusion (2.5, 1.2-5.4), and inversely correlated with a decreased level of consciousness (.3, .1-.8), and EC (.3, .1-.6) and basilar artery pathology (.1, .0-.6). CONCLUSIONS Various clinical findings, cardiovascular risk factors, and arterial pathology on acute CTA-based imaging are moderately associated with spontaneous and post-thrombolytic arterial recanalization at 24 hours. If confirmed in other studies, this information may influence patient selection toward the most appropriate revascularization strategy.
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Affiliation(s)
- Peter Vanacker
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology, University Hospital Antwerp, Edegem, Belgium.
| | - Dimitris Lambrou
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Ashraf Eskandari
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - George Ntaios
- Department of Medicine, University of Thessaly, Larissa, Greece
| | - Patrick Cras
- Department of Neurology, University Hospital Antwerp, Edegem, Belgium
| | - Philippe Maeder
- Department of Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Reto Meuli
- Department of Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Patrik Michel
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Horsch AD, Dankbaar JW, Niesten JM, van Seeters T, van der Schaaf IC, van der Graaf Y, Mali WPTM, Velthuis BK. Predictors of reperfusion in patients with acute ischemic stroke. AJNR Am J Neuroradiol 2015; 36:1056-62. [PMID: 25907522 DOI: 10.3174/ajnr.a4283] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/11/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE Ischemic stroke studies emphasize a difference between reperfusion and recanalization, but predictors of reperfusion have not been elucidated. The aim of this study was to evaluate the relationship between reperfusion and recanalization and identify predictors of reperfusion. MATERIALS AND METHODS From the Dutch Acute Stroke Study, 178 patients were selected with an MCA territory deficit on admission CTP and day 3 follow-up CTP and CTA. Reperfusion was evaluated on CTP, and recanalization on CTA, follow-up imaging. Reperfusion percentages were calculated in patients with and without recanalization. Patient admission and treatment characteristics and admission CT imaging parameters were collected. Their association with complete reperfusion was analyzed by using univariate and multivariate logistic regression. RESULTS Sixty percent of patients with complete recanalization showed complete reperfusion (relative risk, 2.60; 95% CI, 1.63-4.13). Approximately one-third of patients showed some discrepancy between recanalization and reperfusion status. Lower NIHSS score (OR, 1.06; 95% CI, 1.01-1.11), smaller infarct core size (OR, 3.11; 95% CI, 1.46-6.66; and OR, 2.40; 95% CI, 1.14-5.02), smaller total ischemic area (OR, 4.20; 95% CI, 1.91-9.22; and OR, 2.35; 95% CI, 1.12-4.91), lower clot burden (OR, 1.35; 95% CI, 1.14-1.58), distal thrombus location (OR, 3.02; 95% CI, 1.76-5.20), and good collateral score (OR, 2.84; 95% CI, 1.34-6.02) significantly increased the odds of complete reperfusion. In multivariate analysis, only total ischemic area (OR, 6.12; 95% CI, 2.69-13.93; and OR, 1.91; 95% CI, 0.91-4.02) was an independent predictor of complete reperfusion. CONCLUSIONS Recanalization and reperfusion are strongly associated but not always equivalent in ischemic stroke. A smaller total ischemic area is the only independent predictor of complete reperfusion.
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Affiliation(s)
- A D Horsch
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands Department of Radiology (A.D.H.), Rijnstate Hospital, Arnhem, the Netherlands
| | - J W Dankbaar
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - J M Niesten
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - T van Seeters
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - I C van der Schaaf
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - Y van der Graaf
- Julius Center for Health Sciences and Primary Care (Y.v.d.G.), Utrecht, the Netherlands
| | - W P Th M Mali
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - B K Velthuis
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands
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Bivard A, Levi C, Krishnamurthy V, McElduff P, Miteff F, Spratt NJ, Bateman G, Donnan G, Davis S, Parsons M. Perfusion computed tomography to assist decision making for stroke thrombolysis. Brain 2015; 138:1919-31. [PMID: 25808369 PMCID: PMC4572482 DOI: 10.1093/brain/awv071] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 01/21/2015] [Indexed: 11/13/2022] Open
Abstract
The use of perfusion imaging to guide selection of patients for stroke thrombolysis remains controversial because of lack of supportive phase three clinical trial evidence. We aimed to measure the outcomes for patients treated with intravenous recombinant tissue plasminogen activator (rtPA) at a comprehensive stroke care facility where perfusion computed tomography was routinely used for thrombolysis eligibility decision assistance. Our overall hypothesis was that patients with 'target' mismatch on perfusion computed tomography would have improved outcomes with rtPA. This was a prospective cohort study of consecutive ischaemic stroke patients who fulfilled standard clinical/non-contrast computed tomography eligibility criteria for treatment with intravenous rtPA, but for whom perfusion computed tomography was used to guide the final treatment decision. The 'real-time' perfusion computed tomography assessments were qualitative; a large perfusion computed tomography ischaemic core, or lack of significant perfusion lesion-core mismatch were considered relative exclusion criteria for thrombolysis. Specific volumetric perfusion computed tomography criteria were not used for the treatment decision. The primary analysis compared 3-month modified Rankin Scale in treated versus untreated patients after 'off-line' (post-treatment) quantitative volumetric perfusion computed tomography eligibility assessment based on presence or absence of 'target' perfusion lesion-core mismatch (mismatch ratio >1.8 and volume >15 ml, core <70 ml). In a second analysis, we compared outcomes of the perfusion computed tomography-selected rtPA-treated patients to an Australian historical cohort of non-contrast computed tomography-selected rtPA-treated patients. Of 635 patients with acute ischaemic stroke eligible for rtPA by standard criteria, thrombolysis was given to 366 patients, with 269 excluded based on visual real-time perfusion computed tomography assessment. After off-line quantitative perfusion computed tomography classification: 253 treated patients and 83 untreated patients had 'target' mismatch, 56 treated and 31 untreated patients had a large ischaemic core, and 57 treated and 155 untreated patients had no target mismatch. In the primary analysis, only in the target mismatch subgroup did rtPA-treated patients have significantly better outcomes (odds ratio for 3-month, modified Rankin Scale 0-2 = 13.8, P < 0.001). With respect to the perfusion computed tomography selected rtPA-treated patients (n = 366) versus the clinical/non-contrast computed tomography selected rtPA-treated patients (n = 396), the perfusion computed tomography selected group had higher adjusted odds of excellent outcome (modified Rankin Scale 0-1 odds ratio 1.59, P = 0.009) and lower mortality (odds ratio 0.56, P = 0.021). Although based on observational data sets, our analyses provide support for the hypothesis that perfusion computed tomography improves the identification of patients likely to respond to thrombolysis, and also those in whom natural history may be difficult to modify with treatment.
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Affiliation(s)
- Andrew Bivard
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
| | - Christopher Levi
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
| | - Venkatesh Krishnamurthy
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
| | - Patrick McElduff
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
| | - Ferdi Miteff
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
| | - Neil J Spratt
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
| | - Grant Bateman
- 2 Department of Radiology, John Hunter Hospital, University of Newcastle New South Wales, Australia
| | - Geoffrey Donnan
- 3 Melbourne Brain Centre, Florey Neuroscience Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Stephen Davis
- 3 Melbourne Brain Centre, Florey Neuroscience Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Mark Parsons
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
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Ramani L, Huang X, Cheripelli B, Muir KW. Intravenous thrombolysis for acute stroke: current standards and future directions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:373. [PMID: 25778425 DOI: 10.1007/s11936-015-0373-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OPINION STATEMENT Intravenous thrombolysis with the recombinant tissue plasminogen activator alteplase is the standard of care for patients with acute ischaemic stroke presenting within 4.5 h of symptom onset. The odds of independent survival decline steeply with longer time to treatment delivery, reflecting progressive ischaemic damage to the brain. Standards accordingly emphasise optimisation of patient pathways to minimise treatment delays. Observational data and international clinical guidelines support the safety and efficacy of alteplase in many patient groups currently excluded from treatment (e.g. seizure at onset, concomitant diabetes and previous stroke) on the basis of historical clinical trial criteria. Future evolution of thrombolysis will optimise dosing, apply advanced imaging to extend treatment to groups currently excluded and investigate novel drugs, and adjunctive drug and device therapies. To date, trials of novel therapeutic approaches that have been applied at later time points have failed to demonstrate benefit, suggesting that the future gains are likely to arise from applications within current time windows.
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Affiliation(s)
- Lucille Ramani
- Institute of Neuroscience and Psychology, University of Glasgow, Southern General Hospital, 1345 Govan Road, Glasgow, G51 3TF, Scotland, UK
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Abstract
PURPOSE OF REVIEW To summarize what is known about the use of MRI in acute stroke treatment (predominantly thrombolysis), to examine the assumptions and theories behind the interpretation of magnetic resonance images of acute ischemic stroke and how they are used to select patients for therapies, and to suggest directions for future research. RECENT FINDINGS Recent studies have been contradictory about the usefulness of MRI in selecting patients for treatment. New MRI models for selecting patients have emerged that focus not only on the ischemic penumbra but also on the infarct core. Fixed time-window selection parameters are being replaced by timing-based individualized MRI stroke features. New ways to interpret traditional MRI stroke sequences are emerging. SUMMARY Although the efficacy of acute stroke treatment is time dependent, the use of fixed time windows cannot account for individual differences in infarct evolution, which could potentially be detected with MRI. Although MRI shows promise for identifying patients who should be treated, as well as excluding patients who should not be treated, definitive evidence is still lacking. Future research should focus on validating the use of MRI to select patients for intravenous therapies in extended time windows.
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Motta M, Ramadan A, Hillis AE, Gottesman RF, Leigh R. Diffusion-perfusion mismatch: an opportunity for improvement in cortical function. Front Neurol 2015; 5:280. [PMID: 25642208 PMCID: PMC4294157 DOI: 10.3389/fneur.2014.00280] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 12/09/2014] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE There has been controversy over whether diffusion-perfusion mismatch provides a biomarker for the ischemic penumbra. In the context of clinical stroke trials, regions of the diffusion-perfusion mismatch that do not progress to infarct in the absence of reperfusion are considered to represent "benign oligemia." However, at least in some cases (particularly large vessel stenosis), some of this hypoperfused tissue may remain dysfunctional for a prolonged period without progressing to infarct and may recover function if eventually reperfused. We hypothesized that patients with persistent diffusion-perfusion mismatch using a hypoperfusion threshold of 4-5.9 s delay on time-to-peak (TTP) maps at least sometimes have persistent cognitive deficits relative to those who show some reperfusion of this hypoperfused tissue. METHODS We tested this hypothesis in 38 patients with acute ischemic stroke who had simple cognitive tests (naming or line cancelation) and MRI with diffusion and perfusion imaging within 24 h of onset and again within 10 days, most of whom had large vessel stenosis or occlusion. RESULTS A persistent perfusion deficit of 4-5.9 s delay in TTP on follow up MRI was associated with a persistent cognitive deficit at that time point (p < 0.001). When we evaluated only patients who did not have infarct growth (n = 14), persistent hypoperfusion (persistent mismatch) was associated with a lack of cognitive improvement compared with those who had reperfused. The initial volume of hypoperfusion did not correlate with the later infarct volume (progression to infarct), but change in volume of hypoperfusion correlated with change in cognitive performance (p = 0.0001). Moreover, multivariable regression showed that the change in volume of hypoperfused tissue of 4-5.9 s delay (p = 0.002), and change in volume of ischemic tissue on diffusion weighted imaging (p = 0.02) were independently associated with change in cognitive function. CONCLUSION Our results provide additional evidence that non-infarcted tissue with a TTP delay of 4-5.9 s may be associated with persistent deficits, even if it does not always result in imminent progression to infarct. This tissue may represent the occasional opportunity to intervene to improve function even days after onset of symptoms.
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Affiliation(s)
- Melissa Motta
- R Adams Shock Trauma Center, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Amanda Ramadan
- Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | - Argye E Hillis
- Department of Neurology, Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | - Rebecca F Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | - Richard Leigh
- Department of Neurology, Johns Hopkins University School of Medicine , Baltimore, MD , USA
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Haussen DC, Nogueira RG, Elhammady MS, Yavagal DR, Aziz-Sultan MA, Johnson JN, Gaynor BG, Jen S, Dehkharghani S, Peterson EC. Infarct growth despite full reperfusion in endovascular therapy for acute ischemic stroke. J Neurointerv Surg 2014; 8:117-21. [DOI: 10.1136/neurintsurg-2014-011497] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 12/07/2014] [Indexed: 11/03/2022]
Abstract
AimTo explore the predictors of infarct core expansion despite full reperfusion after intra-arterial therapy (IAT).MethodsWe retrospectively reviewed 604 consecutive patients who underwent IAT for anterior circulation large vessel occlusion acute ischemic stroke in two tertiary centers (2008–2013/2010–2013). Sixty patients selected by MRI or CT perfusion presenting within <24 h of onset with modified Thrombolysis In Cerebral Infarction (mTICI) grade 3 or 2c reperfusion were included. Significant infarct growth (SIG) was defined as infarct expansion >11.6 mL.ResultsMean age was 67.0±13.7 years, 56% were men. Mean National Institute of Health Stroke Scale (NIHSS) score was 16.2±6.1, time from onset to puncture was 6.8±3.1 h, and procedure length was 1.3±0.6 h. MRI was used for baseline core analysis in 43% of patients. Mean baseline infarct volume was 17.1±19.1 mL, absolute infarct growth was 30.6±74.5 mL, and final infarct volume was 47.7±77.7 mL. Overall, 35% of patients had SIG. Three of 21 patients (14%) treated with stent-retrievers had SIG compared with 14 of 39 (36%) with first-generation devices. Eight of 21 patients (38%) with intravenous tissue plasminogen activator (IV t-PA) had infarct growth compared with 25/39 (64%) without. 23% of patients with SIG had a modified Rankin Scale score ≤2 at 3 months compared with 48% of those without SIG. Multivariate logistic regression indicated that race affected infarct growth. Use of IV t-PA (p=0.03) and stent-retrievers (p=0.03) were independently and inversely correlated with SIG.ConclusionsDespite full reperfusion, infarct growth is relatively frequent and may explain poor clinical outcomes in this setting. Ethnicity was found to influence SIG. Use of IV t-PA and stent-retrievers were associated with less infarct core expansion.
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Zhang S, Tang H, Yu YN, Yan SQ, Parsons MW, Lou M. Optimal magnetic resonance perfusion thresholds identifying ischemic penumbra and infarct core: a Chinese population-based study. CNS Neurosci Ther 2014; 21:289-95. [PMID: 25476071 DOI: 10.1111/cns.12367] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 10/30/2014] [Accepted: 11/01/2014] [Indexed: 12/26/2022] Open
Abstract
AIMS To validate whether the optimal magnetic resonance perfusion (MRP) thresholds for ischemic penumbra and infarct core, between voxel and volume-based analysis, are varied greatly among Chinese acute ischemic stroke patients. MATERIALS AND METHODS Acute ischemic stroke patients receiving intravenous thrombolysis within 6 h of onset that obtained acute and 24-h MRP were reviewed. Patients with either no reperfusion (<30% reperfusion at 24 h) or successful reperfusion (>70% reperfusion at 24 h) were enrolled to investigate the ischemic penumbra and infarct core, respectively. The final infarct was assessed on 24-h diffusion-weighted imaging (DWI), which was retrospectively matched to the baseline perfusion-weighted imaging (PWI) images by volume or voxel-based analysis. The optimal thresholds that determined by each approach were compared. RESULTS From June 2009 to Jan 2014, of 50 patients enrolled, 19 patients achieved no reperfusion, and 20 patients reperfused at 24 h. In patients with no reperfusion, Tmax > 6 seconds was proved of the best agreement with the final infarct in both volumetric analysis (ratio: 1.05, 95% limits of agreement:-0.23 to 2.33, P < 0.001) and voxel-by-voxel analysis (sensitivity: 72.3%, specificity: 74.3%). In patients with reperfusion, rMTT>225% (ratio:2.4, 95% limits of agreement: -6.5 to 11.4, P < 0.001) was found of the best volumetric agreement with the final infarct, while Tmax > 5.6 seconds (sensitivity: 76.8%, specificity: 70.3%) performed most accurately in voxel-based analysis. CONCLUSION Among Chinese acute stroke patients, volume of Tmax >6 seconds may precisely target ischemic penumbra tissue as good as voxel-based analysis performed, albeit no concordant MRP parameter is found to accurately predict infarct core because reperfusion occurred within 24 h after thrombolysis fails to restrain the infarct growth.
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Affiliation(s)
- Sheng Zhang
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
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Abstract
Intravenous recombinant tissue plasminogen activator (rt-PA or alteplase) is the only approved medical intervention for treatment of acute ischemic stroke within the first hours of symptom onset. In this article, we review the preliminary studies of rt-PA in acute ischemic stroke that led to US FDA approval of its use within 3 h of symptom onset. The studies on rt-PA for use beyond 3 h of symptom onset and future reperfusion therapies are discussed. Overviews of the clinical presentation and treatment of acute ischemic stroke and stroke systems of care are described.
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Lee JI, Jander S, Oberhuber A, Schelzig H, Hänggi D, Turowski B, Seitz RJ. Stroke in patients with occlusion of the internal carotid artery: options for treatment. Expert Rev Neurother 2014; 14:1153-67. [PMID: 25245575 DOI: 10.1586/14737175.2014.955477] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ischemic stroke may occur in patients in whom vascular imaging shows the ipsilateral internal carotid artery (ICA) to be occluded. In younger patients this is often due to carotid artery dissection, while in older people this most likely results from cardiac embolism or thrombosis secondary to high-grade stenosis at the carotid bifurcation. Interventional techniques aim at recanalization of the carotid artery for early restoration of cerebral blood flow and secondary prevention of future strokes. In chronic ICA occlusion the ischemic infarct may be related to hemodynamic compromise. In this situation, extracranial-intracranial bypass surgery was introduced, but its role remains still unclear. Ischemic stroke may also occur in patients with a chronic occlusion of the contralateral ICA. This situation demands the usual stroke treatment, but surgical and neuroradiological interventions face a higher risk than unilateral vascular pathology. Medical treatment supports stroke prevention in carotid artery occlusion.
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Affiliation(s)
- John Ih Lee
- LVR-Klinikum Düsseldorf, University Hospital Düsseldorf, Düsseldorf, Germany
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The ischemic penumbra: the location rather than the volume of recovery determines outcome. Curr Opin Neurol 2014; 27:35-41. [PMID: 24275722 DOI: 10.1097/wco.0000000000000047] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The clinical efficiency of thrombolysis is explained by the rescue of ischemic penumbra areas resulting from early arterial recanalization. The perfusion-diffusion weighted imaging mismatch is a commonly used MRI surrogate of the ischemic penumbra. However, the randomized trials testing the mismatch hypothesis have been negative. We will review the 'mismatch concept' and the recent studies that aim to localize the clinically eloquent areas of penumbra in middle cerebral artery (MCA) infarcts. RECENT FINDINGS New methods of image analysis have shown that poor outcomes after MCA stroke are related to infarction of an extremely well localized area of the periventricular white matter and adjacent internal capsule, where projections and association tracts are crossing and converging. This area almost colocalizes with the area salvaged by early arterial recanalization and is located extremely close to the initial ischemic core. SUMMARY The location of the area that correlates with disability in MCA stroke patients and that is salvaged by early arterial recanalization is in the same specific region of the deep white matter, close to the initial ischemic core. These findings may have important implications for designing new recanalization trials and support the importance of basic research on white-matter neuroprotection.
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Abstract
BACKGROUND Most strokes are due to blockage of an artery in the brain by a blood clot. Prompt treatment with thrombolytic drugs can restore blood flow before major brain damage has occurred and improve recovery after stroke in some people. Thrombolytic drugs, however, can also cause serious bleeding in the brain, which can be fatal. One drug, recombinant tissue plasminogen activator (rt-PA), is licensed for use in selected patients within 4.5 hours of stroke in Europe and within three hours in the USA. There is an upper age limit of 80 years in some countries, and a limitation to mainly non-severe stroke in others. Forty per cent more data are available since this review was last updated in 2009. OBJECTIVES To determine whether, and in what circumstances, thrombolytic therapy might be an effective and safe treatment for acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched November 2013), MEDLINE (1966 to November 2013) and EMBASE (1980 to November 2013). We also handsearched conference proceedings and journals, searched reference lists and contacted pharmaceutical companies and trialists. SELECTION CRITERIA Randomised trials of any thrombolytic agent compared with control in people with definite ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors applied the inclusion criteria, extracted data and assessed trial quality. We verified the extracted data with investigators of all major trials, obtaining additional unpublished data if available. MAIN RESULTS We included 27 trials, involving 10,187 participants, testing urokinase, streptokinase, rt-PA, recombinant pro-urokinase or desmoteplase. Four trials used intra-arterial administration, while the rest used the intravenous route. Most data come from trials that started treatment up to six hours after stroke. About 44% of the trials (about 70% of the participants) were testing intravenous rt-PA. In earlier studies very few of the participants (0.5%) were aged over 80 years; in this update, 16% of participants are over 80 years of age due to the inclusion of IST-3 (53% of participants in this trial were aged over 80 years). Trials published more recently utilised computerised randomisation, so there are less likely to be baseline imbalances than in previous versions of the review. More than 50% of trials fulfilled criteria for high-grade concealment; there were few losses to follow-up for the main outcomes.Thrombolytic therapy, mostly administered up to six hours after ischaemic stroke, significantly reduced the proportion of participants who were dead or dependent (modified Rankin 3 to 6) at three to six months after stroke (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.78 to 0.93). Thrombolytic therapy increased the risk of symptomatic intracranial haemorrhage (OR 3.75, 95% CI 3.11 to 4.51), early death (OR 1.69, 95% CI 1.44 to 1.98; 13 trials, 7458 participants) and death by three to six months after stroke (OR 1.18, 95% CI 1.06 to 1.30). Early death after thrombolysis was mostly attributable to intracranial haemorrhage. Treatment within three hours of stroke was more effective in reducing death or dependency (OR 0.66, 95% CI 0.56 to 0.79) without any increase in death (OR 0.99, 95% CI 0.82 to 1.21; 11 trials, 2187 participants). There was heterogeneity between the trials. Contemporaneous antithrombotic drugs increased the risk of death. Trials testing rt-PA showed a significant reduction in death or dependency with treatment up to six hours (OR 0.84, 95% CI 0.77 to 0.93, P = 0.0006; 8 trials, 6729 participants) with significant heterogeneity; treatment within three hours was more beneficial (OR 0.65, 95% CI 0.54 to 0.80, P < 0.0001; 6 trials, 1779 participants) without heterogeneity. Participants aged over 80 years benefited equally to those aged under 80 years, particularly if treated within three hours of stroke. AUTHORS' CONCLUSIONS Thrombolytic therapy given up to six hours after stroke reduces the proportion of dead or dependent people. Those treated within the first three hours derive substantially more benefit than with later treatment. This overall benefit was apparent despite an increase in symptomatic intracranial haemorrhage, deaths at seven to 10 days, and deaths at final follow-up (except for trials testing rt-PA, which had no effect on death at final follow-up). Further trials are needed to identify the latest time window, whether people with mild stroke benefit from thrombolysis, to find ways of reducing symptomatic intracranial haemorrhage and deaths, and to identify the environment in which thrombolysis may best be given in routine practice.
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Affiliation(s)
- Joanna M Wardlaw
- University of EdinburghCentre for Clinical Brain SciencesThe Chancellor's Building49 Little France CrescentEdinburghUKEH16 4SB
| | - Veronica Murray
- Danderyd HospitalDepartment of Clinical Sciences, Karolinska InstitutetStockholmSwedenSE‐182 88
| | - Eivind Berge
- Oslo University HospitalDepartment of Internal MedicineOsloNorwayNO‐0407
| | - Gregory J del Zoppo
- University of WashingtonDepartment of Medicine (Division of Hematology), Department of Neurology325 Ninth AvenueBox 359756SeattleWashingtonUSA98104
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Vanacker P, Lambrou D, Eskandari A, Maeder P, Meuli R, Ntaios G, Michel P. Improving prediction of recanalization in acute large-vessel occlusive stroke. J Thromb Haemost 2014; 12:814-21. [PMID: 24628853 DOI: 10.1111/jth.12561] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recanalization in acute ischemic stroke with large-vessel occlusion is a potent indicator of good clinical outcome. OBJECTIVE To identify easily available clinical and radiologic variables predicting recanalization at various occlusion sites. METHODS All consecutive, acute stroke patients from the Acute STroke Registry and Analysis of Lausanne (2003-2011) who had a large-vessel occlusion on computed tomographic angiography (CTA) (< 12 h) were included. Recanalization status was assessed at 24 h (range: 12-48 h) with CTA, magnetic resonance angiography, or ultrasonography. Complete and partial recanalization (corresponding to the modified Treatment in Cerebral Ischemia scale 2-3) were grouped together. Patients were categorized according to occlusion site and treatment modality. RESULTS Among 439 patients, 51% (224) showed complete or partial recanalization. In multivariate analysis, recanalization of any occlusion site was most strongly associated with endovascular treatment, including bridging therapy (odds ratio [OR] 7.1, 95% confidence interval [CI] 2.2-23.2), and less so with intravenous thrombolysis (OR 1.6, 95% CI 1.0-2.6) and recanalization treatments performed beyond guidelines (OR 2.6, 95% CI 1.2-5.7). Clot location (large vs. intermediate) and tandem pathology (the combination of intracranial occlusion and symptomatic extracranial stenosis) were other variables discriminating between recanalizers and non-recanalizers. For patients with intracranial occlusions, the variables significantly associated with recanalization after 24 h were: baseline National Institutes of Health Stroke Scale (NIHSS) (OR 1.04, 95% CI 1.02-1.1), Alberta Stroke Program Early CT Score (ASPECTS) on initial computed tomography (OR 1.2, 95% CI 1.1-1.3), and an altered level of consciousness (OR 0.2, 95% CI 0.1-0.5). CONCLUSIONS Acute endovascular treatment is the single most important factor promoting recanalization in acute ischemic stroke. The presence of extracranial vessel stenosis or occlusion decreases recanalization rates. In patients with intracranial occlusions, higher NIHSS score and ASPECTS and normal vigilance facilitate recanalization. Clinical use of these predictors could influence recanalization strategies in individual patients.
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Affiliation(s)
- P Vanacker
- Neurology Service, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland; Department of Neurology, University Hospital Antwerp, Edegem, Belgium
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Hirano T. Searching for Salvageable Brain: The Detection of Ischemic Penumbra Using Various Imaging Modalities? J Stroke Cerebrovasc Dis 2014; 23:795-8. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.10.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 10/07/2013] [Accepted: 10/07/2013] [Indexed: 11/25/2022] Open
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Muchada M, Rubiera M, Rodriguez-Luna D, Pagola J, Flores A, Kallas J, Sanjuan E, Meler P, Alvarez-Sabin J, Ribo M, Molina CA. Baseline National Institutes of Health Stroke Scale–Adjusted Time Window for Intravenous Tissue-Type Plasminogen Activator in Acute Ischemic Stroke. Stroke 2014; 45:1059-63. [DOI: 10.1161/strokeaha.113.004307] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background and Purpose—
The effect of tissue-type plasminogen activator on functional outcome decreases progressively over time. However, given the differential pattern of arterial occlusion, stroke severity, and speed of ischemic lesion growth among candidates for reperfusion, the time window should be adjusted accordingly. We aimed to identify the impact of time-to-treatment according to stroke severity on functional outcome in patients with acute ischemic stroke.
Methods—
We included 581 consecutive patients treated with alteplase according to the European Summary of Product Characteristics criteria. Patients were categorized according to National Institutes of Health Stroke Scale (NIHSS) severity in mild NIHSS (≤8), moderate NIHSS (9–15), and severe stroke NIHSS (≥16). We sequentially analyzed time-to-treatment to achieve favorable outcome (modified Rankin Scale ≤2 at 3 months).
Results—
Overall, 19.8% had mild, 30.3% had moderate, and 49.9% had severe stroke. Favorable outcome occurred in 79.1%, 60.8%, and 26.2%, respectively. In patients with mild stroke, younger age (odds ratio [OR], 0.88; 95% confidence intervals [CI], 0.8–0.95), no previous history of stroke (OR, 0.16; 95% CI [0.039–0.65]), and no proximal occlusion (OR, 0.183; 95% CI [0.038–0.89]) independently predicted favorable outcome. In patients with moderate stroke, age (OR, 0.95; 95% CI [0.92–0.98]), no proximal occlusion (OR, 0.362; 95% CI [0.17–0.75]), and time-to-treatment before 120 minutes (OR, 2.70; 95% CI [1.14–6.38]) emerged as independent predictors of favorable outcome. In patients with severe stroke, younger age (OR, 0.96; 95% CI [0.94–0.99]), lower previous modified Rankin Scale (OR, 0.42; 95% CI [0.21–0.82]), and absence of proximal occlusion (OR, 0.48; 95% CI [0.25–0.94]) appeared as independent predictors.
Conclusions—
The impact of time-to-treatment on favorable outcome varies widely depending on baseline stroke severity. The window for favorable outcome was ≤120 min for moderate strokes. However, time-to-treatment seemed unrelated to functional outcome in mild and severe stroke.
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Affiliation(s)
- Marián Muchada
- From the Stroke Unit, Department of Neurology, Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Departament de Medicina, Universitat Autonoma de Barcelona, Spain
| | - Marta Rubiera
- From the Stroke Unit, Department of Neurology, Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Departament de Medicina, Universitat Autonoma de Barcelona, Spain
| | - David Rodriguez-Luna
- From the Stroke Unit, Department of Neurology, Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Departament de Medicina, Universitat Autonoma de Barcelona, Spain
| | - Jorge Pagola
- From the Stroke Unit, Department of Neurology, Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Departament de Medicina, Universitat Autonoma de Barcelona, Spain
| | - Alan Flores
- From the Stroke Unit, Department of Neurology, Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Departament de Medicina, Universitat Autonoma de Barcelona, Spain
| | - Julia Kallas
- From the Stroke Unit, Department of Neurology, Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Departament de Medicina, Universitat Autonoma de Barcelona, Spain
| | - Estela Sanjuan
- From the Stroke Unit, Department of Neurology, Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Departament de Medicina, Universitat Autonoma de Barcelona, Spain
| | - Pilar Meler
- From the Stroke Unit, Department of Neurology, Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Departament de Medicina, Universitat Autonoma de Barcelona, Spain
| | - Jose Alvarez-Sabin
- From the Stroke Unit, Department of Neurology, Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Departament de Medicina, Universitat Autonoma de Barcelona, Spain
| | - Marc Ribo
- From the Stroke Unit, Department of Neurology, Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Departament de Medicina, Universitat Autonoma de Barcelona, Spain
| | - Carlos A. Molina
- From the Stroke Unit, Department of Neurology, Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Departament de Medicina, Universitat Autonoma de Barcelona, Spain
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