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Bui Q, Kumar A, Chen Y, Hamzehloo A, Heitsch L, Slowik A, Strbian D, Lee JM, Dhar R. CSF-Based Volumetric Imaging Biomarkers Highlight Incidence and Risk Factors for Cerebral Edema After Ischemic Stroke. Neurocrit Care 2024; 40:303-313. [PMID: 37188885 PMCID: PMC11025464 DOI: 10.1007/s12028-023-01742-0] [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: 01/24/2023] [Accepted: 04/19/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Cerebral edema has primarily been studied using midline shift or clinical deterioration as end points, which only captures the severe and delayed manifestations of a process affecting many patients with stroke. Quantitative imaging biomarkers that measure edema severity across the entire spectrum could improve its early detection, as well as identify relevant mediators of this important stroke complication. METHODS We applied an automated image analysis pipeline to measure the displacement of cerebrospinal fluid (ΔCSF) and the ratio of lesional versus contralateral hemispheric cerebrospinal fluid (CSF) volume (CSF ratio) in a cohort of 935 patients with hemispheric stroke with follow-up computed tomography scans taken a median of 26 h (interquartile range 24-31) after stroke onset. We determined diagnostic thresholds based on comparison to those without any visible edema. We modeled baseline clinical and radiographic variables against each edema biomarker and assessed how each biomarker was associated with stroke outcome (modified Rankin Scale at 90 days). RESULTS The displacement of CSF and CSF ratio were correlated with midline shift (r = 0.52 and - 0.74, p < 0.0001) but exhibited broader ranges. A ΔCSF of greater than 14% or a CSF ratio below 0.90 identified those with visible edema: more than half of the patients with stroke met these criteria, compared with only 14% who had midline shift at 24 h. Predictors of edema across all biomarkers included a higher National Institutes of Health Stroke Scale score, a lower Alberta Stroke Program Early CT score, and lower baseline CSF volume. A history of hypertension and diabetes (but not acute hyperglycemia) predicted greater ΔCSF but not midline shift. Both ΔCSF and a lower CSF ratio were associated with worse outcome, adjusting for age, National Institutes of Health Stroke Scale score, and Alberta Stroke Program Early CT score (odds ratio 1.7, 95% confidence interval 1.3-2.2 per 21% ΔCSF). CONCLUSIONS Cerebral edema can be measured in a majority of patients with stroke on follow-up computed tomography using volumetric biomarkers evaluating CSF shifts, including in many without visible midline shift. Edema formation is influenced by clinical and radiographic stroke severity but also by chronic vascular risk factors and contributes to worse stroke outcomes.
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Affiliation(s)
- Quoc Bui
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Atul Kumar
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Yasheng Chen
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Ali Hamzehloo
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Laura Heitsch
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Jin-Moo Lee
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Rajat Dhar
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA.
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Predictors of malignant middle cerebral artery infarction after endovascular thrombectomy: results of DIRECT-MT trial. Eur Radiol 2022; 33:135-143. [PMID: 35849176 DOI: 10.1007/s00330-022-09013-w] [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: 03/14/2022] [Revised: 05/18/2022] [Accepted: 07/03/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Predictors of malignant middle cerebral artery infarction (mMCAi) in patients after intravenous thrombolysis were well documented, but the risk factors of mMCAi after endovascular thrombectomy (EVT) were not fully explored. Therefore, the present study aimed to investigate the predictors of mMCAi after EVT in stroke patients. METHODS This was a secondary analysis of the DIRECT-MT trial. Patients who underwent EVT for the occlusions of MCA and/or intracranial internal carotid artery were analyzed. Primary outcome was the occurrence of mMCAi after EVT. Demographic, clinical, imaging, and treatment data were recorded, and multivariate logistic regression analysis was used to identify independent predictors. All of the candidate predictors were included, and forward elimination was applied to establish the most effective predictive model. Predictive ability and calibration of the model were assessed using the area under the receiver operating characteristic curve (AUC) and Hosmer-Lemeshow test, respectively. RESULTS Of 559 enrolled patients, 74 (13.2%) patients developed mMCAi. Predictors of mMCAi included unsuccessful reperfusion, higher serum glucose, lower Alberta Stroke Project Early Computed Tomography Change Score (ASPECTS), higher clot burden score (CBS), lower collateral score, and higher pass number of thrombectomy device. AUC of predictive model integrating all independent variables was 0.836. The Hosmer-Lemeshow test showed appropriate calibration (p = 0.859). CONCLUSIONS Reperfusion, serum glucose, ASPECTS, CBS, collateral, and pass number of thrombectomy device were associated with the occurrence of mMCAi in stroke patients after EVT, while alteplase treatment was not. Our findings might facilitate the early identification and management of stroke patients at a high risk of mMCAi. KEY POINTS • A total of 13.2% of stroke patients with large vessel occlusion of anterior circulation developed mMCAi after EVT. • The occurrence of mMCAi had a definite negative impact on the outcome for stroke patients. • Reperfusion, serum glucose, ASPECTS, CBS, collateral score, and the pass number of thrombectomy device were associated with the occurrence of mMCAi after EVT in stroke patients.
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3
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Zhang X, Huang P, Zhang R. Evaluation and Prediction of Post-stroke Cerebral Edema Based on Neuroimaging. Front Neurol 2022; 12:763018. [PMID: 35087464 PMCID: PMC8786707 DOI: 10.3389/fneur.2021.763018] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022] Open
Abstract
Cerebral edema is a common complication of acute ischemic stroke that leads to poorer functional outcomes and substantially increases the mortality rate. Given that its negative effects can be reduced by more intensive monitoring and evidence-based interventions, the early identification of patients with a high risk of severe edema is crucial. Neuroimaging is essential for the assessment and prediction of edema. Simple markers, such as midline shift and hypodensity volume on computed tomography, have been used to evaluate edema in clinical trials; however, advanced techniques can be applied to examine the underlying mechanisms. In this study, we aimed to review current imaging tools in the assessment and prediction of cerebral edema to provide guidance for using these methods in clinical practice.
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Affiliation(s)
| | | | - Ruiting Zhang
- Department of Radiology, School of Medicine, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
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4
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Foroushani HM, Hamzehloo A, Kumar A, Chen Y, Heitsch L, Slowik A, Strbian D, Lee JM, Marcus DS, Dhar R. Accelerating Prediction of Malignant Cerebral Edema After Ischemic Stroke with Automated Image Analysis and Explainable Neural Networks. Neurocrit Care 2021; 36:471-482. [PMID: 34417703 DOI: 10.1007/s12028-021-01325-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 08/02/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Malignant cerebral edema is a devastating complication of stroke, resulting in deterioration and death if hemicraniectomy is not performed prior to herniation. Current approaches for predicting this relatively rare complication often require advanced imaging and still suffer from suboptimal performance. We performed a pilot study to evaluate whether neural networks incorporating data extracted from routine computed tomography (CT) imaging could enhance prediction of edema in a large diverse stroke cohort. METHODS An automated imaging pipeline retrospectively extracted volumetric data, including cerebrospinal fluid (CSF) volumes and the hemispheric CSF volume ratio, from baseline and 24 h CT scans performed in participants of an international stroke cohort study. Fully connected and long short-term memory (LSTM) neural networks were trained using serial clinical and imaging data to predict those who would require hemicraniectomy or die with midline shift. The performance of these models was tested, in comparison with regression models and the Enhanced Detection of Edema in Malignant Anterior Circulation Stroke (EDEMA) score, using cross-validation to construct precision-recall curves. RESULTS Twenty of 598 patients developed malignant edema (12 required surgery, 8 died). The regression model provided 95% recall but only 32% precision (area under the precision-recall curve [AUPRC] 0.74), similar to the EDEMA score (precision 28%, AUPRC 0.66). The fully connected network did not perform better (precision 33%, AUPRC 0.71), but the LSTM model provided 100% recall and 87% precision (AUPRC 0.97) in the overall cohort and the subgroup with a National Institutes of Health Stroke Scale (NIHSS) score ≥ 8 (p = 0.0001 vs. regression and fully connected models). Features providing the most predictive importance were the hemispheric CSF ratio and NIHSS score measured at 24 h. CONCLUSIONS An LSTM neural network incorporating volumetric data extracted from routine CT scans identified all cases of malignant cerebral edema by 24 h after stroke, with significantly fewer false positives than a fully connected neural network, regression model, and the validated EDEMA score. This preliminary work requires prospective validation but provides proof of principle that a deep learning framework could assist in selecting patients for surgery prior to deterioration.
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Affiliation(s)
- Hossein Mohammadian Foroushani
- Department of Electrical and Systems Engineering, Washington University in St. Louis McKelvey School of Engineering, 1 Brookings Drive, St. Louis, MO, 63130-4899, USA
| | - Ali Hamzehloo
- Department of Neurology, Washington University in St. Louis School of Medicine, 660 S Euclid Avenue, Campus, Box 8111, St. Louis, MO, 63110, USA
| | - Atul Kumar
- Department of Neurology, Washington University in St. Louis School of Medicine, 660 S Euclid Avenue, Campus, Box 8111, St. Louis, MO, 63110, USA
| | - Yasheng Chen
- Department of Neurology, Washington University in St. Louis School of Medicine, 660 S Euclid Avenue, Campus, Box 8111, St. Louis, MO, 63110, USA
| | - Laura Heitsch
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, 660 S. Euclid Ave, Campus, Box 8072, St. Louis, MO, 63110, USA
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Jin-Moo Lee
- Department of Neurology, Washington University in St. Louis School of Medicine, 660 S Euclid Avenue, Campus, Box 8111, St. Louis, MO, 63110, USA
| | - Daniel S Marcus
- Department of Radiology, Washington University in St. Louis School of Medicine, 525 Scott Ave, Campus, Box 8225, St. Louis, MO, 63110, USA
| | - Rajat Dhar
- Department of Neurology, Washington University in St. Louis School of Medicine, 660 S Euclid Avenue, Campus, Box 8111, St. Louis, MO, 63110, USA.
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Ng FC, Yassi N, Sharma G, Brown SB, Goyal M, Majoie CBLM, Jovin TG, Hill MD, Muir KW, Saver JL, Guillemin F, Demchuk AM, Menon BK, San Roman L, Liebeskind DS, White P, Dippel DWJ, Davalos A, Bracard S, Mitchell PJ, Wald MJ, Davis SM, Sheth KN, Kimberly WT, Campbell BCV. Cerebral Edema in Patients With Large Hemispheric Infarct Undergoing Reperfusion Treatment: A HERMES Meta-Analysis. Stroke 2021; 52:3450-3458. [PMID: 34384229 DOI: 10.1161/strokeaha.120.033246] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Whether reperfusion into infarcted tissue exacerbates cerebral edema has treatment implications in patients presenting with extensive irreversible injury. We investigated the effects of endovascular thrombectomy and reperfusion on cerebral edema in patients presenting with radiological evidence of large hemispheric infarction at baseline. METHODS In a systematic review and individual patient-level meta-analysis of 7 randomized controlled trials comparing thrombectomy versus medical therapy in anterior circulation ischemic stroke published between January 1, 2010, and May 31, 2017 (Highly Effective Reperfusion Using Multiple Endovascular Devices collaboration), we analyzed the association between thrombectomy and reperfusion with maximal midline shift (MLS) on follow-up imaging as a measure of the space-occupying effect of cerebral edema in patients with large hemispheric infarction on pretreatment imaging, defined as diffusion-magnetic resonance imaging or computed tomography (CT)-perfusion ischemic core 80 to 300 mL or noncontrast CT-Alberta Stroke Program Early CT Score ≤5. Risk of bias was assessed using the Cochrane tool. RESULTS Among 1764 patients, 177 presented with large hemispheric infarction. Thrombectomy and reperfusion were associated with functional improvement (thrombectomy common odds ratio =2.30 [95% CI, 1.32-4.00]; reperfusion common odds ratio =4.73 [95% CI, 1.66-13.52]) but not MLS (thrombectomy β=-0.27 [95% CI, -1.52 to 0.98]; reperfusion β=-0.78 [95% CI, -3.07 to 1.50]) when adjusting for age, National Institutes of Health Stroke Score, glucose, and time-to-follow-up imaging. In an exploratory analysis of patients presenting with core volume >130 mL or CT-Alberta Stroke Program Early CT Score ≤3 (n=76), thrombectomy was associated with greater MLS after adjusting for age and National Institutes of Health Stroke Score (β=2.76 [95% CI, 0.33-5.20]) but not functional improvement (odds ratio, 1.71 [95% CI, 0.24-12.08]). CONCLUSIONS In patients presenting with large hemispheric infarction, thrombectomy and reperfusion were not associated with MLS, except in the subgroup with very large core volume (>130 mL) in whom thrombectomy was associated with increased MLS due to space-occupying ischemic edema. Mitigating cerebral edema-mediated secondary injury in patients with very large infarcts may further improve outcomes after reperfusion therapies.
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Affiliation(s)
- Felix C Ng
- Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.S., S.M.D., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
- Department of Neurology, Austin Health, Heidelberg, Australia (F.C.N.)
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.S., S.M.D., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research. Parkville, Australia (N.Y.)
| | - Gagan Sharma
- Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.S., S.M.D., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | | | - Mayank Goyal
- Department of Radiology (M.G.), University of Calgary, Foothills Hospital, AB, Canada
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, the Netherlands (C.B.L.M.M.)
| | - Tudor G Jovin
- Cooper Neurological Institute, Cooper University Health Care, Camden, NJ (T.G.J.)
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine (M.D.H., A.M.D., B.K.M.), University of Calgary, Foothills Hospital, AB, Canada
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, United Kingdom (K.W.M.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California, Los Angeles
- Stanford Stroke Center, Stanford University, CA (J.L.S.)
| | - Francis Guillemin
- Clinical Investigation Centre-Clinical Epidemiology INSERM 1433, University of Lorraine, University Hospital of Nancy, France (F.G.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine (M.D.H., A.M.D., B.K.M.), University of Calgary, Foothills Hospital, AB, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine (M.D.H., A.M.D., B.K.M.), University of Calgary, Foothills Hospital, AB, Canada
| | - Luis San Roman
- Department of Radiology, Hospital Clínic, Barcelona, Spain (L.S.R.)
| | - David S Liebeskind
- Neurovascular Imaging Research Core, Department of Neurology (D.S.L.), University of California, Los Angeles
| | - Philip White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom (P.W.)
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands (D.W.J.D.)
| | - Antoni Davalos
- Department of Neuroscience, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Spain (A.D.)
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, INSERM U 947, University of Lorraine and University Hospital of Nancy, France (S.B.)
| | - Peter J Mitchell
- Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | | | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.S., S.M.D., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Kevin N Sheth
- Department of Neurology, Yale-New Haven Hospital, CT (K.N.S.)
| | - W Taylor Kimberly
- Centre for Genomic Medicine, Department of Neurology, Massachusetts General Hospital, Boston (W.T.K.)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.S., S.M.D., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
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Bernsen MLE, Kauw F, Martens JM, van der Lugt A, Yo LS, van Walderveen MA, Roos YB, van der Worp HB, Dankbaar JW, Hofmeijer J. Malignant infarction after endovascular treatment: Incidence and prediction. Int J Stroke 2021; 17:198-206. [PMID: 33724092 DOI: 10.1177/17474930211006290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Early prediction of malignant infarction may guide treatment decisions. For patients who received endovascular treatment, the risk of malignant infarction is unknown and risk factors are unrevealed. AIMS The objective of this study is to estimate the incidence of malignant infarction after endovascular treatment in patients with an occlusion of the anterior circulation, to identify independent risk factors, and to establish a model for prediction. METHODS We analyzed patients who received endovascular treatment for a large vessel occlusion in the anterior circulation within 6.5 h after symptom onset, included in the Dutch MR CLEAN Registry between March 2014 and June 2016. We compared patients with and without malignant infarction. Candidate predictors were incorporated in a multivariable binary logistic regression model. The final prediction model was established using backward elimination. Discrimination and calibration were evaluated with the area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow test. RESULTS Of 1445 patients, 82 (6%) developed malignant infarction. Independent predictors were lower age, higher National Institutes of Health Stroke Scale (NIHSS), lower alberta stroke program early CT score (ASPECTS), internal carotid artery occlusion, lower collateral score, longer times from onset to groin puncture, and unsuccessful reperfusion. The AUROC of a prediction model combining these features was 0.83 (95% confidence interval (CI): 0.79-0.88) and the Hosmer-Lemeshow test indicated appropriate calibration (P = 0.937). CONCLUSION The risk of malignant infarction after endovascular treatment started within 6.5 h of stroke onset is approximately 6%. Successful reperfusion decreases the risk. A prediction model combining easily retrievable measures of age, ASPECTS, collateral status, and reperfusion shows good discrimination between patients who will develop malignant infarction and those who will not.
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Affiliation(s)
| | - Frans Kauw
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jasper M Martens
- Department of Radiology & Nuclear Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Aad van der Lugt
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Lonneke Sf Yo
- Department of Radiology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Yvo Bwem Roos
- Department of Neurology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - H Bart van der Worp
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan W Dankbaar
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands.,Faculty of Science and Technology, Technical Medical Center, University of Twente, Enschede, The Netherlands
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Xu HB, Sun YF, Luo N, Wang JQ, Chang GC, Tao L, Yang BQ, Chen HS. Net Water Uptake Calculated in Standardized and Blindly Outlined Regions of the Middle Cerebral Artery Territory Predicts the Development of Malignant Edema in Patients With Acute Large Hemispheric Infarction. Front Neurol 2021; 12:645590. [PMID: 33776897 PMCID: PMC7994596 DOI: 10.3389/fneur.2021.645590] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/16/2021] [Indexed: 12/19/2022] Open
Abstract
Background and purpose: Previous studies have demonstrated that Net Water Uptake (NWU) is associated with the development of malignant edema (ME). The current study aimed to investigate whether NWU calculated in standardized and blindly outlined regions of the middle cerebral artery can predict the development of ME. Methods: We retrospectively included 119 patients suffering from large hemispheric infarction within onset of 24 h. The region of the middle cerebral artery territory was blindly outlined in a standard manner to calculate NWU. Patients were divided into two groups according to the occurrence of ME, which is defined as space-occupying infarct requiring decompressive craniotomy or death due to cerebral hernia in 7 days from onset. The clinical characteristics were analyzed, and the receiver operating characteristic curve (ROC curve) was used to assess the predictive ability of NWU and other factors for ME. Results: Multivariable analysis showed that NWU was an independent predictor of ME (OR 1.168, 95% CI 1.041-1.310). According to the ROC curve, NWU≥8.127% identified ME with good predictive power (AUC 0.734, sensitivity 0.656, specificity 0.862). Conclusions: NWU calculated in standardized and blindly outlined regions of the middle cerebral artery territory is also a good predictor for the development of ME in patients with large hemispheric infarction.
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Affiliation(s)
- Hai-Bin Xu
- Department of Neurology, General Hospital of Northern Theater Command, ShenYang, China
| | - Yu-Fei Sun
- Department of Neurology, General Hospital of Northern Theater Command, ShenYang, China
| | - Na Luo
- Department of Neurology, General Hospital of Northern Theater Command, ShenYang, China
| | - Jia-Qi Wang
- Department of Neurology, General Hospital of Northern Theater Command, ShenYang, China
| | - Guo-Can Chang
- Department of Neurology, General Hospital of Northern Theater Command, ShenYang, China
| | - Lin Tao
- Department of Neurology, General Hospital of Northern Theater Command, ShenYang, China
| | - Ben-Qiang Yang
- Department of Radiology, General Hospital of Northern Theater Command, ShenYang, China
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, ShenYang, China
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8
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Cai JC, Akkus Z, Philbrick KA, Boonrod A, Hoodeshenas S, Weston AD, Rouzrokh P, Conte GM, Zeinoddini A, Vogelsang DC, Huang Q, Erickson BJ. Fully Automated Segmentation of Head CT Neuroanatomy Using Deep Learning. Radiol Artif Intell 2020; 2:e190183. [PMID: 33937839 DOI: 10.1148/ryai.2020190183] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 06/02/2020] [Accepted: 06/16/2020] [Indexed: 12/17/2022]
Abstract
Purpose To develop a deep learning model that segments intracranial structures on head CT scans. Materials and Methods In this retrospective study, a primary dataset containing 62 normal noncontrast head CT scans from 62 patients (mean age, 73 years; age range, 27-95 years) acquired between August and December 2018 was used for model development. Eleven intracranial structures were manually annotated on the axial oblique series. The dataset was split into 40 scans for training, 10 for validation, and 12 for testing. After initial training, eight model configurations were evaluated on the validation dataset and the highest performing model was evaluated on the test dataset. Interobserver variability was reported using multirater consensus labels obtained from the test dataset. To ensure that the model learned generalizable features, it was further evaluated on two secondary datasets containing 12 volumes with idiopathic normal pressure hydrocephalus (iNPH) and 30 normal volumes from a publicly available source. Statistical significance was determined using categorical linear regression with P < .05. Results Overall Dice coefficient on the primary test dataset was 0.84 ± 0.05 (standard deviation). Performance ranged from 0.96 ± 0.01 (brainstem and cerebrum) to 0.74 ± 0.06 (internal capsule). Dice coefficients were comparable to expert annotations and exceeded those of existing segmentation methods. The model remained robust on external CT scans and scans demonstrating ventricular enlargement. The use of within-network normalization and class weighting facilitated learning of underrepresented classes. Conclusion Automated segmentation of CT neuroanatomy is feasible with a high degree of accuracy. The model generalized to external CT scans as well as scans demonstrating iNPH.Supplemental material is available for this article.© RSNA, 2020.
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Affiliation(s)
- Jason C Cai
- Departments of Radiology (J.C.C., K.A.P., S.H., P.R., G.M.C., D.C.V., Q.H., B.J.E.) and Cardiovascular Science (Z.A.), Mayo Clinic Rochester, 200 First St. SW, RO_PB_02_RIL, Rochester, MN 55905; Department of Radiology, Khon Kaen University, Khon Kaen, Thailand (A.B.); Department of Health Sciences Research, Mayo Clinic Florida, Jacksonville, Fla (A.D.W.); and Department of Internal Medicine, Ascension St. John Hospital, Detroit, Mich (A.Z.)
| | - Zeynettin Akkus
- Departments of Radiology (J.C.C., K.A.P., S.H., P.R., G.M.C., D.C.V., Q.H., B.J.E.) and Cardiovascular Science (Z.A.), Mayo Clinic Rochester, 200 First St. SW, RO_PB_02_RIL, Rochester, MN 55905; Department of Radiology, Khon Kaen University, Khon Kaen, Thailand (A.B.); Department of Health Sciences Research, Mayo Clinic Florida, Jacksonville, Fla (A.D.W.); and Department of Internal Medicine, Ascension St. John Hospital, Detroit, Mich (A.Z.)
| | - Kenneth A Philbrick
- Departments of Radiology (J.C.C., K.A.P., S.H., P.R., G.M.C., D.C.V., Q.H., B.J.E.) and Cardiovascular Science (Z.A.), Mayo Clinic Rochester, 200 First St. SW, RO_PB_02_RIL, Rochester, MN 55905; Department of Radiology, Khon Kaen University, Khon Kaen, Thailand (A.B.); Department of Health Sciences Research, Mayo Clinic Florida, Jacksonville, Fla (A.D.W.); and Department of Internal Medicine, Ascension St. John Hospital, Detroit, Mich (A.Z.)
| | - Arunnit Boonrod
- Departments of Radiology (J.C.C., K.A.P., S.H., P.R., G.M.C., D.C.V., Q.H., B.J.E.) and Cardiovascular Science (Z.A.), Mayo Clinic Rochester, 200 First St. SW, RO_PB_02_RIL, Rochester, MN 55905; Department of Radiology, Khon Kaen University, Khon Kaen, Thailand (A.B.); Department of Health Sciences Research, Mayo Clinic Florida, Jacksonville, Fla (A.D.W.); and Department of Internal Medicine, Ascension St. John Hospital, Detroit, Mich (A.Z.)
| | - Safa Hoodeshenas
- Departments of Radiology (J.C.C., K.A.P., S.H., P.R., G.M.C., D.C.V., Q.H., B.J.E.) and Cardiovascular Science (Z.A.), Mayo Clinic Rochester, 200 First St. SW, RO_PB_02_RIL, Rochester, MN 55905; Department of Radiology, Khon Kaen University, Khon Kaen, Thailand (A.B.); Department of Health Sciences Research, Mayo Clinic Florida, Jacksonville, Fla (A.D.W.); and Department of Internal Medicine, Ascension St. John Hospital, Detroit, Mich (A.Z.)
| | - Alexander D Weston
- Departments of Radiology (J.C.C., K.A.P., S.H., P.R., G.M.C., D.C.V., Q.H., B.J.E.) and Cardiovascular Science (Z.A.), Mayo Clinic Rochester, 200 First St. SW, RO_PB_02_RIL, Rochester, MN 55905; Department of Radiology, Khon Kaen University, Khon Kaen, Thailand (A.B.); Department of Health Sciences Research, Mayo Clinic Florida, Jacksonville, Fla (A.D.W.); and Department of Internal Medicine, Ascension St. John Hospital, Detroit, Mich (A.Z.)
| | - Pouria Rouzrokh
- Departments of Radiology (J.C.C., K.A.P., S.H., P.R., G.M.C., D.C.V., Q.H., B.J.E.) and Cardiovascular Science (Z.A.), Mayo Clinic Rochester, 200 First St. SW, RO_PB_02_RIL, Rochester, MN 55905; Department of Radiology, Khon Kaen University, Khon Kaen, Thailand (A.B.); Department of Health Sciences Research, Mayo Clinic Florida, Jacksonville, Fla (A.D.W.); and Department of Internal Medicine, Ascension St. John Hospital, Detroit, Mich (A.Z.)
| | - Gian Marco Conte
- Departments of Radiology (J.C.C., K.A.P., S.H., P.R., G.M.C., D.C.V., Q.H., B.J.E.) and Cardiovascular Science (Z.A.), Mayo Clinic Rochester, 200 First St. SW, RO_PB_02_RIL, Rochester, MN 55905; Department of Radiology, Khon Kaen University, Khon Kaen, Thailand (A.B.); Department of Health Sciences Research, Mayo Clinic Florida, Jacksonville, Fla (A.D.W.); and Department of Internal Medicine, Ascension St. John Hospital, Detroit, Mich (A.Z.)
| | - Atefeh Zeinoddini
- Departments of Radiology (J.C.C., K.A.P., S.H., P.R., G.M.C., D.C.V., Q.H., B.J.E.) and Cardiovascular Science (Z.A.), Mayo Clinic Rochester, 200 First St. SW, RO_PB_02_RIL, Rochester, MN 55905; Department of Radiology, Khon Kaen University, Khon Kaen, Thailand (A.B.); Department of Health Sciences Research, Mayo Clinic Florida, Jacksonville, Fla (A.D.W.); and Department of Internal Medicine, Ascension St. John Hospital, Detroit, Mich (A.Z.)
| | - David C Vogelsang
- Departments of Radiology (J.C.C., K.A.P., S.H., P.R., G.M.C., D.C.V., Q.H., B.J.E.) and Cardiovascular Science (Z.A.), Mayo Clinic Rochester, 200 First St. SW, RO_PB_02_RIL, Rochester, MN 55905; Department of Radiology, Khon Kaen University, Khon Kaen, Thailand (A.B.); Department of Health Sciences Research, Mayo Clinic Florida, Jacksonville, Fla (A.D.W.); and Department of Internal Medicine, Ascension St. John Hospital, Detroit, Mich (A.Z.)
| | - Qiao Huang
- Departments of Radiology (J.C.C., K.A.P., S.H., P.R., G.M.C., D.C.V., Q.H., B.J.E.) and Cardiovascular Science (Z.A.), Mayo Clinic Rochester, 200 First St. SW, RO_PB_02_RIL, Rochester, MN 55905; Department of Radiology, Khon Kaen University, Khon Kaen, Thailand (A.B.); Department of Health Sciences Research, Mayo Clinic Florida, Jacksonville, Fla (A.D.W.); and Department of Internal Medicine, Ascension St. John Hospital, Detroit, Mich (A.Z.)
| | - Bradley J Erickson
- Departments of Radiology (J.C.C., K.A.P., S.H., P.R., G.M.C., D.C.V., Q.H., B.J.E.) and Cardiovascular Science (Z.A.), Mayo Clinic Rochester, 200 First St. SW, RO_PB_02_RIL, Rochester, MN 55905; Department of Radiology, Khon Kaen University, Khon Kaen, Thailand (A.B.); Department of Health Sciences Research, Mayo Clinic Florida, Jacksonville, Fla (A.D.W.); and Department of Internal Medicine, Ascension St. John Hospital, Detroit, Mich (A.Z.)
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Sun W, Li G, Song Y, Zhu Z, Yang Z, Chen Y, Miao J, Song X, Lan Y, Qiu X, Zhu S, Fan Y. A web based dynamic MANA Nomogram for predicting the malignant cerebral edema in patients with large hemispheric infarction. BMC Neurol 2020; 20:360. [PMID: 32993551 PMCID: PMC7523347 DOI: 10.1186/s12883-020-01935-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 09/17/2020] [Indexed: 12/04/2022] Open
Abstract
Background For large hemispheric infarction (LHI), malignant cerebral edema (MCE) is a life-threatening complication with a mortality rate approaching 80%. Establishing a convenient prediction model of MCE after LHI is vital for the rapid identification of high-risk patients as well as for a better understanding of the potential mechanism underlying MCE. Methods One hundred forty-two consecutive patients with LHI within 24 h of onset between January 1, 2016 and August 31, 2019 were retrospectively reviewed. MCE was defined as patient death or received decompressive hemicraniectomy (DHC) with obvious mass effect (≥ 5 mm midline shift or Basal cistern effacement). Binary logistic regression was performed to identify independent predictors of MCE. Independent prognostic factors were incorporated to build a dynamic nomogram for MCE prediction. Results After adjusting for confounders, four independent factors were identified, including previously known atrial fibrillation (KAF), midline shift (MLS), National Institutes of Health Stroke Scale (NIHSS) and anterior cerebral artery (ACA) territory involvement. To facilitate the nomogram use for clinicians, we used the “Dynnom” package to build a dynamic MANA (acronym for MLS, ACA territory involvement, NIHSS and KAF) nomogram on web (http://www.MANA-nom.com) to calculate the exact probability of developing MCE. The MANA nomogram’s C-statistic was up to 0.887 ± 0.041 and the AUC-ROC value in this cohort was 0.887 (95%CI, 0.828 ~ 0.934). Conclusions Independent MCE predictors included KAF, MLS, NIHSS, and ACA territory involvement. The dynamic MANA nomogram is a convenient, practical and effective clinical decision-making tool for predicting MCE after LHI in Chinese patients.
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Affiliation(s)
- Wenzhe Sun
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Guo Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Yang Song
- School of Medicine and Health Management; Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Zhou Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Zhaoxia Yang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Yuxi Chen
- The Solomon H. Snyder Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - Jinfeng Miao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Xiaoyan Song
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Yan Lan
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Xiuli Qiu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Suiqiang Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China.
| | - Yebin Fan
- School of Computer Science and Technology, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China.
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Wu C, Xu J, Ji X. Letter by Wu et al Regarding Article, "Intracranial Cerebrospinal Fluid Volume as a Predictor of Malignant Middle Cerebral Artery Infarction". Stroke 2019; 50:e303. [PMID: 31451101 DOI: 10.1161/strokeaha.119.026615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Chuanjie Wu
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jiali Xu
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
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