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Lambrou V, Gory B, Lapergue B, Marnat G, Pop R, Calviere L, Anadani M, Blanc R, Finitsis SN. Number of passes and outcome of endovascular treatment of anterior circulation large core ischemic stroke: insights from the Endovascular Treatment in Ischemic Stroke (ETIS) registry. J Neurointerv Surg 2024:jnis-2024-021857. [PMID: 38816202 DOI: 10.1136/jnis-2024-021857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 05/14/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND The effect of multiple attempts on the outcome of endovascular treatment (EVT) of anterior circulation large ischemic core (LIC) stroke has not been fully explored. METHODS We analyzed data from the Endovascular Treatment in Ischemic Stroke (ETIS) registry, a prospective, observational, multicenter study of acute ischemic stroke patients treated with EVT at 21 centers in France between January 1, 2015 and June 31, 2023. We included patients with proximal intracranial occlusion and LIC defined as Alberta Stroke Program Early CT Score (ASPECTS) of 0-5 up to 24 hours after last being seen well. We divided patients according to the number of passes with successful reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2b) into seven groups, according to the corresponding number of passes. We compared them to the group of patients with unsuccessful reperfusion. RESULTS A total of 1235 patients with LIC constituted the study cohort. The rate of a modified Rankin Scale (mRS) score of 0 to 3 at 90 days was significantly higher for the one-pass successful recanalization category compared to no recanalization (48.1% vs 17.2%; adjusted OR (aOR) 7.99, 95% CI 4.30 to 14.8, P<0.001) and remained so even after six or more attempts (27.7% vs 17.2%; aOR 3.59, 95% CI 1.37 to 9.39, P=0.009). The rate of symptomatic intracranial hemorrhage was lower for successful recanalization up to two passes (11.1% vs 18.8%; aOR 0.36, 95% CI 0.18 to 0.69, P=0.002) without any significant differences for a higher number of passes. CONCLUSION In anterior circulation LIC patients, successful reperfusion, even after six passes, is associated with favorable clinical outcomes with no increased hemorrhagic risk when compared to unsuccessful reperfusion.
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Affiliation(s)
- Victoria Lambrou
- Neuroradiology, Aristotle University of Thessaloniki, Thessalonike, Kentrikḗ Makedonía, Greece
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, France
| | - Bertrand Lapergue
- Hôpital Foch Suresnes FR, University of Versailles Saint Quentin-en-Yvelines, Suresnes, France
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Raoul Pop
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
- Interventional Radiology, Institut de Chirurgie Guidée par l'Image, Strasbourg, France
| | | | - Mohammad Anadani
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Raphael Blanc
- Interventional Neuroradiology, Fondation Rothschild, Paris, France
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Klapproth S, Meyer L, Kniep H, Bechstein M, Kyselyova A, Hanning U, Schön G, Rimmele L, Fiehler J, Broocks G. Effect of short- versus long-term serum glucose levels on early ischemic water homeostasis and functional outcome in patients with large vessel occlusion stroke. Eur J Neurol 2024; 31:e16166. [PMID: 38015448 DOI: 10.1111/ene.16166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND AND PURPOSE In ischemic stroke, the impact of short- versus long-term blood glucose level (BGL) on early lesion pathophysiology and functional outcome has not been assessed. The purpose of this study was to directly compare the effect of long-term blood glucose (glycated hemoglobin [HbA1c]) versus serum BGL on early edema formation and functional outcome. METHODS Anterior circulation ischemic stroke patients who underwent mechanical thrombectomy after multimodal computed tomography (CT) on admission were analyzed. Endpoints were early ischemic cerebral edema, measured by quantitative net water uptake (NWU) on initial CT and functional independence at Day 90. RESULTS A total of 345 patients were included. Patients with functional independence had significantly lower baseline NWU (3.1% vs. 8.3%; p < 0.001) and lower BGL (113 vs. 123 mg/dL; p < 0.001) than those without functional independence, while HbA1c levels did not differ significantly (5.7% vs. 5.8%; p = 0.15). A significant association was found for NWU and BGL (ß = 0.02, 95% confidence interval [CI] 0.006-0.03; p = 0.002), but not for HbA1c and NWU (ß = -0.16, 95% CI -0.53-0.21; p = 0.39). Mediation analysis showed that 67% of the effect of BGL on functional outcome was mediated by early edema formation. CONCLUSION Aggravated early edema and worse functional outcome was associated with elevated short-term serum BGL, but not with HbA1c levels. Hence, the link between short-term BGL and early edema development might be used as a target for adjuvant therapy in patients with ischemic stroke.
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Affiliation(s)
- Susan Klapproth
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Kyselyova
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Leander Rimmele
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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3
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Steffen P, Winkelmeier L, Kniep H, Geest V, Soltanipanah S, Fiehler J, Broocks G. Quantification of ischemic brain edema after mechanical thrombectomy using dual-energy computed tomography in patients with ischemic stroke. Sci Rep 2024; 14:4148. [PMID: 38378795 PMCID: PMC10879140 DOI: 10.1038/s41598-024-54600-0] [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: 09/27/2023] [Accepted: 02/14/2024] [Indexed: 02/22/2024] Open
Abstract
Net water uptake (NWU) is a quantitative imaging biomarker used to assess cerebral edema resulting from ischemia via Computed Tomography (CT)-densitometry. It serves as a strong predictor of clinical outcome. Nevertheless, NWU measurements on follow-up CT scans after mechanical thrombectomy (MT) can be affected by contrast staining. To improve the accuracy of edema estimation, virtual non-contrast images (VNC-I) from dual-energy CT scans (DECT) were compared to conventional polychromatic CT images (CP-I) in this study. We examined NWU measurements derived from VNC-I and CP-I to assess their agreement and predictive value in clinical outcome. 88 consecutive patients who received DECT as follow-up after MT were included. NWU was quantified on CP-I (cNWU) and VNC-I (vNWU). The clinical endpoint was functional independence at discharge. cNWU and vNWU were highly correlated (r = 0.71, p < 0.0001). The median difference between cNWU and vNWU was 8.7% (IQR: 4.5-14.1%), associated with successful vessel recanalization (mTICI2b-3) (ß: 11.6%, 95% CI 2.9-23.0%, p = 0.04), and age (ß: 4.2%, 95% CI 1.3-7.0%, p = 0.005). The diagnostic accuracy to classify outcome between cNWU and vNWU was similar (AUC:0.78 versus 0.77). Although there was an 8.7% median difference, indicating potential edema underestimation on CP-I, it did not have short-term clinical implications.
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Affiliation(s)
- Paul Steffen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany.
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Vincent Geest
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Setareh Soltanipanah
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
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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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Pham J, Ng FC. Novel advanced imaging techniques for cerebral oedema. Front Neurol 2024; 15:1321424. [PMID: 38356883 PMCID: PMC10865379 DOI: 10.3389/fneur.2024.1321424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 01/09/2024] [Indexed: 02/16/2024] Open
Abstract
Cerebral oedema following acute ischemic infarction has been correlated with poor functional outcomes and is the driving mechanism of malignant infarction. Measurements of midline shift and qualitative assessment for herniation are currently the main CT indicators for cerebral oedema but have limited sensitivity for small cortical infarcts and are typically a delayed sign. In contrast, diffusion-weighted (DWI) or T2-weighted magnetic resonance imaging (MRI) are highly sensitive but are significantly less accessible. Due to the need for early quantification of cerebral oedema, several novel imaging biomarkers have been proposed. Based on neuroanatomical shift secondary to space-occupying oedema, measures such as relative hemispheric volume and cerebrospinal fluid displacement are correlated with poor outcomes. In contrast, other imaging biometrics, such as net water uptake, T2 relaxometry and blood brain barrier permeability, reflect intrinsic tissue changes from the influx of fluid into the ischemic region. This review aims to discuss quantification of cerebral oedema using current and developing advanced imaging techniques, and their role in predicting clinical outcomes.
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Affiliation(s)
- Jenny Pham
- Department of Radiology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Felix C. Ng
- Department of Neurology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
- Department of Medicine at Royal Melbourne Hospital, Melbourne Brain Centre, University of Melbourne, Parkville, VIC, Australia
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Thorén M, Escudero-Martínez I, Andersson T, Chen SY, Tsao N, Khurana D, Beretta S, Peeters A, Tsivgoulis G, Roffe C, Ahmed N. Reperfusion by endovascular thrombectomy and early cerebral edema in anterior circulation stroke: Results from the SITS-International Stroke Thrombectomy Registry. Int J Stroke 2023; 18:1193-1201. [PMID: 37226337 PMCID: PMC10676032 DOI: 10.1177/17474930231180451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/08/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND A large infarct and expanding cerebral edema (CED) due to a middle cerebral artery occlusion confers a 70% mortality unless treated surgically. There is still conflicting evidence whether reperfusion is associated with a lower risk for CED in acute ischemic stroke. AIM To investigate the association of reperfusion with development of early CED after stroke thrombectomy. METHODS From the SITS-International Stroke Thrombectomy Registry, we selected patients with occlusion of the intracranial internal carotid or middle cerebral artery (M1 or M2). Successful reperfusion was defined as mTICI ⩾ 2b. Primary outcome was moderate or severe CED, defined as focal brain swelling ⩾1/3 of the hemisphere on imaging scans at 24 h. We used regression methods while adjusting for baseline variables. Effect modification by severe early neurological deficits, as indicators of large infarct at baseline and at 24 h, were explored. RESULTS In total, 4640 patients, median age 70 years and median National Institutes of Health Stroke Score (NIHSS) 16, were included. Of these, 86% had successful reperfusion. Moderate or severe CED was less frequent among patients who had reperfusion compared to patients without reperfusion: 12.5% versus 29.6%, p < 0.05, crude risk ratio (RR) 0.42 (95% confidence interval (CI): 0.37-0.49), and adjusted RR 0.50 (95% CI: 0.44-0.57). Analysis of effect modification indicated that severe neurological deficits weakened the association between reperfusion and lower risk of CED. The RR reduction was less favorable in patients with severe neurological deficits, defined as NIHSS score 15 or more at baseline and at 24 h, used as an indicator for larger infarction. CONCLUSION In patients with large artery anterior circulation occlusion stroke who underwent thrombectomy, successful reperfusion was associated with approximately 50% lower risk for early CED. Severe neurological deficit at baseline seems to be a predictor for moderate or severe CED also in patients with successful reperfusion by thrombectomy.
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Affiliation(s)
- Magnus Thorén
- Stroke Research Unit, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Danderyd Hospital, Stockholm, Sweden
| | - Irene Escudero-Martínez
- Department of Neurology, Hospital Universitari i Politécnic La Fe, Valencia, Spain
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain
| | - Tomas Andersson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | - Nicole Tsao
- Global Medical Affairs, Biogen, Cambridge, MA, USA
| | - Dheeraj Khurana
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Simone Beretta
- Department of Neurology and Stroke Unit, San Gerardo Hospital, Monza, Italy
| | - Andre Peeters
- Department of Neurology and Stroke Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, Athens, Greece
| | | | - Niaz Ahmed
- Stroke Research Unit, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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7
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Pham J, Gan C, Dabboucy J, Stella DL, Dowling R, Yan B, Bush S, Williams C, Mitchell PJ, Desmond P, Thijs V, Asadi H, Brooks M, Maingard J, Jhamb A, Pavlin-Premrl D, Campbell BC, Ng FC. Occult contrast retention post-thrombectomy on 24-h follow-up dual-energy CT: Associations and impact on imaging analysis. Int J Stroke 2023; 18:1228-1237. [PMID: 37260232 DOI: 10.1177/17474930231182018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Following reperfusion treatment in ischemic stroke, computed tomography (CT) imaging at 24 h is widely used to assess radiological outcomes. Even without visible hyperattenuation, occult angiographic contrast may persist in the brain and confound Hounsfield unit-based imaging metrics, such as net water uptake (NWU). AIMS We aimed to assess the presence and factors associated with retained contrast post-thrombectomy on 24-h imaging using dual-energy CT (DECT), and its impact on the accuracy of NWU as a measure of cerebral edema. METHODS Consecutive patients with anterior circulation large vessel occlusion who had post-thrombectomy DECT performed 24-h post-treatment from two thrombectomy stroke centers were retrospectively studied. NWU was calculated by interside comparison of HUs of the infarct lesion and its mirror homolog. Retained contrast was quantified by the difference in NWU values with and without adjustment for iodine. Patients with visible hyperdensities from hemorrhagic transformation or visible contrast retention and bilateral infarcts were excluded. Cerebral edema was measured by relative hemispheric volume (rHV) and midline shift (MLS). RESULTS Of 125 patients analyzed (median age 71 (IQR = 61-80), baseline National Institutes of Health Stroke Scale (NIHSS) 16 (IQR = 9.75-21)), reperfusion (defined as extended-Thrombolysis-In-Cerebral-Infarction 2b-3) was achieved in 113 patients (90.4%). Iodine-subtracted NWU was significantly higher than unadjusted NWU (17.1% vs 10.8%, p < 0.001). In multivariable median regression analysis, increased age (p = 0.024), number of passes (p = 0.006), final infarct volume (p = 0.023), and study site (p = 0.021) were independently associated with amount of retained contrast. Iodine-subtracted NWU correlated with rHV (rho = 0.154, p = 0.043) and MLS (rho = 0.165, p = 0.033) but unadjusted NWU did not (rHV rho = -0.035, p = 0.35; MLS rho = 0.035, p = 0.347). CONCLUSIONS Angiographic iodine contrast is retained in brain parenchyma 24-h post-thrombectomy, even without visually obvious hyperdensities on CT, and significantly affects NWU measurements. Adjustment for retained iodine using DECT is required for accurate NWU measurements post-thrombectomy. Future quantitative studies analyzing CT after thrombectomy should consider occult contrast retention.
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Affiliation(s)
- Jenny Pham
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Calvin Gan
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Jasmin Dabboucy
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Damien L Stella
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Richard Dowling
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Bernard Yan
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Steven Bush
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Cameron Williams
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Peter J Mitchell
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Patricia Desmond
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- The University of Melbourne, Parkville, VIC, Australia
| | - Vincent Thijs
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
- Division of Stroke, Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - Hamed Asadi
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Mark Brooks
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Julian Maingard
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Ash Jhamb
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Davor Pavlin-Premrl
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
- Melbourne Brain Centre, Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Bruce Cv Campbell
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Melbourne Brain Centre, Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Felix C Ng
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
- Melbourne Brain Centre, Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
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8
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Faizy TD, Winkelmeier L, Mlynash M, Broocks G, Heitkamp C, Thaler C, van Horn N, Seners P, Kniep H, Stracke P, Zelenak K, Lansberg MG, Albers GW, Wintermark M, Fiehler J, Heit JJ. Brain edema growth after thrombectomy is associated with comprehensive collateral blood flow. J Neurointerv Surg 2023:jnis-2023-020921. [PMID: 37918909 DOI: 10.1136/jnis-2023-020921] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/13/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND We determined whether a comprehensive assessment of cerebral collateral blood flow is associated with ischemic lesion edema growth in patients successfully treated by thrombectomy. METHODS This was a multicenter retrospective study of ischemic stroke patients who underwent thrombectomy treatment of large vessel occlusions. Collateral status was determined using the cerebral collateral cascade (CCC) model, which comprises three components: arterial collaterals (Tan Scale) and venous outflow profiles (Cortical Vein Opacification Score) on CT angiography, and tissue-level collaterals (hypoperfusion intensity ratio) on CT perfusion. Quantitative ischemic lesion net water uptake (NWU) was used to determine edema growth between admission and follow-up non-contrast head CT (ΔNWU). Three groups were defined: CCC+ (good pial collaterals, tissue-level collaterals, and venous outflow), CCC- (poor pial collaterals, tissue-level collaterals, and venous outflow), and CCCmixed (remainder of patients). Primary outcome was ischemic lesion edema growth (ΔNWU). Multivariable regression models were used to assess the primary and secondary outcomes. RESULTS 538 patients were included. 157 patients had CCC+, 274 patients CCCmixed, and 107 patients CCC- profiles. Multivariable regression analysis showed that compared with patients with CCC+ profiles, CCC- (β 1.99, 95% CI 0.68 to 3.30, P=0.003) and CCC mixed (β 1.65, 95% CI 0.75 to 2.56, P<0.001) profiles were associated with greater ischemic lesion edema growth (ΔNWU) after successful thrombectomy treatment. ΔNWU (OR 0.74, 95% CI 0.68 to 0.8, P<0.001) and CCC+ (OR 13.39, 95% CI 4.88 to 36.76, P<0.001) were independently associated with functional independence. CONCLUSION A comprehensive assessment of cerebral collaterals using the CCC model is strongly associated with edema growth and functional independence in acute stroke patients successfully treated by endovascular thrombectomy.
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Affiliation(s)
- Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Mlynash
- Department of Neurology, Stanford Stroke Center, Stanford University, Stanford, California, USA
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Heitkamp
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Thaler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Paul Stracke
- Section of Interventional Neuroradiology, University Hospital Munster, Munster, Germany
| | - Kamil Zelenak
- Clinic of Radiology, Comenius University in Bratislava Jessenius Faculty of Medicine in Martin, Martin, Slovakia
- Clinic of Radiology, University Hospital Martin, Martin, Slovakia
| | - Maarten G Lansberg
- Department of Neurology, Stanford Stroke Center, Stanford University, Stanford, California, USA
| | - Gregory W Albers
- Stanford Stroke Center, Stanford Medicine, Stanford, California, USA
| | - Max Wintermark
- Department of Neuroradiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
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Broocks G, Meyer L, Hanning U, Faizy TD, Bechstein M, Kniep H, Van Horn N, Schön G, Barow E, Thomalla G, Fiehler J, Kemmling A. Haemorrhage after thrombectomy with adjuvant thrombolysis in unknown onset stroke depends on high early lesion water uptake. Stroke Vasc Neurol 2023:svn-2022-002264. [PMID: 37699728 DOI: 10.1136/svn-2022-002264] [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: 12/21/2022] [Accepted: 08/29/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND AND PURPOSE In wake-up stroke, CT-based quantitative net water uptake (NWU) might serve as an alternative tool to MRI to guide intravenous thrombolysis with alteplase (IVT). An important complication after IVT is symptomatic intracerebral haemorrhage (sICH). As NWU directly implies ischaemic lesion progression, reflecting blood-brain barrier injury, we hypothesised that NWU predicts sICH in patients who had a ischaemic stroke undergoing thrombectomy with unknown onset. METHODS Consecutive analysis of all patients who had unknown onset anterior circulation ischaemic stroke who underwent CT at baseline and endovascular treatment between December 2016 and October 2020. Quantitative NWU was assessed on baseline CT. The primary endpoint was sICH. The association of NWU and other baseline parameters to sICH was investigated using inverse-probability weighting (IPW) analysis. RESULTS A total of 88 patients were included, of which 46 patients (52.3%) received IVT. The median NWU was 10.7% (IQR: 5.1-17.7). The proportion of patients with any haemorrhage and sICH were 35.2% and 13.6%. NWU at baseline was significantly higher in patients with sICH (19.1% vs 9.6%, p<0.0001) and the median Alberta Stroke Program Early CT Score (ASPECTS) was lower (5 vs 8, p<0.0001). Following IPW, there was no association between IVT and sICH in unadjusted analysis. However, after adjusting for ASPECTS and NWU, there was a significant association between IVT administration and sICH (14.6%, 95% CI: 3.3% to 25.6%, p<0.01). CONCLUSION In patients with ischaemic stroke with unknown onset, the combination of high NWU with IVT is directly linked to higher rates of sICH. Besides ASPECTS for evaluating the extent of the early infarct lesion, quantitative NWU could be used as an imaging biomarker to assess the degree of blood-brain barrier damage in order to predict the risk of sICH in patients with wake up stroke.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias Djamsched Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel Van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Ewgenia Barow
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, University Marburg, Marburg, Germany
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10
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Winkelmeier L, Faizy TD, Broocks G, Meyer L, Heitkamp C, Brekenfeld C, Thaler C, Steffen P, Schell M, Deb-Chatterji M, Hanning U, Kniep H, Maros ME, Thomalla G, Fiehler J, Flottmann FA. Association Between Recanalization Attempts and Functional Outcome After Thrombectomy for Large Ischemic Stroke. Stroke 2023; 54:2304-2312. [PMID: 37492970 PMCID: PMC10464881 DOI: 10.1161/strokeaha.123.042794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 04/26/2023] [Accepted: 05/09/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Recently, 3 randomized controlled trials provided high-level evidence that patients with large ischemic stroke achieved better functional outcomes after endovascular therapy than with medical care alone. We aimed to investigate whether the clinical benefit of endovascular therapy is associated with the number of recanalization attempts in extensive baseline infarction. METHODS This retrospective multicenter study enrolled patients from the German Stroke Registry who underwent endovascular therapy for anterior circulation large vessel occlusion between 2015 and 2021. Large ischemic stroke was defined as an Alberta Stroke Program Early Computed Tomography Score of 3 to 5. The study cohort was divided into patients with unsuccessful reperfusion (Thrombolysis in Cerebral Infarction score, 0-2a) and successful reperfusion (Thrombolysis in Cerebral Infarction score, 2b/3) at attempts 1, 2, 3, or ≥4. The primary outcome was favorable functional outcome defined as modified Rankin Scale score of 0 to 3 at 90 days. Safety outcomes were symptomatic intracranial hemorrhage after 24 hours and death within 90 days. Multivariable logistic regression was used to identify independent determinants of primary and secondary outcomes. RESULTS A total of 348 patients met the inclusion criteria. Successful reperfusion was observed in 83.3% and favorable functional outcomes in 36.2%. Successful reperfusion at attempts 1 (adjusted odds ratio, 5.97 [95% CI, 1.71-24.43]; P=0.008) and 2 (adjusted odds ratio, 6.32 [95% CI, 1.73-26.92]; P=0.008) increased the odds of favorable functional outcome, whereas success at attempts 3 or ≥4 did not. Patients with >2 attempts showed higher rates of symptomatic intracranial hemorrhage (12.8% versus 6.5%; P=0.046). Successful reperfusion at any attempt lowered the odds of death compared with unsuccessful reperfusion. CONCLUSIONS In patients with large vessel occlusion and Alberta Stroke Program Early Computed Tomography Score of 3 to 5, the clinical benefit of endovascular therapy was linked to the number of recanalization attempts required for successful reperfusion. Our findings encourage to perform at least 2 recanalization attempts to seek for successful reperfusion in large ischemic strokes, while >2 attempts should follow a careful risk-benefit assessment in these highly affected patients. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03356392.
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Affiliation(s)
- Laurens Winkelmeier
- Departments of Neuroradiology (L.W., T.D.F., G.B., L.M., C.H., C.B., C.T., P.S., U.H., H.K., J.F., F.F.)
| | - Tobias D. Faizy
- Departments of Neuroradiology (L.W., T.D.F., G.B., L.M., C.H., C.B., C.T., P.S., U.H., H.K., J.F., F.F.)
| | - Gabriel Broocks
- Departments of Neuroradiology (L.W., T.D.F., G.B., L.M., C.H., C.B., C.T., P.S., U.H., H.K., J.F., F.F.)
| | - Lukas Meyer
- Departments of Neuroradiology (L.W., T.D.F., G.B., L.M., C.H., C.B., C.T., P.S., U.H., H.K., J.F., F.F.)
| | - Christian Heitkamp
- Departments of Neuroradiology (L.W., T.D.F., G.B., L.M., C.H., C.B., C.T., P.S., U.H., H.K., J.F., F.F.)
| | - Caspar Brekenfeld
- Departments of Neuroradiology (L.W., T.D.F., G.B., L.M., C.H., C.B., C.T., P.S., U.H., H.K., J.F., F.F.)
| | - Christian Thaler
- Departments of Neuroradiology (L.W., T.D.F., G.B., L.M., C.H., C.B., C.T., P.S., U.H., H.K., J.F., F.F.)
| | - Paul Steffen
- Departments of Neuroradiology (L.W., T.D.F., G.B., L.M., C.H., C.B., C.T., P.S., U.H., H.K., J.F., F.F.)
| | - Maximilian Schell
- Neurology (M.S., M.D.-C., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Milani Deb-Chatterji
- Neurology (M.S., M.D.-C., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Uta Hanning
- Departments of Neuroradiology (L.W., T.D.F., G.B., L.M., C.H., C.B., C.T., P.S., U.H., H.K., J.F., F.F.)
| | - Helge Kniep
- Departments of Neuroradiology (L.W., T.D.F., G.B., L.M., C.H., C.B., C.T., P.S., U.H., H.K., J.F., F.F.)
| | - Máté E. Maros
- Department of Neuroradiology, Medical Faculty Mannheim, Heidelberg University, Germany (M.E.M.)
| | - Götz Thomalla
- Neurology (M.S., M.D.-C., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Jens Fiehler
- Departments of Neuroradiology (L.W., T.D.F., G.B., L.M., C.H., C.B., C.T., P.S., U.H., H.K., J.F., F.F.)
| | - Fabian Alexander Flottmann
- Departments of Neuroradiology (L.W., T.D.F., G.B., L.M., C.H., C.B., C.T., P.S., U.H., H.K., J.F., F.F.)
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11
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Dhar R, Kumar A, Chen Y, Begunova Y, Olexa M, Prasad A, Carey G, Gonzalez I, Bhatia K, Hamed M, Heitsch L, Mainali S, Petersen N, Lee JM. Imaging biomarkers of cerebral edema automatically extracted from routine CT scans of large vessel occlusion strokes. J Neuroimaging 2023; 33:606-616. [PMID: 37095592 PMCID: PMC10524672 DOI: 10.1111/jon.13109] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/13/2023] [Accepted: 04/15/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND AND PURPOSE Volumetric and densitometric biomarkers have been proposed to better quantify cerebral edema after stroke, but their relative performance has not been rigorously evaluated. METHODS Patients with large vessel occlusion stroke from three institutions were analyzed. An automated pipeline extracted brain, cerebrospinal fluid (CSF), and infarct volumes from serial CTs. Several biomarkers were measured: change in global CSF volume from baseline (ΔCSF); ratio of CSF volumes between hemispheres (CSF ratio); and relative density of infarct region compared with mirrored contralateral region (net water uptake [NWU]). These were compared to radiographic standards, midline shift and relative hemispheric volume (RHV) and malignant edema, defined as deterioration resulting in need for osmotic therapy, decompressive surgery, or death. RESULTS We analyzed 255 patients with 210 baseline CTs, 255 24-hour CTs, and 81 72-hour CTs. Of these, 35 (14%) developed malignant edema and 63 (27%) midline shift. CSF metrics could be calculated for 310 (92%), while NWU could only be obtained from 193 (57%). Peak midline shift was correlated with baseline CSF ratio (ρ = -.22) and with CSF ratio and ΔCSF at 24 hours (ρ = -.55/.63) and 72 hours (ρ = -.66/.69), but not with NWU (ρ = .15/.25). Similarly, CSF ratio was correlated with RHV (ρ = -.69/-.78), while NWU was not. Adjusting for age, National Institutes of Health Stroke Scale, tissue plasminogen activator treatment, and Alberta Stroke Program Early CT Score, CSF ratio (odds ratio [OR]: 1.95 per 0.1, 95% confidence interval [CI]: 1.52-2.59) and ΔCSF at 24 hours (OR: 1.87 per 10%, 95% CI: 1.47-2.49) were associated with malignant edema. CONCLUSION CSF volumetric biomarkers can be automatically measured from almost all routine CTs and correlate better with standard edema endpoints than net water uptake.
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Affiliation(s)
- Rajat Dhar
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
| | - Atul Kumar
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
| | - Yasheng Chen
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
| | | | - Madelynne Olexa
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Ayush Prasad
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Grace Carey
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
| | - Isabella Gonzalez
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
| | - Kunal Bhatia
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
| | - Mohammad Hamed
- Department of Neurology, The Ohio State University, Columbus, OH
| | - Laura Heitsch
- Department of Emergency Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA
| | - Nils Petersen
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Jin-Moo Lee
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
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12
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Nie X, Leng X, Miao Z, Fisher M, Liu L. Clinically Ineffective Reperfusion After Endovascular Therapy in Acute Ischemic Stroke. Stroke 2023; 54:873-881. [PMID: 36475464 DOI: 10.1161/strokeaha.122.038466] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Endovascular treatment is a highly effective therapy for acute ischemic stroke due to large vessel occlusion. However, in clinical practice, nearly half of the patients do not have favorable outcomes despite successful recanalization of the occluded artery. This unfavorable outcome can be defined as having clinically ineffective reperfusion. The objective of the review is to describe clinically ineffective reperfusion after endovascular therapy and its underlying risk factors and mechanisms, including initial tissue damage, cerebral edema, the no-reflow phenomenon, reperfusion injury, procedural features, and variations in postprocedural management. Further research is needed to more accurately identify patients at a high risk of clinically ineffective reperfusion after endovascular therapy and to improve individualized periprocedural management strategies, to increase the chance of achieving favorable clinical outcomes.
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Affiliation(s)
- Ximing Nie
- Department of Neurology (X.N., L.L.), Beijing Tiantan Hospital, Capital Medical University, China.,China National Clinical Research Center for Neurological Diseases, Beijing (X.N., L.L.)
| | - Xinyi Leng
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, SAR (X.L.)
| | - Zhongrong Miao
- Department of Interventional Neuroradiology (Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.)
| | - Liping Liu
- Department of Neurology (X.N., L.L.), Beijing Tiantan Hospital, Capital Medical University, China.,China National Clinical Research Center for Neurological Diseases, Beijing (X.N., L.L.)
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13
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Sporns PB, Rusche T, Lee S, Hanning U, Meyer L, Faizy T, Fiehler J, Psychogios M, Kemmling A, Broocks G. Impact of edema formation on functional outcome in pediatric stroke patients. Eur J Neurol 2023; 30:150-154. [PMID: 36168926 DOI: 10.1111/ene.15576] [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: 08/18/2022] [Accepted: 09/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Quantitative lesion net water uptake (NWU) has been described as an imaging biomarker reflecting vasogenic edema as an early indicator of infarct progression. We hypothesized that edema formation measured by NWU is higher in children compared to adults but despite this functional outcome may be better in children. METHODS This study analyzed children enrolled in the Save ChildS Study who had baseline and follow-up computed tomography available and the data were compared to adult patients. RESULTS Some 207 patients, of whom 13 were children and 194 were adults, were analyzed. Median NWU at baseline was 7.8% (IQR: 4.3-11.3), and there were no significant differences between children and adults (7.5% vs. 7.8%; p = 0.87). The early edema progression rate was 3.0%/h in children and 2.3%/h in adults. Median ΔNWU was 15.1% in children and 10.5% in adults. Children had significantly more often excellent (mRS 0-1; children 10/13 = 77% vs. adults 28/196 = 14%; p < 0.0001) and favorable clinical outcomes (mRS 0-2, 12/13 = 92% vs. 39/196 = 20%; p < 0.0001). CONCLUSIONS In this study, clinical outcomes in children with large vessel occlusion strokes were better than in adults despite similar clinical and imaging characteristics and similar edema formation. This may be impacted by the generally better outcomes of children after strokes but may demonstrate that the degree of early ischemic changes using Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and edema progression rate may not be a reason for exclusion from endovascular thrombectomy.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thilo Rusche
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marios Psychogios
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Andre Kemmling
- Department of Neuroradiology, University Hospital Marburg, Marburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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14
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Sarraj A, Pujara DK, Churilov L, Sitton CW, Ng F, Hassan AE, Abraham MG, Blackburn SL, Sharma G, Yassi N, Kleinig T, Shah D, Wu TY, Tekle WG, Budzik RF, Hicks WJ, Vora N, Edgell RC, Haussen D, Ortega-Gutierrez S, Toth G, Maali L, Abdulrazzak MA, Al-Shaibi F, AlMaghrabi T, Yogendrakumar V, Shaker F, Mir O, Arora A, Duncan K, Sundararajan S, Opaskar A, Hu Y, Ray A, Sunshine J, Bambakidis N, Martin-Schild S, Hussain MS, Nogueira R, Furlan A, Sila CA, Grotta JC, Parsons M, Mitchell PJ, Donnan GA, Davis SM, Albers GW, Campbell BCV. Mediation of Successful Reperfusion Effect through Infarct Growth and Cerebral Edema: A Pooled, Patient-Level Analysis of EXTEND-IA Trials and SELECT Prospective Cohort. Ann Neurol 2022; 93:793-804. [PMID: 36571388 DOI: 10.1002/ana.26587] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/01/2022] [Accepted: 12/16/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Reperfusion therapy is highly beneficial for ischemic stroke. Reduction in both infarct growth and edema are plausible mediators of clinical benefit with reperfusion. We aimed to quantify these mediators and their interrelationship. METHODS In a pooled, patient-level analysis of the EXTEND-IA trials and SELECT study, we used a mediation analysis framework to quantify infarct growth and cerebral edema (midline shift) mediation effect on successful reperfusion (modified Treatment in Cerebral Ischemia ≥ 2b) association with functional outcome (modified Rankin Scale distribution). Furthermore, we evaluated an additional pathway to the original hypothesis, where infarct growth mediated successful reperfusion effect on midline shift. RESULTS A total 542 of 665 (81.5%) eligible patients achieved successful reperfusion. Baseline clinical and imaging characteristics were largely similar between those achieving successful versus unsuccessful reperfusion. Median infarct growth was 12.3ml (interquartile range [IQR] = 1.8-48.4), and median midline shift was 0mm (IQR = 0-2.2). Of 249 (37%) demonstrating a midline shift of ≥1mm, median shift was 2.75mm (IQR = 1.89-4.21). Successful reperfusion was associated with reductions in both predefined mediators, infarct growth (β = -1.19, 95% confidence interval [CI] = -1.51 to -0.88, p < 0.001) and midline shift (adjusted odds ratio = 0.36, 95% CI = 0.23-0.57, p < 0.001). Successful reperfusion association with improved functional outcome (adjusted common odds ratio [acOR] = 2.68, 95% CI = 1.86-3.88, p < 0.001) became insignificant (acOR = 1.39, 95% CI = 0.95-2.04, p = 0.094) when infarct growth and midline shift were added to the regression model. Infarct growth and midline shift explained 45% and 34% of successful reperfusion effect, respectively. Analysis considering an alternative hypothesis demonstrated consistent results. INTERPRETATION In this mediation analysis from a pooled, patient-level cohort, a significant proportion (~80%) of successful reperfusion effect on functional outcome was mediated through reduction in infarct growth and cerebral edema. Further studies are required to confirm our findings, detect additional mediators to explain successful reperfusion residual effect, and identify novel therapeutic targets to further enhance reperfusion benefits. ANN NEUROL 2023.
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Affiliation(s)
- Amrou Sarraj
- Department of Neurology, Case Western Reserve University, Cleveland, OH, USA.,Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Deep K Pujara
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Leonid Churilov
- Department of Neurology, Royal Melbourne Hospitals, University of Melbourne, Parkville, Victoria, Australia
| | - Clark W Sitton
- Department of Diagnostic and Interventional Radiology, UTHealth McGovern Medical School, Houston, TX, USA
| | - Felix Ng
- Department of Neurology, Royal Melbourne Hospitals, University of Melbourne, Parkville, Victoria, Australia
| | - Ameer E Hassan
- University of Texas Rio Grande Valley-Valley Baptist Medical Center, Harlingen, TX, USA
| | - Michael G Abraham
- Department of Neurology and Radiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Spiros L Blackburn
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX, USA
| | - Gagan Sharma
- Department of Neurology, Royal Melbourne Hospitals, University of Melbourne, Parkville, Victoria, Australia
| | - Nawaf Yassi
- Department of Neurology, Royal Melbourne Hospitals, University of Melbourne, Parkville, Victoria, Australia.,Walter and Eliza Hall Institute of Medical Research, Population Health and Immunity, Parkville, Victoria, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Darshan Shah
- Department of Neurology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Wondwossen G Tekle
- University of Texas Rio Grande Valley-Valley Baptist Medical Center, Harlingen, TX, USA
| | | | | | - Nirav Vora
- Riverside Methodist Hospital, Colombia, OH, USA
| | - Randall C Edgell
- Department of Neurology, Saint Louis University, Saint Louis, MO, USA
| | - Diogo Haussen
- Department of Neurology, Emory University, Atlanta, GA, USA
| | | | - Gabor Toth
- Department of Neurology, Cleveland Clinic, Cleveland, OH, USA
| | - Laith Maali
- Department of Neurology and Radiology, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Faisal Al-Shaibi
- Department of Neurology, Case Western Reserve University, Cleveland, OH, USA
| | - Tareq AlMaghrabi
- Department of Neurology, University of Tabuk, Tabuk, Kingdom of Saudi Arabia
| | - Vignan Yogendrakumar
- Department of Neurology, Royal Melbourne Hospitals, University of Melbourne, Parkville, Victoria, Australia
| | - Faris Shaker
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX, USA
| | - Osman Mir
- Department of Neurology, Baylor Scott & White Health, Dallas, TX, USA
| | - Ashish Arora
- Department of Neurology, Greensboro
- Cone Health, Greensboro, NC, USA
| | - Kelsey Duncan
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sophia Sundararajan
- Department of Neurology, Case Western Reserve University, Cleveland, OH, USA.,Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Amanda Opaskar
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Yin Hu
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Abhishek Ray
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey Sunshine
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Nicholas Bambakidis
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sheryl Martin-Schild
- Department of Neurology, Touro Infirmary and New Orleans East Hospital, New Orleans, LA, USA
| | | | - Raul Nogueira
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Anthony Furlan
- Department of Neurology, Case Western Reserve University, Cleveland, OH, USA.,Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Cathy A Sila
- Department of Neurology, Case Western Reserve University, Cleveland, OH, USA.,Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - James C Grotta
- Department of Neurology, Memorial Hermann Hospital Texas Medical Center, Houston, TX, USA
| | - Mark Parsons
- Department of Neurology, University of Newcastle, Newcastle, New South Wales, Australia
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital-University of Melbourne, Parkville, Victoria, Australia
| | - Geoffrey A Donnan
- Department of Neurology, Royal Melbourne Hospitals, University of Melbourne, Parkville, Victoria, Australia
| | - Stephen M Davis
- Department of Neurology, Royal Melbourne Hospitals, University of Melbourne, Parkville, Victoria, Australia
| | | | - Bruce C V Campbell
- Department of Neurology, Royal Melbourne Hospitals, University of Melbourne, Parkville, Victoria, Australia
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15
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Liu S, Li F, Yang J, Xie D, Yue C, Luo W, Hu J, Song J, Li L, Huang J, Zhao C, Gong Z, Yang Q, Zi W. Efficacy and safety of 3-n-butylphthalide combined with endovascular treatment in acute ischemic stroke due to large vessel occlusion. CNS Neurosci Ther 2022; 28:2298-2307. [PMID: 36184804 PMCID: PMC9627349 DOI: 10.1111/cns.13978] [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: 04/25/2022] [Revised: 08/19/2022] [Accepted: 09/03/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The drug 3-n-butylphthalide (NBP) was developed and approved in China, where it has been used to treat ischemic cerebrovascular diseases. It is also considered to have a neuroprotective effect. This study aimed to evaluate whether NBP combined with endovascular treatment (EVT) can improve the clinical outcome and safety in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). METHODS Data from three studies of patients treated with EVT for AIS due to LVO were combined in this study. Patients of LVO undergoing EVT were dichotomized into NBP and non-NBP subgroups. The primary efficacy outcome was the shift of the modified Rankin Scale (mRS) score at 90 days. The secondary efficacy outcome included favorable functional outcomes, functional independence, and excellent outcome (defined as an mRS score of 3 or less) at 90 days. Safety outcomes included mortality within 90 days and symptomatic intracranial hemorrhage (sICH) within 48 h. RESULTS A total of 1820 patients undergoing EVT were included in this study; 628 (37.5%) patients received NBP treatment, whereas 1138 (62.5%) did not. After adjusting for multiple factors, NBP was associated with the improvement of functional outcomes at 90 days (adjusted common odds ratio [OR]: 1.503; 95% confidence interval (CI): 1.254-1.801; p < 0.001). NBP was associated with a higher rate of 90-day favorable outcomes (adjusted OR: 1.589; 95% CI: 1.251-2.020; p < 0.001) and a lower rate of 90-day mortality (adjusted OR: 0.486 [95% CI: 0.372-0.635]; p < 0.001). sICH occurred in 74 of 682 (10.9%) patients in the NBP group and 155 of 1126 (13.8%) patients in the non-NBP group; no statistical difference was detected (adjusted OR: 0.787 [95% CI: 0.567-1.092]; p = 0.152). CONCLUSION Among patients with AIS due to LVO, NBP combined with EVT is associated with better functional outcomes and reduced mortality risk without increasing the risk of sICH.
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Affiliation(s)
- Shuai Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated HospitalArmy Medical University (Third Military Medical University)ChongqingChina,Department of Neurology, Chongqing Institute for Brain and IntelligenceGuangyang Bay LaboratoryChongqingChina
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated HospitalArmy Medical University (Third Military Medical University)ChongqingChina,Department of Neurology, Chongqing Institute for Brain and IntelligenceGuangyang Bay LaboratoryChongqingChina
| | - Jie Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated HospitalArmy Medical University (Third Military Medical University)ChongqingChina,Department of Neurology, Chongqing Institute for Brain and IntelligenceGuangyang Bay LaboratoryChongqingChina
| | - Dongjie Xie
- Department of Neurology, Xinqiao Hospital and The Second Affiliated HospitalArmy Medical University (Third Military Medical University)ChongqingChina,Department of Neurology, Chongqing Institute for Brain and IntelligenceGuangyang Bay LaboratoryChongqingChina
| | - Chengsong Yue
- Department of Neurology, Xinqiao Hospital and The Second Affiliated HospitalArmy Medical University (Third Military Medical University)ChongqingChina,Department of Neurology, Chongqing Institute for Brain and IntelligenceGuangyang Bay LaboratoryChongqingChina
| | - Weidong Luo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated HospitalArmy Medical University (Third Military Medical University)ChongqingChina,Department of Neurology, Chongqing Institute for Brain and IntelligenceGuangyang Bay LaboratoryChongqingChina
| | - Jinrong Hu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated HospitalArmy Medical University (Third Military Medical University)ChongqingChina,Department of Neurology, Chongqing Institute for Brain and IntelligenceGuangyang Bay LaboratoryChongqingChina
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated HospitalArmy Medical University (Third Military Medical University)ChongqingChina,Department of Neurology, Chongqing Institute for Brain and IntelligenceGuangyang Bay LaboratoryChongqingChina
| | - Linyu Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated HospitalArmy Medical University (Third Military Medical University)ChongqingChina,Department of Neurology, Chongqing Institute for Brain and IntelligenceGuangyang Bay LaboratoryChongqingChina
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated HospitalArmy Medical University (Third Military Medical University)ChongqingChina,Department of Neurology, Chongqing Institute for Brain and IntelligenceGuangyang Bay LaboratoryChongqingChina
| | - Chenhao Zhao
- Department of Neurology, Xinqiao Hospital and The Second Affiliated HospitalArmy Medical University (Third Military Medical University)ChongqingChina,Department of Neurology, Chongqing Institute for Brain and IntelligenceGuangyang Bay LaboratoryChongqingChina
| | - Zili Gong
- Department of Neurology, Xinqiao Hospital and The Second Affiliated HospitalArmy Medical University (Third Military Medical University)ChongqingChina,Department of Neurology, Chongqing Institute for Brain and IntelligenceGuangyang Bay LaboratoryChongqingChina
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated HospitalArmy Medical University (Third Military Medical University)ChongqingChina,Department of Neurology, Chongqing Institute for Brain and IntelligenceGuangyang Bay LaboratoryChongqingChina
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated HospitalArmy Medical University (Third Military Medical University)ChongqingChina,Department of Neurology, Chongqing Institute for Brain and IntelligenceGuangyang Bay LaboratoryChongqingChina
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16
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Yin T, Hao J, Jiang Q, Xu X, Xu B, Lv H, Liu W, Xiao Y, Jiao L, Wang J, Zhang L. Dynamics of intracranial and peripheral plasma Syndecan‐1 after ischemic stroke with large vessel occlusion. CNS Neurosci Ther 2022; 28:1648-1650. [PMID: 35790077 PMCID: PMC9437231 DOI: 10.1111/cns.13898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Tengkun Yin
- From the Department of Neurosurgery Liaocheng People's Hospital Liaocheng China
| | - Jiheng Hao
- From the Department of Neurosurgery Liaocheng People's Hospital Liaocheng China
| | - Qunlong Jiang
- From the Department of Neurosurgery Liaocheng People's Hospital Liaocheng China
| | - Xin Xu
- Department of Neurosurgery Xuanwu Hospital, Capital Medical University Beijing China
| | - Bin Xu
- Department of Neurosurgery Xuanwu Hospital, Capital Medical University Beijing China
- School of Clinical Medicine Weifang Medical College Weifang China
| | - Hang Lv
- Department of Neurosurgery Xuanwu Hospital, Capital Medical University Beijing China
- School of Clinical Medicine Weifang Medical College Weifang China
| | - Weidong Liu
- From the Department of Neurosurgery Liaocheng People's Hospital Liaocheng China
| | - Yilei Xiao
- From the Department of Neurosurgery Liaocheng People's Hospital Liaocheng China
| | - Liqun Jiao
- Department of Neurosurgery Xuanwu Hospital, Capital Medical University Beijing China
| | - Jiyue Wang
- From the Department of Neurosurgery Liaocheng People's Hospital Liaocheng China
| | - Liyong Zhang
- From the Department of Neurosurgery Liaocheng People's Hospital Liaocheng China
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17
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Kumar A, Chen Y, Corbin A, Hamzehloo A, Abedini A, Vardar Z, Carey G, Bhatia K, Heitsch L, Derakhshan JJ, Lee JM, Dhar R. Automated Measurement of Net Water Uptake From Baseline and Follow-Up CTs in Patients With Large Vessel Occlusion Stroke. Front Neurol 2022; 13:898728. [PMID: 35832178 PMCID: PMC9271791 DOI: 10.3389/fneur.2022.898728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
Quantifying the extent and evolution of cerebral edema developing after stroke is an important but challenging goal. Lesional net water uptake (NWU) is a promising CT-based biomarker of edema, but its measurement requires manually delineating infarcted tissue and mirrored regions in the contralateral hemisphere. We implement an imaging pipeline capable of automatically segmenting the infarct region and calculating NWU from both baseline and follow-up CTs of large-vessel occlusion (LVO) patients. Infarct core is extracted from CT perfusion images using a deconvolution algorithm while infarcts on follow-up CTs were segmented from non-contrast CT (NCCT) using a deep-learning algorithm. These infarct masks were flipped along the brain midline to generate mirrored regions in the contralateral hemisphere of NCCT; NWU was calculated as one minus the ratio of densities between regions, removing voxels segmented as CSF and with HU outside thresholds of 20-80 (normal hemisphere and baseline CT) and 0-40 (infarct region on follow-up). Automated results were compared with those obtained using manually-drawn infarcts and an ASPECTS region-of-interest based method that samples densities within the infarct and normal hemisphere, using intraclass correlation coefficient (ρ). This was tested on serial CTs from 55 patients with anterior circulation LVO (including 66 follow-up CTs). Baseline NWU using automated core was 4.3% (IQR 2.6-7.3) and correlated with manual measurement (ρ = 0.80, p < 0.0001) and ASPECTS (r = -0.60, p = 0.0001). Automatically segmented infarct volumes (median 110-ml) correlated to manually-drawn volumes (ρ = 0.96, p < 0.0001) with median Dice similarity coefficient of 0.83 (IQR 0.72-0.90). Automated NWU was 24.6% (IQR 20-27) and highly correlated to NWU from manually-drawn infarcts (ρ = 0.98) and the sampling-based method (ρ = 0.68, both p < 0.0001). We conclude that this automated imaging pipeline is able to accurately quantify region of infarction and NWU from serial CTs and could be leveraged to study the evolution and impact of edema in large cohorts of stroke patients.
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Affiliation(s)
- Atul Kumar
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Yasheng Chen
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Aaron Corbin
- Saint Louis University School of Medicine, Saint Louis, MO, United States
| | - Ali Hamzehloo
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Amin Abedini
- Department of Radiology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Zeynep Vardar
- Department of Radiology, University of Massachusetts Medical School, Worcester, MA, United States
| | - Grace Carey
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Kunal Bhatia
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Laura Heitsch
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Jamal J. Derakhshan
- Department of Radiology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Jin-Moo Lee
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Rajat Dhar
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States,*Correspondence: Rajat Dhar
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18
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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, White P, van der Lugt A, Ribo M, Bracard S, Mitchell PJ, Davis SM, Sheth KN, Kimberly WT, Campbell BCV. Correlation Between Computed Tomography-Based Tissue Net Water Uptake and Volumetric Measures of Cerebral Edema After Reperfusion Therapy. Stroke 2022; 53:2628-2636. [PMID: 35450438 DOI: 10.1161/strokeaha.121.037073] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cerebral edema after large hemispheric infarction is associated with poor functional outcome and mortality. Net water uptake (NWU) quantifies the degree of hypoattenuation on unenhanced-computed tomography (CT) and is increasingly used to measure cerebral edema in stroke research. Hemorrhagic transformation and parenchymal contrast staining after thrombectomy may confound NWU measurements. We investigated the correlation of NWU measured postthrombectomy with volumetric markers of cerebral edema and association with functional outcomes. METHODS In a pooled individual patient level analysis of patients presenting with anterior circulation large hemispheric infarction (core 80-300 mL or Alberta Stroke Program Early CT Score ≤5) in the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke trials) data set, cerebral edema was defined as the volumetric expansion of the ischemic hemisphere expressed as a ratio to the contralateral hemisphere(rHV). NWU and midline-shift were compared with rHV as the reference standard on 24-hour follow-up CT, adjusted for hemorrhagic transformation and the use of thrombectomy. Association between edema markers and day 90 functional outcomes (modified Rankin Scale) was assessed using ordinal logistic regression. RESULTS Overall (n=144), there was no correlation between NWU and rHV (rs=0.055, P=0.51). In sub-group analyses, a weak correlation between NWU with rHV was observed after excluding patients with any degree of hemorrhagic transformation (rs=0.211, P=0.015), which further improved after excluding thrombectomy patients (rs=0.453, P=0.001). Midline-shift correlated strongly with rHV in all sub-group analyses (rs>0.753, P=0.001). Functional outcome at 90 days was negatively associated with rHV (adjusted common odds ratio, 0.46 [95% CI, 0.32-0.65]; P<0.001) and midline-shift (adjusted common odds ratio, 0.85 [95% CI, 0.78-0.92]; P<0.001) but not NWU (adjusted common odds ratio, 1.00 [95% CI, 0.97-1.03]; P=0.84), adjusted for age, baseline National Institutes of Health Stroke Scale, and thrombectomy. Prognostic performance of NWU improved after excluding patients with hemorrhagic transformation and thrombectomy (adjusted odds ratio, 0.90 [95% CI, 0.80-1.02]; P=0.10). CONCLUSIONS NWU correlated poorly with conventional markers of cerebral edema and was not associated with clinical outcome in the presence of hemorrhagic transformation and thrombectomy. Measuring NWU postthrombectomy requires validation before implementation into clinical research. At present, the use of NWU should be limited to baseline CT, or follow-up CT only in patients without hemorrhagic transformation or treatment with thrombectomy.
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Affiliation(s)
- Felix C Ng
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., N.Y., G.S., S.M.D., B.C.V.C.).,Austin Health, Heidelberg, Australia (F.C.N.)
| | - Nawaf Yassi
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia (N.Y.)
| | - Gagan Sharma
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., N.Y., G.S., S.M.D., B.C.V.C.)
| | | | - Mayank Goyal
- Department of Radiology, University of Calgary, Foothills Hospital, AB, Canada (M.G.)
| | - 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, University of Calgary, Foothills Hospital, AB, Canada (M.D.H., A.M.D., B.K.M.)
| | - Keith W Muir
- Institute of Neuroscience & 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 at the University of California, Los Angeles, California Stanford Stroke Center, Stanford University (J.L.S.)
| | - Francis Guillemin
- Clinical Investigation Centre-Clinical Epidemiology INSERM 1433, University of Lorraine and University Hospital of Nancy, France (F.G.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, AB, Canada (M.D.H., A.M.D., B.K.M.)
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, AB, Canada (M.D.H., A.M.D., B.K.M.)
| | - Luis San Roman
- Department of Radiology, Hospital Clínic, Barcelona, Spain (L.S.R.)
| | - Philip White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom (P.W.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands (A.v.d.L.)
| | - Marc Ribo
- Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain (M.R.)
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, Université de Lorraine, Inserm, IADI, CHRU Nancy, France (S.B.)
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (P.J.M.)
| | - Stephen M Davis
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., N.Y., G.S., S.M.D., B.C.V.C.)
| | - Kevin N Sheth
- Department of Neurology, Yale New Haven Hospital, CT (K.N.S.)
| | - W Taylor Kimberly
- Center for Genomic Medicine and Department of Neurology, Massachusetts General Hospital, Boston (W.T.K.)
| | - Bruce C V Campbell
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., N.Y., G.S., S.M.D., B.C.V.C.)
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19
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New imaging score for outcome prediction in basilar artery occlusion stroke. Eur Radiol 2022; 32:4491-4499. [PMID: 35333974 DOI: 10.1007/s00330-022-08684-9] [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: 11/17/2021] [Revised: 01/13/2022] [Accepted: 02/20/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE In ischemic posterior circulation stroke, the utilization of standardized image scores is not established in daily clinical practice. We aimed to test a novel imaging score that combines the collateral status with the rating of the posterior circulation Acute Stroke Prognosis Early CT score (pcASPECTS). We hypothesized that this score (pcASCO) predicts functional outcome and malignant cerebellar edema (MCE). METHODS Ischemic stroke patients with acute BAO who received multimodal-CT and underwent thrombectomy on admission at two comprehensive stroke centers were analyzed. The posterior circulation collateral score by van der Hoeven et al was added to the pcASPECTS to define pcASCO as a 20-point score. Multivariable logistic regression analyses were performed to predict functional independence at day 90, assessed using modified Rankin Scale scores, and occurrence of MCE in follow-up CT using the established Jauss scale score as endpoints. RESULTS A total of 118 patients were included, of which 84 (71%) underwent successful thrombectomy. Based on receiver operating characteristic curve analysis, pcASCO ≥ 14 classified functional independence with higher discriminative power (AUC: 0.83, 95%CI: 0.71-0.91) than pcASPECTS (AUC: 0.74). In multivariable logistic regression analysis, pcASCO was significantly and independently associated with functional independence (aOR: 1.91, 95%CI: 1.25-2.92, p = 0.003), and MCE (aOR: 0.71, 95%CI: 0.53-0.95, p = 0.02). CONCLUSION The pcASCO could serve as a simple and feasible imaging tool to assess BAO stroke patients on admission and might be tested as a complementary tool to select patients for thrombectomy in uncertain situations, or to predict clinical outcome. KEY POINTS • The neurological assessment of basilar artery occlusion stroke patients can be challenging and there are yet no validated imaging scores established in daily clinical practice. • The pcASCO combines the rating of early ischemic changes with the status of the intracranial posterior circulation collaterals. • The pcASCO showed high diagnostic accuracy to predict functional outcome and malignant cerebellar edema and could serve as a simple and feasible imaging tool to support treatment selection in uncertain situations, or to predict clinical outcome.
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20
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Broocks G, Meyer L, Ruppert C, Haupt W, Faizy TD, Van Horn N, Bechstein M, Kniep H, Elsayed S, Kemmling A, Barow E, Fiehler J, Hanning U. Effect of Intravenous Alteplase on Functional Outcome and Secondary Injury Volumes in Stroke Patients with Complete Endovascular Recanalization. J Clin Med 2022; 11:jcm11061565. [PMID: 35329891 PMCID: PMC8949925 DOI: 10.3390/jcm11061565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/04/2022] [Accepted: 03/08/2022] [Indexed: 11/22/2022] Open
Abstract
Intravenous thrombolytic therapy with alteplase (IVT) is a standard of care in ischemic stroke, while recent trials investigating direct endovascular thrombectomy (EVT) approaches showed conflicting results. Yet, the effect of IVT on secondary injury volumes in patients with complete recanalization has not been analyzed. We hypothesized that IVT is associated with worse functional outcome and aggravated secondary injury volumes when administered to patients who subsequently attained complete reperfusion after EVT. Anterior circulation ischemic stroke patients with complete reperfusion after thrombectomy defined as thrombolysis in cerebral infarctions (TICI) scale 3 after thrombectomy admitted between January 2013–January 2021 were analyzed. Primary endpoints were the proportion of patients with functional independence defined as modified Rankin Scale (mRS) score 0–2 at day 90, and secondary injury volumes: Edema volume in follow-up imaging measured using quantitative net water uptake (NWU), and the rate of symptomatic intracerebral hemorrhage (sICH). A total of 219 patients were included and 128 (58%) patients received bridging IVT before thrombectomy. The proportion of patients with functional independence was 28% for patients with bridging IVT, and 34% for patients with direct thrombectomy (p = 0.35). The rate of sICH was significantly higher after bridging IVT (20% versus 7.7%, p = 0.01). Multivariable logistic and linear regression analysis confirmed the independent association of bridging IVT with sICH (aOR: 2.78, 95% CI: 1.02–7.56, p = 0.046), and edema volume (aOR: 8.70, 95% CI: 2.57–14.85, p = 0.006). Bridging IVT was associated with increased edema volume and risk for sICH as secondary injury volumes. The results of this study encourage direct EVT approaches, particularly in patients with higher likelihood of successful EVT.
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Affiliation(s)
- Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
- Correspondence:
| | - Lukas Meyer
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Celine Ruppert
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Wolfgang Haupt
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Tobias D. Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Noel Van Horn
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Matthias Bechstein
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Sarah Elsayed
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Andre Kemmling
- Department of Neuroradiology, Philipps-University Marburg, 35037 Marburg, Germany;
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Campus Lübeck, 23538 Lübeck, Germany
| | - Ewgenia Barow
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany;
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Uta Hanning
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
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21
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Review of net water uptake in the management of acute ischemic stroke. Eur Radiol 2022; 32:5517-5524. [DOI: 10.1007/s00330-022-08658-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/24/2022] [Accepted: 02/12/2022] [Indexed: 12/15/2022]
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22
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Broocks G, Minnerup J, Kamalian S, Kemmling A. Editorial: Mechanisms, Measurement, and Management of Vasogenic Edema After Stroke. Front Neurol 2022; 13:865078. [PMID: 35280263 PMCID: PMC8907884 DOI: 10.3389/fneur.2022.865078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 02/01/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- *Correspondence: Gabriel Broocks
| | - Jens Minnerup
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Shervin Kamalian
- Department of Neuroradiology, Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States
| | - Andre Kemmling
- Department of Neuroradiology, University Marburg, Marburg, Germany
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23
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Ng FC, Churilov L, Yassi N, Kleinig TJ, Thijs V, Wu TY, Shah DG, Dewey HM, Sharma G, Desmond PM, Yan B, Parsons MW, Donnan GA, Davis SM, Mitchell PJ, Leigh R, Campbell BCV. Reduced Severity of Tissue Injury Within the Infarct May Partially Mediate the Benefit of Reperfusion in Ischemic Stroke. Stroke 2022; 53:1915-1923. [PMID: 35135319 DOI: 10.1161/strokeaha.121.036670] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Emerging data suggest tissue within the infarct lesion is not homogenously damaged following ischemic stroke but has a gradient of injury. Using blood-brain-barrier (BBB) disruption as a marker of tissue injury, we tested whether therapeutic reperfusion improves clinical outcome by reducing the severity of tissue injury within the infarct in patients with ischemic stroke. METHODS In a pooled analysis of patients treated for anterior circulation large vessel occlusion in the EXTEND-IA TNK (Tenecteplase Versus Alteplase Before Endovascular Therapy for Ischemic Stroke) and EXTEND-IA part-2 (Determining the Optimal Dose of Tenecteplase Before Endovascular Therapy for Ischaemic Stroke) trials, post-treatment BBB permeability at 24 hours was calculated based on the extent of T1-brightening by extravascular gadolinium on T2* perfusion-weighted imaging and measured within the diffusion-weighted-imaging lesion. First, to determine the clinical significance of BBB disruption as a marker of severity of tissue injury, we examined the association between post-treatment BBB permeability and functional outcome. Second, we performed an exploratory (reperfusion, BBB permeability, functional outcome) mediation analysis to estimate the proportion of the reperfusion-outcome relationship that is mediated by change in BBB permeability. RESULTS In the 238 patients analyzed, an increased BBB permeability measured within the infarct at 24 hours was associated with a reduced likelihood of favorable outcome (90-day modified Rankin Scale score of ≤2) after adjusting for age, baseline National Institutes of Health Stroke Scale, premorbid modified Rankin Scale, infarct topography, laterality, thrombolytic agent, sex, parenchymal hematoma, and follow-up infarct volume (adjusted odds ratio, 0.86 [95% CI, 0.75-0.98], P=0.023). Mediation analysis suggested reducing the severity of tissue injury (as estimated by BBB permeability) accounts for 18.2% of the association between reperfusion and favorable outcome, as indicated by a reduction in the regression coefficient of reperfusion after addition of BBB permeability as a covariate. CONCLUSIONS In patients with ischemic stroke, reduced severity of tissue injury within the infarct, as determined by assessing the integrity of the BBB, is independently associated with improved functional outcome. In addition to reducing diffusion-weighted imaging-defined infarct volume, reperfusion may also improve clinical outcome by reducing tissue injury severity within the infarct.
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Affiliation(s)
- Felix C Ng
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.).,Department of Neurology, Austin Hospital, Austin Health, Heidelberg, Australia (F.C.N., V.T.)
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.).,The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia. (L.C., V.T., B.C.V.C.).,Melbourne Medical School, The University of Melbourne, Heidelberg, Victoria, Australia (L.C.)
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.).,Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia (N.Y.)
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Australia (T.J.K.)
| | - Vincent Thijs
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia. (L.C., V.T., B.C.V.C.).,Department of Neurology, Austin Hospital, Austin Health, Heidelberg, Australia (F.C.N., V.T.)
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, New Zealand (T.Y.W.)
| | - Darshan G Shah
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia (D.G.S.)
| | - Helen M Dewey
- Eastern Health and Eastern Health Clinical School, Department of Neurosciences, Monash University, Clayton, Australia (H.M.D.)
| | - Gagan Sharma
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.)
| | - Patricia M Desmond
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (P.M.D., B.Y., P.J.M.)
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.).,Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (P.M.D., B.Y., P.J.M.)
| | - Mark W Parsons
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.)
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.)
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.)
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (P.M.D., B.Y., P.J.M.)
| | - Richard Leigh
- Department of Neurology, John Hopkins University, Baltimore, MD (R.L.)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.).,The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia. (L.C., V.T., B.C.V.C.)
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24
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Broocks G, Meyer L, McDonough R, Bechstein M, Hanning U, Fiehler J, Kemmling A. The Benefit of Thrombectomy in Patients With Low ASPECTS Is a Matter of Shades of Gray—What Current Trials May Have Missed. Front Neurol 2022; 12:718046. [PMID: 35095708 PMCID: PMC8795604 DOI: 10.3389/fneur.2021.718046] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022] Open
Abstract
Randomized trials supporting the benefit of endovascular treatment in acute ischemic stroke patients with a large early infarction are not yet available. Few retrospective studies exist that suggest a potential positive treatment effect on functional outcome, as well as procedural safety. However, potential benefit or harm of MT in patients with low initial ASPECTS is still a subject of current debate, and in particular, how to select these patients for treatment. The purpose of this pilot study was to evaluate how early tissue water uptake in acute ischemic brain might determine lesion fate and functional outcome in low ASPECTS patients undergoing MT. We observed that the degree of early water uptake measured by quantitative NWU was significantly associated with functional outcome in low ASPECTS patients, yielding a higher diagnostic power compared to other parameters such as ASPECTS, age, or NIHSS. No conclusive evidence of a beneficial effect of successful reperfusion was observed in patients with low ASPECTS and high NWU, which highlights the potential of NWU as a tool to specify patient selection.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- *Correspondence: Gabriel Broocks
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, University Hospital Schleswig-Holstein, Lübeck, Germany
- Department of Neuroradiology, University of Marburg, Marburg, Germany
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25
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Shi J, Li W, Zhang F, Park JH, An H, Guo S, Duan Y, Wu D, Hayakawa K, Lo EH, Ji X. CCL2 (C-C Motif Chemokine Ligand 2) Biomarker Responses in Central Versus Peripheral Compartments After Focal Cerebral Ischemia. Stroke 2021; 52:3670-3679. [PMID: 34587791 PMCID: PMC8545911 DOI: 10.1161/strokeaha.120.032782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background and Purpose Inflammatory mediators in blood have been proposed as potential biomarkers in stroke. However, a direct relationship between these circulating factors and brain-specific ischemic injury remains to be fully defined. Methods An unbiased screen in a nonhuman primate model of stroke was used to find out the most responsive circulating biomarker flowing ischemic stroke. Then this phenomenon was checked in human beings and mice. Finally, we observed the temporospatial responsive characteristics of this biomarker after ischemic brain injury in mice to evaluate the direct relationship between this circulating factor and central nervous system–specific ischemic injury. Results In a nonhuman primate model, an unbiased screen revealed CCL2 (C-C motif chemokine ligand 2) as a major response factor in plasma after stroke. In mouse models of focal cerebral ischemia, plasma levels of CCL2 showed a transient response, that is, rapidly elevated by 2 to 3 hours postischemia but then renormalized back to baseline levels by 24 hours. However, a different CCL2 temporal profile was observed in whole brain homogenate, cerebrospinal fluid, and isolated brain microvessels, with a progressive increase over 24 hours, demonstrating a mismatch between brain versus plasma responses. In contrast to the lack of correlation with central nervous system responses, 2 peripheral compartments showed transient profiles that matched circulating plasma signatures. CCL2 protein in lymph nodes and adipose tissue was significantly increased at 2 hours and renormalized by 24 hours. Conclusions These findings may provide a cautionary tale for biomarker pursuits in plasma. Besides a direct central nervous system response, peripheral organs may also contribute to blood signatures in complex and indirect ways.
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Affiliation(s)
- Jingfei Shi
- Cerebrovascular and Neuroscience Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China.,Neuroprotection Research Laboratories, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Wenlu Li
- Neuroprotection Research Laboratories, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Fang Zhang
- Neuroprotection Research Laboratories, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ji Hyun Park
- Neuroprotection Research Laboratories, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hong An
- Cerebrovascular and Neuroscience Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China.,Neuroprotection Research Laboratories, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Shuzhen Guo
- Neuroprotection Research Laboratories, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yunxia Duan
- Cerebrovascular and Neuroscience Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Di Wu
- Cerebrovascular and Neuroscience Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China.,Neuroprotection Research Laboratories, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kazuhide Hayakawa
- Neuroprotection Research Laboratories, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Eng H. Lo
- Neuroprotection Research Laboratories, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Xunming Ji
- Cerebrovascular and Neuroscience Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China.,Departments of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
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26
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Broocks G, Faizy TD, Meyer L, Groffmann M, Elsayed S, Kniep H, Flottmann F, Bechstein M, Rusche T, Schön G, Nawabi J, Sporns P, Fiehler J, Kemmling A, Hanning U. Posterior circulation collateral flow modifies the effect of thrombectomy on outcome in acute basilar artery occlusion. Int J Stroke 2021; 17:761-769. [PMID: 34569885 DOI: 10.1177/17474930211052262] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In basilar artery occlusion stroke, the impact of the collateral circulation on infarct progression in the context of endovascular treatment is yet poorly studied. AIM This study investigates the impact of the posterior circulation collateral score (PCCS) on functional outcome according to the extent of early ischemic changes and treatment. We hypothesized that the presence of collaterals, quantified by the PCCS, mediates the effect of endovascular treatment on functional outcome in patients with acute basilar artery occlusion. METHODS In this multicenter observational study, patients with basilar artery occlusion and admission computed tomography were analyzed. At baseline, Posterior circulation Acute Stroke Prognosis Early Computed Tomography score (pcASPECTS) was assessed and PCCS was quantified using an established 10-point grading system. Logistic regression analyses were performed to identify factors associated with good functional outcome (modified Rankin Scale scores 0-2 at day 90). RESULTS A total of 151 patients were included, of which 112 patients (74%) underwent endovascular treatment. In patients with a better PCCS (>5), the rate of good outcome was significantly higher (55% vs. 11%; p = 0.001). After adjusting for PCCS, vessel recanalization was significantly associated with improved functional outcome (aOR: 4.53, 95%CI: 1.25-16.4, p = 0.02), while there was no association between recanalization status and outcome in univariable analysis. Patients with low pcASPECTS generally showed very poor outcomes (mean modified Rankin Scale score 5.3, 95%CI: 4.9-5.8). CONCLUSION PCCS modified the effect of recanalization on functional outcome, particularly in patients with less pronounced ischemic changes in admission computed tomography. These results should be validated to improve patient selection for endovascular treatment in basilar artery occlusion, particularly in uncertain indications, or to triage patients at risk for very poor outcomes.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Groffmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thilo Rusche
- Department of Neuroradiology, Universitätsspital Basel, Basel, Switzerland.,Department of Clinical Radiology, University of Münster, Münster, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jawed Nawabi
- Department of Radiology, Charité University Medical Center, Berlin, Germany
| | - Peter Sporns
- Department of Neuroradiology, Universitätsspital Basel, Basel, Switzerland
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, 9377University of Marburg, Marburg, Germany.,Department of Neuroradiology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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27
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Dhar R. Commentary on "Midline Shift Greater than 3 mm Independently Predicts Outcome After Ischemic Stroke". Neurocrit Care 2021; 36:18-20. [PMID: 34580827 DOI: 10.1007/s12028-021-01355-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Rajat Dhar
- Division of Neurocritical Care, Department of Neurology, Washington University in Saint Louis School of Medicine, 660 S Euclid Avenue, Campus Box 8111, Saint Louis, MO, USA.
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28
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Hong L, Lin L, Li G, Yang J, Geng Y, Lou M, Parsons M, Cheng X, Dong Q. Identification of embolic stroke in patients with large vessel occlusion: The Chinese embolic stroke score, CHESS. CNS Neurosci Ther 2021; 28:531-539. [PMID: 34559949 PMCID: PMC8928917 DOI: 10.1111/cns.13729] [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: 05/11/2021] [Revised: 08/17/2021] [Accepted: 08/29/2021] [Indexed: 11/28/2022] Open
Abstract
Aims The aim of the study was to develop a simple and objective score using clinical variables and quantified perfusion measures to identify embolic stroke with large vessel occlusions. Methods Eligible patients from five centers participating in the International Stroke Perfusion Imaging Registry were included in this study. Patients were split into a derivation cohort (n = 213) and a validation cohort (n = 116). A score was developed according to the coefficients of independent predictors of embolic stroke from stepwise logistic regression model in the derivation cohort. The performance of the score was validated by assessing its discrimination and calibration. Results The independent predictors of embolic stroke made up the Chinese Embolic Stroke Score (CHESS). There were: history of atrial fibrillation (3 points), non‐hypertension history (2 points), and delay time>6 s volume/delay time>3 s volume on perfusion imaging ≥0.23 (2 points). The AUC of CHESS in the derivation cohort and validation cohort were 0.87 and 0.79, respectively. Patients with a CHESS of 0 could be identified as low‐risk of embolic stroke, with a CHESS of 2–4 could be identified as medium‐risk and with a CHESS of 5–7 could be regarded as high‐risk. The observed rate of embolic stroke of each risk group was well‐calibrated with the predicted rate. Conclusion CHESS could reliably and independently identify embolic stroke as the cause of large vessel occlusion.
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Affiliation(s)
- Lan Hong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Longting Lin
- South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia
| | - Gang Li
- Department of Neurology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Jianhong Yang
- Department of Neurology, Ningbo First Hospital, Ningbo, China
| | - Yu Geng
- Department of Neurology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Min Lou
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Mark Parsons
- South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia
| | - Xin Cheng
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Qiang Dong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
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29
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Broocks G, Kemmling A, Teßarek S, McDonough R, Meyer L, Faizy TD, Kniep H, Schön G, Nawka MT, Elsayed S, van Horn N, Cheng B, Thomalla G, Fiehler J, Hanning U. Quantitative Lesion Water Uptake as Stroke Imaging Biomarker: A Tool for Treatment Selection in the Extended Time Window? Stroke 2021; 53:201-209. [PMID: 34538082 DOI: 10.1161/strokeaha.120.033025] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND PURPOSE Patients presenting in the extended time window may benefit from mechanical thrombectomy. However, selection for mechanical thrombectomy in this patient group has only been performed using specialized image processing platforms, which are not widely available. We hypothesized that quantitative lesion water uptake calculated in acute stroke computed tomography (CT) may serve as imaging biomarker to estimate ischemic lesion progression and predict clinical outcome in patients undergoing mechanical thrombectomy in the extended time window. METHODS All patients with ischemic anterior circulation stroke presenting within 4.5 to 24 hours after symptom onset who received initial multimodal CT between August 2014 and March 2020 and underwent mechanical thrombectomy were analyzed. Quantitative lesion net water uptake was calculated from the admission CT. Prediction of clinical outcome was assessed using univariable receiver operating characteristic curve analysis and logistic regression analyses. RESULTS One hundred two patients met the inclusion criteria. In the multivariable logistic regression analysis, net water uptake (odds ratio, 0.78 [95% CI, 0.64-0.95], P=0.01), age (odds ratio, 0.94 [95% CI, 0.88-0.99]; P=0.02), and National Institutes of Health Stroke Scale (odds ratio, 0.88 [95% CI, 0.79-0.99], P=0.03) were significantly and independently associated with favorable outcome (modified Rankin Scale score ≤1), adjusted for degree of recanalization and Alberta Stroke Program Early CT Score. A multivariable predictive model including the above parameters yielded the highest diagnostic ability in the classification of functional outcome, with an area under the curve of 0.88 (sensitivity 92.3%, specificity 82.9%). CONCLUSIONS The implementation of quantitative lesion water uptake as imaging biomarker in the diagnosis of patients with ischemic stroke presenting in the extended time window might improve clinical prognosis. Future studies could test this biomarker as complementary or even alternative tool to CT perfusion.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (G.B., S.T., R.M., L.M., T.D.F., H.K., M.T.N., S.E., N.v.H., J.F., U.H.).,Department of Neuroradiology, University Hospital Marburg, Germany (A.K.).,Department of Neuroradiology, Westpfalzklinikum, Kaiserslautern, Germany (T.D.F.)
| | | | - Svenja Teßarek
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (G.B., S.T., R.M., L.M., T.D.F., H.K., M.T.N., S.E., N.v.H., J.F., U.H.).,Department of Radiology (S.T.)
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (G.B., S.T., R.M., L.M., T.D.F., H.K., M.T.N., S.E., N.v.H., J.F., U.H.)
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (G.B., S.T., R.M., L.M., T.D.F., H.K., M.T.N., S.E., N.v.H., J.F., U.H.)
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (G.B., S.T., R.M., L.M., T.D.F., H.K., M.T.N., S.E., N.v.H., J.F., U.H.).,Department of Radiology, Stanford University (B.C., G.T., T.D.F.)
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (G.B., S.T., R.M., L.M., T.D.F., H.K., M.T.N., S.E., N.v.H., J.F., U.H.)
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany. (G.S.).,Lüneburg Medical Center, Germany (G.S.)
| | - Marie Teresa Nawka
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (G.B., S.T., R.M., L.M., T.D.F., H.K., M.T.N., S.E., N.v.H., J.F., U.H.)
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (G.B., S.T., R.M., L.M., T.D.F., H.K., M.T.N., S.E., N.v.H., J.F., U.H.)
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (G.B., S.T., R.M., L.M., T.D.F., H.K., M.T.N., S.E., N.v.H., J.F., U.H.)
| | - Bastian Cheng
- Department of Radiology, Stanford University (B.C., G.T., T.D.F.)
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany. (G.T.).,Department of Radiology, Stanford University (B.C., G.T., T.D.F.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (G.B., S.T., R.M., L.M., T.D.F., H.K., M.T.N., S.E., N.v.H., J.F., U.H.)
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (G.B., S.T., R.M., L.M., T.D.F., H.K., M.T.N., S.E., N.v.H., J.F., U.H.)
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30
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Konduri P, van Kranendonk K, Boers A, Treurniet K, Berkhemer O, Yoo AJ, van Zwam W, van Oostenbrugge R, van der Lugt A, Dippel D, Roos Y, Bot J, Majoie C, Marquering H. The Role of Edema in Subacute Lesion Progression After Treatment of Acute Ischemic Stroke. Front Neurol 2021; 12:705221. [PMID: 34354669 PMCID: PMC8329530 DOI: 10.3389/fneur.2021.705221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/18/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Ischemic lesions commonly continue to progress even days after treatment, and this lesion growth is associated with unfavorable functional outcome in acute ischemic stroke patients. The aim of this study is to elucidate the role of edema in subacute lesion progression and its influence on unfavorable functional outcome by quantifying net water uptake. Methods: We included all 187 patients from the MR CLEAN trial who had high quality follow-up non-contrast CT at 24 h and 1 week. Using a CT densitometry-based method to calculate the net water uptake, we differentiated total ischemic lesion volume (TILV) into edema volume (EV) and edema-corrected infarct volume (ecIV). We calculated these volumes at 24 h and 1 week after stroke and determined their progression in the subacute period. We assessed the effect of 24-h lesion characteristics on EV and ecIV progression. We evaluated the influence of edema and edema-corrected infarct progression on favorable functional outcome after 90 days (modified Rankin Scale: 0-2) after correcting for potential confounders. Lastly, we compared these volumes between subgroups of patients with and without successful recanalization using the Mann-Whitney U-test. Results: Median TILV increased from 37 (IQR: 18-81) ml to 68 (IQR: 30-130) ml between 24 h and 1 week after stroke, while the net water uptake increased from 22 (IQR: 16-26)% to 27 (IQR: 22-32)%. The TILV progression of 20 (8.8-40) ml was mostly caused by ecIV with a median increase of 12 (2.4-21) ml vs. 6.5 (2.7-15) ml of EV progression. Larger TILV, EV, and ecIV volumes at 24 h were all associated with more edema and lesion progression. Edema progression was associated with unfavorable functional outcome [aOR: 0.53 (0.28-0.94) per 10 ml; p-value: 0.05], while edema-corrected infarct progression showed a similar, non-significant association [aOR: 0.80 (0.62-0.99); p-value: 0.06]. Lastly, edema progression was larger in patients without successful recanalization, whereas ecIV progression was comparable between the subgroups. Conclusion: EV increases in evolving ischemic lesions in the period between 1 day and 1 week after acute ischemic stroke. This progression is larger in patients without successful recanalization and is associated with unfavorable functional outcome. However, the extent of edema cannot explain the total expansion of ischemic lesions since edema-corrected infarct progression is larger than the edema progression.
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Affiliation(s)
- Praneeta Konduri
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Amsterdam, Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Katinka van Kranendonk
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Anna Boers
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Amsterdam, Netherlands.,Nico.lab, Amsterdam, Netherlands
| | - Kilian Treurniet
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands.,Department of Radiology and Nuclear Medicine, Haaglanden Medisch Centrum, The Hague, Netherlands
| | - Olvert Berkhemer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands.,Department of Neurology, Erasmus MC-University Medical Center, Rotterdam, Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus MC-University Medical Center, Rotterdam, Netherlands
| | - Albert J Yoo
- Department of Radiology, Texas Stroke Institute, Dallas-Fort Worth, TX, United States
| | - Wim van Zwam
- Department of Radiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Robert van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC-University Medical Center, Rotterdam, Netherlands
| | - Diederik Dippel
- Department of Neurology, Erasmus MC-University Medical Center, Rotterdam, Netherlands
| | - Yvo Roos
- Department of Neurology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Joost Bot
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Vrije Universiteit van Amsterdam, Amsterdam, Netherlands
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Henk Marquering
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Amsterdam, Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
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Steffen P, Austein F, Lindner T, Meyer L, Bechstein M, Rümenapp J, Klintz T, Jansen O, Gellißen S, Hanning U, Fiehler J, Broocks G. Value of Dual-Energy Dual-Layer CT After Mechanical Recanalization for the Quantification of Ischemic Brain Edema. Front Neurol 2021; 12:668030. [PMID: 34349718 PMCID: PMC8326321 DOI: 10.3389/fneur.2021.668030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Ischemic brain edema can be measured in computed tomography (CT) using quantitative net water uptake (NWU), a recently established imaging biomarker. NWU determined in follow-up CT after mechanical thrombectomy (MT) has shown to be a strong predictor of functional outcome. However, disruption of the blood-brain barrier after MT may also lead to contrast staining, increasing the density on CT scans, and hence, directly impairing measurements of NWU. The purpose of this study was to determine whether dual-energy dual-layer CT (DDCT) after MT can improve the quantification of NWU by measuring NWU in conventional polychromatic CT images (CP-I) and virtual non-contrast images (VNC-I). We hypothesized that VNC-based NWU (vNWU) differs from NWU in conventional CT (cNWU). Methods: Ten patients with middle cerebral artery occlusion who received a DDCT follow-up scan after MT were included. NWU was quantified in conventional and VNC images as previously published and was compared using paired sample t-tests. Results: The mean cNWU was 3.3% (95%CI: 0-0.41%), and vNWU was 11% (95%CI: 1.3-23.4), which was not statistically different (p = 0.09). Two patients showed significant differences between cNWU and vNWU (Δ = 24% and Δ = 36%), while the agreement of cNWU/vNWU in 8/10 patients was high (difference 2.3%, p = 0.23). Conclusion: NWU may be quantified precisely on conventional CT images, as the underestimation of ischemic edema due to contrast staining was low. However, a proportion of patients after MT might show significant contrast leakage resulting in edema underestimation. Further research is needed to validate these findings and investigate clinical implications.
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Affiliation(s)
- Paul Steffen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friederike Austein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Thomas Lindner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johanna Rümenapp
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Tristan Klintz
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Olav Jansen
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Broocks G, McDonough R, Meyer L, Bechstein M, Dipl Ing HK, Schön G, Nawka MT, Fiehler J, Hanning U, Sporns P, Barow E, Minnerup J, Kemmling A. Reversible Ischemic Lesion Hypodensity in Acute Stroke CT Following Endovascular Reperfusion. Neurology 2021; 97:e1075-e1084. [PMID: 34261783 DOI: 10.1212/wnl.0000000000012484] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/16/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In acute stroke, early ischemic lesion hypodensity in computed tomography (CT) is considered the imaging hallmark of brain infarction, representing a state of irreversible tissue damage with a continual increase of net water uptake. This dogma is however challenged by rare cases of apparently reversed early lesion hypodensity following complete reperfusion. The purpose of this study was to investigate the occurrence of reversible ischemic edema after endovascular treatment. METHODS 184 acute ischemic anterior circulation stroke patients were included after consecutive screening. Ischemic brain edema was determined using quantitative lesion net water uptake (NWU) in admission-CT and follow-up CT based on CT-densitometry and ΔNWU was calculated as the difference. The association of edema progression to imaging and clinical parameters was investigated. Clinical outcome was assessed using modified Ranking Scale (mRS) scores at day 90. RESULTS 27/184 patients (14.7%) showed edema arrest and 3 patients (1.6%) exhibited significant edema reversibility. Higher degree of recanalization (odds ratio (OR): 2.96, 95%CI: 1.46-6.01, p<0.01) and shorter time from imaging to recanalization (OR/hour: 0.32, 95%CI: 0.18-0.54, p<0.0001) were significantly associated with edema arrest or reversibility. Clinical outcome was significantly better in patients without edema progression (median mRS 2 versus mRS 5, p=0.004). DISCUSSION Albeit rare, lesion hypodensity considered to be representative of early infarct in acute stroke CT may be reversible following complete recanalization. Arrest of edema progression of acute brain infarct lesions may occur after successful rapid vessel recanalization, resulting in improved functional outcome. Future research is needed to investigate conditions where early revascularization may halt or even reverse vasogenic edema of ischemic tissue.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep Dipl Ing
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf
| | - Marie Teresa Nawka
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Neuroradiology, Universitaetsspital Basel, Basel, Switzerland
| | - Ewgenia Barow
- Department of Neurology, University Medical Center Hamburg-Eppendorf
| | - Jens Minnerup
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Andre Kemmling
- Department of Neuroradiology, University Hospital Schleswig-Holstein, Lübeck, Germany.,Department of Neuroradiology, Westpfalzklinikum, Kaiserslautern, Germany
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Nawabi J, Elsayed S, Scholz H, Kemmling A, Meyer L, Kniep H, Bechstein M, Flottmann F, Faizy TD, Schön G, Fiehler J, Hanning U, Broocks G. Interaction Effect of Baseline Serum Glucose and Early Ischemic Water Uptake on the Risk of Secondary Hemorrhage After Ischemic Stroke. Front Neurol 2021; 12:690193. [PMID: 34305796 PMCID: PMC8297562 DOI: 10.3389/fneur.2021.690193] [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: 04/02/2021] [Accepted: 06/02/2021] [Indexed: 11/30/2022] Open
Abstract
Background and Purpose: Intracerebral hemorrhage (ICH) after mechanical thrombectomy (MT) for acute ischemic stroke (AIS) remains a major complication and its early prediction is of high relevance. Baseline serum glucose (BGL) is a known predictor of ICH, but its interaction with early ischemic changes remains uncertain. We hypothesized that BGL interacts with the effect of tissue water uptake on the occurrence of ICH. Methods: Three hundred and thirty-six patients with acute ischemic stroke treated with MT were retrospectively analyzed. ICH was diagnosed within 24 h on non-enhanced CT (NECT) and classified according to the Heidelberg Bleeding Classification. Early tissue water homeostasis has been assessed using quantitative lesion net water uptake (NWU) on admission CT. Multivariate logistic regression was used to identify predictors of ICH. Results: One hundred and seven patients fulfilled the inclusion criteria of which 37 (34.6%) were diagnosed with ICH. Patients with ICH had a significant higher BGL on admission (median 177 mg/dl, IQR: 127-221.75, P < 0.001). In patients with low BGL (<120 mg/dl), higher NWU was associated with 1.34-fold increased likelihood of ICH, while higher NWU was associated with a 2.08-fold increased likelihood of ICH in patients with a high BGL (>200 mg/dl). In multivariable logistic regression analysis, BGL (OR: 1.02, 95% CI: 1.00-1.04, P = 0.01) and NWU (OR: 2.32, 95% CI: 1.44-3.73, P < 0.001) were significantly and independently associated with ICH, showing a significant interaction (P = 0.04). Conclusion: A higher degree of early tissue water uptake and high admission BGL were both independent predictors of ICH. Higher BGL was significantly associated with accelerated effects of NWU on the likelihood of ICH. Although a clear causal relationship remains speculative, stricter BGL control and monitoring may be tested to reduce the risk of ICH in patients undergoing thrombectomy.
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Affiliation(s)
- Jawed Nawabi
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Radiology (CCM), Charité - Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität Berlin, Berlin, Germany
- Berlin Institute of Health, BIH Biomedical Innovation Academy, Berlin, Germany
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henriette Scholz
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - André Kemmling
- University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
- University Medical Center Marburg, Marburg University, Marburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D. Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Rocha M, Desai S, Son J, Tonetti DA, Jovin T, Jadhav AP. Clinical characteristics of fast and slow progressors of infarct growth in anterior circulation large vessel occlusion stroke. J Cereb Blood Flow Metab 2021; 41:271678X211015068. [PMID: 34139885 PMCID: PMC8221763 DOI: 10.1177/0271678x211015068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 11/16/2022]
Abstract
Fast and slow progressor phenotypes of infarct growth due to anterior circulation large vessel occlusion (ACLVO) remain poorly understood. We aimed to define clinical predictors of fast and slow progressors in a retrospective study of patients with ACLVO who underwent baseline advanced imaging within 24 hours of stroke onset. Fast progressors (ischemic core > 70 ml, < 6 hours after onset) and slow progressors (ischemic core ≤ 30 ml, 6 to 24 hours after onset) were identified amongst 185 patients. Clinical and laboratory variables were tested for association with fast or slow progressor status. In the early epoch, no significant differences were found between fast progressors and controls. In the delayed epoch, slow progressors had a median NIHSS of 14 versus 20 (p < 0.01) and MCA occlusion in 80% versus 63% (p < 0.05) relative to controls. In multivariate analyses, NIHSS (OR 0.83, 95% CI 0.73-0.95), hyperlipidemia (OR 4.24, 95% CI 1.01 - 19.3) and hemoglobin concentration (OR 0.75, 95% CI 0.57 - 0.99) were independently associated with slow progressor status. This study indicates that lower initial stroke symptom severity, a history of hyperlipidemia and mild anemia are associated with individual tolerance to ACLVO stroke.
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Affiliation(s)
- Marcelo Rocha
- Department of Neurology , University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Shashvat Desai
- Department of Neurology , University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jiyeon Son
- Department of Neurology , University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Tudor Jovin
- Cooper University Hospital Neurological Institute, Camden, NJ, USA
| | - Ashutosh P Jadhav
- Department of Neurology , University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
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35
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Broocks G, Fiehler J, Hanning U. In Reply: Early Prediction of Malignant Cerebellar Edema in Posterior Circulation Stroke Using Quantitative Lesion Water Uptake. Neurosurgery 2021; 88:E476-E477. [PMID: 33555009 DOI: 10.1093/neuros/nyab032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 12/20/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg, Germany
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Bechstein M, Meyer L, Breuel S, Faizy TD, Hanning U, van Horn N, McDonough R, Fiehler J, Broocks G. Computed Tomography Based Score of Early Ischemic Changes Predicts Malignant Infarction. Front Neurol 2021; 12:669828. [PMID: 34163425 PMCID: PMC8215705 DOI: 10.3389/fneur.2021.669828] [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: 02/19/2021] [Accepted: 05/14/2021] [Indexed: 12/23/2022] Open
Abstract
Background and Purpose: Identification of ischemic stroke patients at high risk of developing life-threatening malignant infarction at an early stage is critical to consider more rigorous monitoring and further therapeutic measures. We hypothesized that a score consisting of simple measurements of visually evident ischemic changes in non-enhanced CT (NEMMI score) predicts malignant middle cerebral artery (MCA) infarctions (MMI) with similar diagnostic power compared to other baseline clinical and imaging parameters. Methods: One hundred and nine patients with acute proximal MCA occlusion were included. Fifteen (13.8%) patients developed MMI. NEMMI score was defined using the sum of the maximum diameter (anterior-posterior plus medio-lateral) of the hypoattenuated lesion in baseline-CT multiplied by a hypoattenuation factor (3-point visual grading in non-enhanced CT, no/subtle/clear hypoattenuation = 1/2/3). Receiver operating characteristic (ROC) curve analysis and multivariable logistic regression analysis were used to calculate the predictive values of the NEMMI score, baseline clinical and other imaging parameters. Results: The median NEMMI score at baseline was 13.6 (IQR: 11.6-31.1) for MMI patients, and 7.7 (IQR: 3.9-11.2) for patients with non-malignant infarctions (p < 0.0001). Based on ROC curve analysis, a NEMMI score >10.5 identified MMI with good discriminative power (AUC: 0.84, sensitivity/specificity: 93.3/70.7%), which was higher compared to age (AUC: 0.76), NIHSS (AUC: 0.61), or ischemic core volume (AUC: 0.80). In multivariable logistic regression analysis, NEMMI score was significantly and independently associated with MMI (OR: 1.33, 95%CI: 1.13-1.56, p < 0.001), adjusted for recanalization status. Conclusion: The NEMMI score is a quick and simple rating tool of early ischemic changes on CT and could serve as an important surrogate marker for developing malignant edema. Its diagnostic accuracy was similar to CTP and clinical parameters.
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Affiliation(s)
- Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Silke Breuel
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Broocks G, Elsayed S, Kniep H, Kemmling A, Flottmann F, Bechstein M, Faizy TD, Meyer L, Lindner T, Sporns P, Rusche T, Schön G, Mader MM, Nawabi J, Fiehler J, Hanning U. Early Prediction of Malignant Cerebellar Edema in Posterior Circulation Stroke Using Quantitative Lesion Water Uptake. Neurosurgery 2021; 88:531-537. [PMID: 33040147 DOI: 10.1093/neuros/nyaa438] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/20/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Malignant cerebellar edema (MCE) is a life-threatening complication of ischemic posterior circulation stroke that requires timely diagnosis and management. Yet, there is no established imaging biomarker that may serve as predictor of MCE. Early edematous water uptake can be determined using quantitative lesion water uptake, but this biomarker has only been applied in anterior circulation strokes. OBJECTIVE To test the hypothesis that lesion water uptake in early posterior circulation stroke predicts MCE. METHODS A total 179 patients with posterior circulation stroke and multimodal admission CT were included. A total of 35 (19.5%) patients developed MCE defined by using an established 10-point scale in follow-up CT, of which ≥4 points are considered malignant. Posterior circulation net water uptake (pcNWU) was quantified in admission CT based on CT densitometry and compared with posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) as predictor of MCE using receiver operating curve (ROC) analysis and logistic regression analysis. RESULTS Acute pcNWU within the early ischemic lesion was 24.6% (±8.4) for malignant and 7.2% (±7.4) for nonmalignant infarctions, respectively (P < .0001). Based on ROC analysis, pcNWU above 14.9% identified MCE with high discriminative power (area under the curve: 0.94; 95% CI: 0.89-0.97). Early pcNWU (odds ratio [OR]: 1.28; 95% CI: 1.15-1.42, P < .0001) and pc-ASPECTS (OR: 0.71, 95% CI: 0.53-0.95, P = .02) were associated with MCE, adjusted for age and recanalization status. CONCLUSION Quantitative pcNWU in early posterior circulation stroke is an important marker for MCE. Besides pc-ASPECTS, lesion water uptake measurements may further support identifying patients at risk for MCE at an early stage indicating stricter monitoring and consideration for further therapeutic measures.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany.,Department of Neuroradiology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Radiology, Stanford University, Stanford, California
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Lindner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Neuroradiology, Universitätsspital Basel, Basel, Switzerland
| | - Thilo Rusche
- Department of Neuroradiology, Universitätsspital Basel, Basel, Switzerland.,Department of Radiology, University Hospital Münster, Münster, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marius M Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jawed Nawabi
- Department of Radiology, Charité University Medical Center, Berlin, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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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: 7] [Impact Index Per Article: 2.3] [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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Broocks G, Jafarov H, McDonough R, Austein F, Meyer L, Bechstein M, van Horn N, Nawka MT, Schön G, Fiehler J, Kniep H, Hanning U. Relationship between the degree of recanalization and functional outcome in acute ischemic stroke is mediated by penumbra salvage volume. J Neurol 2021; 268:2213-2222. [PMID: 33486602 PMCID: PMC8179901 DOI: 10.1007/s00415-021-10410-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/13/2021] [Accepted: 01/13/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The presence of metabolically viable brain tissue that may be salvageable with rapid cerebral blood flow restoration is the fundament rationale for reperfusion therapy in patients with large vessel occlusion stroke. The effect of endovascular treatment (EVT) on functional outcome largely depends on the degree of recanalization. However, the relationship of recanalization degree and penumbra salvage has not yet been investigated. We hypothesized that penumbra salvage volume mediates the effect of thrombectomy on functional outcome. METHODS 99 acute anterior circulation stroke patients who received multimodal CT and underwent thrombectomy with resulting partial to complete reperfusion (modified thrombolysis in cerebral infarction scale (mTICI) ≥ 2a) were retrospectively analyzed. Penumbra volume was quantified on CT perfusion and penumbra salvage volume (PSV) was calculated as difference of penumbra and net infarct growth from admission to follow-up imaging. RESULTS In patients with complete reperfusion (mTICI ≥ 2c), the median PSV was significantly higher than the median PSV in patients with partial or incomplete (mTICI 2a-2b) reperfusion (median 224 mL, IQR: 168-303 versus 158 mL, IQR: 129-225; p < 0.01). A higher degree of recanalization was associated with increased PSV (+ 63 mL per grade, 95% CI: 17-110; p < 0.01). Higher PSV was also associated with improved functional outcome (OR/mRS shift: 0.89; 95% CI: 0.85-0.95, p < 0.0001). CONCLUSIONS PSV may be an important mediator between functional outcome and recanalization degree in EVT patients and could serve as a more accurate instrument to compare treatment effects than infarct volumes.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Hashim Jafarov
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Friederike Austein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Marie Teresa Nawka
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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Meyer L, Schönfeld M, Bechstein M, Hanning U, Cheng B, Thomalla G, Schön G, Kemmling A, Fiehler J, Broocks G. Ischemic lesion water homeostasis after thrombectomy for large vessel occlusion stroke within the anterior circulation: The impact of age. J Cereb Blood Flow Metab 2021; 41:45-52. [PMID: 32248730 PMCID: PMC7747157 DOI: 10.1177/0271678x20915792] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/28/2020] [Accepted: 02/20/2020] [Indexed: 12/14/2022]
Abstract
The effect of age on lesion pathophysiology in the context of thrombectomy has been poorly investigated. We aimed to investigate the impact of age on ischemic lesion water homeostasis measured with net water uptake (NWU) within a multicenter cohort of patients receiving thrombectomy for anterior circulation large vessel occlusion (LVO) stroke. Lesion-NWU was quantified in multimodal CT on admission and 24 h for calculating Δ-NWU as their difference. The impact of age and procedural parameters on Δ-NWU was analyzed. Multivariable regression analysis was performed to identify significant predictors for Δ-NWU. Two hundred and four patients with anterior circulation stroke were included in the retrospective analysis. Comparison of younger and elderly patients showed no significant differences in NWU on admission but significantly higher Δ-NWU (p = 0.005) on follow-up CT in younger patients. In multivariable regression analysis, higher age was independently associated with lowered Δ-NWU (95% confidence interval: -0.59 to -0.16, p < 0.001). Although successful recanalization (TICI ≥ 2b) significantly reduced Δ-NWU progression by 6.4% (p < 0.001), younger age was still independently associated with higher Δ-NWU (p < 0.001). Younger age is significantly associated with increased brain edema formation after thrombectomy for LVO stroke. Younger patients might be particularly receptive targets for future adjuvant neuroprotective drugs that influence ischemic edema formation.
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Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Schönfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bastian Cheng
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany
- Faculty of Medicine Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Broocks G, Kemmling A, Faizy T, McDonough R, Van Horn N, Bechstein M, Meyer L, Schön G, Nawabi J, Fiehler J, Kniep H, Hanning U. Effect of thrombectomy on oedema progression and clinical outcome in patients with a poor collateral profile. Stroke Vasc Neurol 2020; 6:222-229. [PMID: 33208492 PMCID: PMC8258058 DOI: 10.1136/svn-2020-000570] [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: 08/08/2020] [Revised: 10/10/2020] [Accepted: 10/23/2020] [Indexed: 11/17/2022] Open
Abstract
Background and purpose The impact of the cerebral collateral circulation on lesion progression and clinical outcome in ischaemic stroke is well established. Moreover, collateral status modifies the effect of endovascular treatment and was therefore used to select patients for therapy in prior trials. The purpose of this study was to quantify the effect of vessel recanalisation on lesion pathophysiology and clinical outcome in patients with a poor collateral profile. Materials and methods 129 patients who had an ischaemic stroke with large vessel occlusion in the anterior circulation and a collateral score (CS) of 0–2 were included. Collateral profile was defined using an established 5-point scoring system in CT angiography. Lesion progression was determined using quantitative lesion water uptake measurements on admission and follow-up CT (FCT), and clinical outcome was assessed using modified Rankin Scale (mRS) scores after 90 days. Results Oedema formation in FCT was significantly lower in patients with vessel recanalisation compared with patients with persistent vessel occlusion (mean 19.5%, 95% CI: 17% to 22% vs mean 27%, 95% CI: 25% to 29%; p<0.0001). In a multivariable linear regression analysis, vessel recanalisation was significantly associated with oedema formation in FCT (ß=−7.31, SD=0.015, p<0.0001), adjusted for CS, age and Alberta Stroke Program Early CT Score (ASPECTS). Functional outcome was significantly better in patients following successful recanalisation (mRS at day 90: 4.5, IQR: 2–6 vs 5, IQR: 5–6, p<0.001). Conclusion Although poor collaterals are known to be associated with poor outcome, endovascular recanalisation was still associated with significant oedema reduction and comparably better outcome in this patient group. Patients with poor collaterals should not generally be excluded from thrombectomy.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Institute of Neuroradiology, University Hospital of Luebeck, Luebeck, Germany.,Neuroradiology, Westpfalzklinikum, Kaiserslautern, Germany
| | - Tobias Faizy
- Department of Diagnostic and Interventional Neuroradiology, Stanford University, Stanford, California, USA
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel Van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Jawed Nawabi
- Department of Radiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Broocks G, Leischner H, Hanning U, Flottmann F, Faizy TD, Schön G, Sporns P, Thomalla G, Kamalian S, Lev MH, Fiehler J, Kemmling A. Lesion Age Imaging in Acute Stroke: Water Uptake in CT Versus DWI-FLAIR Mismatch. Ann Neurol 2020; 88:1144-1152. [PMID: 32939824 DOI: 10.1002/ana.25903] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 09/14/2020] [Accepted: 09/14/2020] [Indexed: 11/11/2022]
Abstract
PURPOSE In acute ischemic stroke with unknown time of onset, magnetic resonance (MR)-based diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) estimates lesion age to guide intravenous thrombolysis. Computed tomography (CT)-based quantitative net water uptake (NWU) may be a potential alternative. The purpose of this study was to directly compare CT-based NWU to magnetic resonance imaging (MRI) at identifying patients with lesion age < 4.5 hours from symptom onset. METHODS Fifty patients with acute anterior circulation stroke were analyzed with both imaging modalities at admission between 0.5 and 8.0 hours after known symptom onset. DWI-FLAIR lesion mismatch was rated and NWU was measured in admission CT. An established NWU threshold (11.5%) was used to classify patients within and beyond 4.5 hours. Multiparametric MRI signal was compared with NWU using logistic regression analyses. The empirical distribution of NWU was analyzed in a consecutive cohort of patients with wake-up stroke. RESULTS The median time between CT and MRI was 35 minutes (interquartile range [IQR] = 24-50). The accuracy of DWI-FLAIR mismatch was 68.8% (95% confidence interval [CI] = 53.7-81.3%) with a sensitivity of 58% and specificity of 82%. The accuracy of NWU threshold was 86.0% (95% CI = 73.3-94.2%) with a sensitivity of 91% and specificity of 78%. The area under the curve (AUC) of multiparametric MRI signal to classify lesion age <4.5 hours was 0.86 (95% CI = 0.64-0.97), and the AUC of quantitative NWU was 0.91 (95% CI = 0.78-0.98). Among 87 patients with wake-up stroke, 46 patients (53%) showed low NWU (< 11.5%). CONCLUSION The predictive power of CT-based lesion water imaging to identify patients within the time window of thrombolysis was comparable to multiparametric DWI-FLAIR MRI. A significant proportion of patients with wake-up stroke exhibit low NWU and may therefore be potentially suitable for thrombolysis. ANN NEUROL 2020;88:1144-1152.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Radiology, Stanford University, Stanford, CA, USA
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Shahmir Kamalian
- Division of Neuroradiology, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - Michael H Lev
- Division of Neuroradiology, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany.,Department of Neuroradiology, University of Schleswig-Holstein, Luebeck, Germany
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43
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Broocks G, Fiehler J, Kemmling A. Collateral scoring in acute stroke patients with low ASPECTS: an unnecessary or underestimated tool for treatment selection? Brain 2020; 142:e36. [PMID: 31209466 DOI: 10.1093/brain/awz159] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Neurology, University Hospital Münster, Münster
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Broocks G, Hanning U, Faizy TD, Scheibel A, Nawabi J, Schön G, Forkert ND, Langner S, Fiehler J, Gellißen S, Kemmling A. Ischemic lesion growth in acute stroke: Water uptake quantification distinguishes between edema and tissue infarct. J Cereb Blood Flow Metab 2020; 40:823-832. [PMID: 31072174 PMCID: PMC7168794 DOI: 10.1177/0271678x19848505] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/11/2019] [Accepted: 04/02/2019] [Indexed: 01/31/2023]
Abstract
Infarct growth from the early ischemic core to the total infarct lesion volume (LV) is often used as an outcome variable of treatment effects, but can be overestimated due to vasogenic edema. The purpose of this study was (1) to assess two components of early lesion growth by distinguishing between water uptake and true net infarct growth and (2) to investigate potential treatment effects on edema-corrected net lesion growth. Sixty-two M1-MCA-stroke patients with acute multimodal and follow-up CT (FCT) were included. Ischemic lesion growth was calculated by subtracting the initial CTP-derived ischemic core volume from the LV in the FCT. To determine edema-corrected net lesion growth, net water uptake of the ischemic lesion on FCT was quantified and subtracted from the volume of uncorrected lesion growth. The mean lesion growth without edema correction was 20.4 mL (95% CI: 8.2-32.5 mL). The mean net lesion growth after edema correction was 7.3 mL (95% CI: -2.1-16.7 mL; p < 0.0001). Lesion growth was significantly overestimated due to ischemic edema when determined in early-FCT imaging. In 18 patients, LV was lower than the initial ischemic core volume by CTP. These apparently "reversible" core lesions were more likely in patients with shorter times from symptom onset to imaging and higher recanalization rates.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional
Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional
Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional
Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexandra Scheibel
- Department of Diagnostic and Interventional
Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jawed Nawabi
- Department of Diagnostic and Interventional
Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and
Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nils D Forkert
- Department of Radiology, Hotchkiss Brain
Institute, University of Calgary, Calgary, Canada
| | - Soenke Langner
- Department of Neuroradiology, University of
Rostock, Rostock, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional
Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional
Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, University
Hospital Schleswig-Holstein, Luebeck, Germany
- Department of Neurology, University Hospital
Münster, Münster, Germany
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45
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Dhar R. Automated quantitative assessment of cerebral edema after ischemic stroke using CSF volumetrics. Neurosci Lett 2020; 724:134879. [PMID: 32126249 DOI: 10.1016/j.neulet.2020.134879] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 02/28/2020] [Accepted: 02/29/2020] [Indexed: 01/20/2023]
Abstract
Reduction in CSF volume from baseline to follow-up CT at or beyond 24 -hs can serve as a quantitative biomarker of cerebral edema after stroke. We have demonstrated that assessment of CSF displacement reflects edema metrics such as lesion volume, midline shift, and neurologic deterioration. We have also developed a neural network-based image segmentation algorithm that can automatically measure CSF volume on serial CT scans from stroke patients. We have integrated this algorithm into an image processing pipeline that can extract this edema biomarker from large cohorts of stroke patients. Finally, we have created a stroke repository that can archive and process images from thousands of stroke patients in order to measure CSF volumetrics. We plan on applying this metric as a quantitative endophenotype of cerebral edema to facilitate early prediction of clinical deterioration as well as large-scale genetic studies.
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Affiliation(s)
- Rajat Dhar
- Department of Neurology (Division of Neurocritical Care), Washington University in St. Louis, 660 S Euclid Avenue, Campus Box 8111, Saint Louis, MO, 63110, United States.
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Broocks G, Kniep H, Schramm P, Hanning U, Flottmann F, Faizy T, Schönfeld M, Meyer L, Schön G, Aulmann L, Machner B, Royl G, Fiehler J, Kemmling A. Patients with low Alberta Stroke Program Early CT Score (ASPECTS) but good collaterals benefit from endovascular recanalization. J Neurointerv Surg 2019; 12:747-752. [DOI: 10.1136/neurintsurg-2019-015308] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/17/2019] [Accepted: 10/29/2019] [Indexed: 11/04/2022]
Abstract
BackgroundBenefit of thrombectomy in patients with a low initial Alberta Stroke Program Early CT Score (ASPECTS) is still uncertain. We hypothesized that, despite low ASPECTS, patients may benefit from endovascular recanalization if good collaterals are present.MethodsIschemic stroke patients with large vessel occlusion in the anterior circulation and an ASPECTS of ≤5 were analyzed. Collateral status (CS) was assessed using a 5-point-scoring system in CT angiography with poor CS defined as CS=0–1. Clinical outcome was determined using the modified Rankin Scale (mRS) score after 90 days. Edema formation was measured in admission and follow-up CT by net water uptake.Results27/100 (27%) patients exhibited a CS of 2–4. 50 patients underwent successful vessel recanalization and 50 patients had a persistent vessel occlusion. In multivariable logistic regression analysis, collateral status (OR 3.0; p=0.003) and vessel recanalization (OR 12.2; p=0.009) significantly increased the likelihood of a good outcome (mRS 0–3). A 1-point increase in CS was associated with 1.9% (95% CI 0.2% to 3.7%) lowered lesion water uptake in follow-up CT .ConclusionEndovascular recanalization in patients with ASPECTS of ≤5 but good collaterals was linked to improved clinical outcome and attenuated edema formation. Collateral status may serve as selection criterion for thrombectomy in low ASPECTS patients.
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47
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A prediction model of brain edema after endovascular treatment in patients with acute ischemic stroke. J Neurol Sci 2019; 407:116507. [PMID: 31644991 DOI: 10.1016/j.jns.2019.116507] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 09/18/2019] [Accepted: 09/23/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Clinical tools predicting brain edema after reperfusion therapy in acute ischemic stroke are scarce. We aim to develop a nomogram model to predict brain edema within the first 24 h after endovascular treatment (EVT) in the anterior cerebral circulation. METHODS A total of 199 patients were retrospectively identified in a single-center stroke registry. Brain edema was measured by midline shift (MLS). The associations between MLS and early neurologic outcomes were described. A nomogram predicting MLS was developed and internally validated. The nomogram was also compared with an available model using the area under the receiver operating characteristic curve (AUC) and decision curve analyses. RESULTS Overall, 87 patients (43.7%) had MLS. The patients with MLS ≥ 6 mm showed progressive neurological deterioration according to repeated measures analysis of variance. Each millimeter increase in MLS was strongly correlated with the presence of in-hospital death or forgoing treatment (Spearman's rho = 0.429, P < .001). Patients with brain edema were less likely to have functional independence at 3 months (19.5% vs. 46.8%, P < .001). A nomogram model including 24-h CT ASPECT scores and cisternal effacement, hypertension and complete recanalization showed a C-index of 0.874. This tool exhibited a higher AUC and higher net benefit than the available model. CONCLUSIONS This study showed a profound association between MLS and early neurologic outcomes. A nomogram model was developed to predict patients at risk of brain edema after EVT in the anterior cerebral circulation.
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48
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Broocks G, Kniep H, Kemmling A, Flottmann F, Nawabi J, Elsayed S, Schön G, Thomalla G, Fiehler J, Hanning U. Effect of intravenous alteplase on ischaemic lesion water homeostasis. Eur J Neurol 2019; 27:376-383. [PMID: 31529738 DOI: 10.1111/ene.14088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 09/03/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Intravenous (IV) lysis with alteplase is known to increase biomarkers of blood-brain barrier breakdown and has therefore been associated with secondary injuries such as hemorrhagic transformation. The impact of alteplase on brain edema formation, however, has not been investigated yet. The purpose was to examine the effects of IV alteplase on ischaemic lesion water homeostasis differentiated from final tissue infarct in patients with and without successful endovascular therapy (sET). METHODS In all, 232 middle cerebral artery stroke patients were analyzed. 147 patients received IV alteplase, of whom 106 patients received subsequent sET. Out of 85 patients without IV alteplase, 50 received sET. Ischaemic brain edema was quantified at admission and follow-up computed tomography using quantitative lesion net water uptake (NWU) and its difference was calculated (ΔNWU). The relationship of alteplase on ΔNWU and edema-corrected final infarct volume was analyzed using univariate and multivariate linear regression models. RESULTS The mean ΔNWU was 11.8% (SD 7.9) in patients with alteplase and 11.5% (SD 8.3) in patients without alteplase (P = 0.8). Alteplase was not associated with lowered ΔNWU whilst being associated with reduced edema-corrected tissue infarct volume [-27.4 ml, 95% confidence interval (CI) -49.4 to -5.4 ml; P = 0.02], adjusted for the Alberta Stroke Program Early Computed Tomography Score and recanalization status. In patients with sET, ΔNWU was 10.5% (95% CI 6.3%-10.5%) for patients with IV alteplase and 8.4% (95% CI 9.1%-12.0%) for patients without IV alteplase. CONCLUSION The application of IV alteplase did not significantly alter ischaemic lesion water homeostasis but was associated with reduced edema-corrected tissue infarct volume, which might be directly linked to improved functional outcome.
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Affiliation(s)
- G Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - H Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Heidelberg, Germany
| | - F Flottmann
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J Nawabi
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - S Elsayed
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - G Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - G Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - U Hanning
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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