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Krawchuk LJ, Sharrock MF. Prognostic Neuroimaging Biomarkers in Acute Vascular Brain Injury and Traumatic Brain Injury. Semin Neurol 2023; 43:699-711. [PMID: 37802120 DOI: 10.1055/s-0043-1775790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Abstract
Prognostic imaging biomarkers after acute brain injury inform treatment decisions, track the progression of intracranial injury, and can be used in shared decision-making processes with families. Herein, key established biomarkers and prognostic scoring systems are surveyed in the literature, and their applications in clinical practice and clinical trials are discussed. Biomarkers in acute ischemic stroke include computed tomography (CT) hypodensity scoring, diffusion-weighted lesion volume, and core infarct size on perfusion imaging. Intracerebral hemorrhage biomarkers include hemorrhage volume, expansion, and location. Aneurysmal subarachnoid biomarkers include hemorrhage grading, presence of diffusion-restricting lesions, and acute hydrocephalus. Traumatic brain injury CT scoring systems, contusion expansion, and diffuse axonal injury grading are reviewed. Emerging biomarkers including white matter disease scoring, diffusion tensor imaging, and the automated calculation of scoring systems and volumetrics are discussed.
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Affiliation(s)
- Lindsey J Krawchuk
- Department of Neurology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matthew F Sharrock
- Department of Neurology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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2
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Gu Y, Hang Y, Jia Z, Zhao L, Shi H, Cao Y, Liu S. Predictive value of computed tomography perfusion for acute ischemic stroke patients with ASPECTS < 6 in an early time window. Clin Neurol Neurosurg 2023; 225:107605. [PMID: 36701939 DOI: 10.1016/j.clineuro.2023.107605] [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: 01/07/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The standard for computed tomography perfusion (CTP) assessment has not been well established in early acute ischemic stroke (AIS). We aimed to examine the prognostic factors for good outcomes in patients who received CTP, with an Alberta Stroke Program Early CT Score (ASPECTS) < 6 after endovascular thrombectomy (EVT) in the early time window (0-6 h). METHODS We retrospectively reviewed 59 patients who met the criteria from October 2019 to April 2021. Based on the modified Rankin Score (mRS) at 90 days, the patients were divided into a good outcome group (mRS 0-2) and a poor outcome group (mRS 3-6). Baseline and procedural characteristics were collected for unilateral and multivariate regression analyses to explore the influencing factors for good outcomes. RESULTS Of the 59 patients included, good outcomes were observed in 21 (35.6%). Multivariate logistic regression analysis showed that smaller ischemic core volume (odds ratio [OR]: 0.950; 95% CI: 0.908-0.994; P = 0.026), lower National Institutes of Health Stroke Scale (NIHSS) score (OR: 0.750; 95% CI: 0.593-0.949; P = 0.017) and shorter stroke onset to reperfusion time (ORT) (OR: 0.981; 95% CI: 0.966-0.996; P = 0.016) were independent predictors for good outcomes at 90 days. CONCLUSION Smaller ischemic core volume based on CTP, lower NIHSS score and shorter ORT were significant independent predictors of good outcomes in patients with ASPECTS < 6 in the early time window after EVT.
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Affiliation(s)
- Yiming Gu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China; Department of Intervention Radiology, Suzhou Municipal Hospital Affiliated to Nanjing Medical University, 242 Guangji Road, Gusu District, Suzhou 215008, China.
| | - Yu Hang
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China.
| | - Zhenyu Jia
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China.
| | - Linbo Zhao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China.
| | - Haibin Shi
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China.
| | - Yuezhou Cao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China.
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China.
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3
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Ng MA. Posterior Circulation Ischaemic Stroke. Am J Med Sci 2022; 363:388-398. [PMID: 35104439 DOI: 10.1016/j.amjms.2021.10.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 06/09/2021] [Accepted: 10/21/2021] [Indexed: 11/16/2022]
Abstract
Posterior circulation ischaemic stroke (PCIS) is a disease of high burden. They account for 20-25% of all ischaemic strokes. However, it is relatively under-researched and requires more clinical attention, since it carries worse functional outcomes. Vertigo, visual disturbances and sensory/motor disturbances are found in PCIS. Large artery atherosclerosis and embolism are main causes of PCIS, while there is growing evidence that vertebrobasilar dolichoectasia is a key association. Hypertension is the commonest risk factor, while diabetes mellitus is more specific to PCIS. PCIS is diagnosed through neuroimaging techniques, which examine structural brain abnormalities, vascular patency and perfusion. PCIS, in line with ischaemic stroke in general, requires medical treatment and lifestyle modifications. This includes smoking cessation, weight control, and dietary alterations. Aspirin use also significantly improves survival outcomes. While intravascular and intra-arterial thrombolysis improve clinical outcomes, this is not proven conclusively for stenting and angioplasty. Future research on PCIS can focus on multi-centre epidemiological studies, clinically significant anatomical variants, and collateralisation.
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Affiliation(s)
- Mr Alexander Ng
- Department of Diagnostic Radiology, Li Ka Shing Faculty of Medicine, University of Hong Kong, Full Address: Block K, Queen Mary Hospital, Pokfulam Road, Hong Kong.
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4
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Ghodsi H, Abouei Mehrizi MA, Khoshdel AR, Shekarchi B. Evaluation of combining Alberta Stroke Program Early CT Score (ASPECTS) with mean platelet volume, plateletcrit, and platelet count in predicting short- and long-term prognosis of patients with acute ischemic stroke. Clin Neurol Neurosurg 2021; 208:106830. [PMID: 34419782 DOI: 10.1016/j.clineuro.2021.106830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is controversy regarding Alberta Stroke Program Early CT Score (ASPECTS) and platelet indices as predictors of outcome in patients with acute ischemic stroke (AIS). We aimed to assess the prognostic value of ASPECTS, mean platelet volume (MPV), plateletcrit (PCT), and platelet count (Plt) in 3-month and 1-year functional outcomes of AIS patients, both independently and in combination. METHODS This prospective study was conducted in Shams Al-shomuos and Ghaem hospitals of Mashhad, Iran from June 2019 to January 2021. Overall, 553 patients above 18 years old with first-ever anterior circulation AIS met the eligibility criteria and were included. Clinical, hematologic, radiologic, and demographic data of patients were recorded at baseline. The 3-month and 1-year functional outcome was evaluated by modified Rankin Scale (mRS). Multivariate logistic regression was used to determine the independent predictors of poor functional outcome (mRS>2) and mortality. RESULTS The mean age of the patients was 65.50 ± 14.41 years and 282 patients (51%) were male. ASPECTS ≤ 7 was an independent predictor of both poor function (OR=1.94, 95%CI=1.04-3.62, P = 0.04) and mortality (OR=2.02, 95%CI=1.14-3.58, P = 0.02) at 1 year. MPV was also a strong predictor of 3-month (OR=3.88, 95%CI=2.04-7.38, P = 0.02) and 1-year (OR=3.32, 95%CI=1.91-5.78, P = 0.01) mortality, as well as 3-month (OR=3.25, 95%CI=1.80-5.86, P < 0.001) and 1-year (OR=4.35, 95%CI=2.36-8.02, P < 0.001) poor function. For 1-year poor function (OR=9.33, 95%CI=2.19-39.73, P = 0.003) and mortality (OR=6.40, 95%CI=2.09-19.64, P = 0.001), ASPECTS combined with all platelet indices found to be a more robust independent predictor compared to each variable alone. CONCLUSION Although MPV is an independent predictor of both 3-month and 1-year poor function and mortality in AIS patients, ASPECTS ≤ 7 was found to be a risk factor for 1-year poor function and mortality. Moreover, the prognostic value of both platelet indices and ASPECTS are greater when they are combined together in AIS patients.
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Affiliation(s)
- Hamidreza Ghodsi
- Department of Neurology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Ali Reza Khoshdel
- Modern Epidemiology Research Center, Faculty of Medicine, AJA University of Medical Sciences, Tehran, Iran
| | - Babak Shekarchi
- Department of Radiology, Faculty of Medicine, AJA University of Medical Sciences, Tehran, Iran.
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Saha D, Ryan KR, Lakkaniga NR, Smith EL, Frett B. Pyrazoloadenine Inhibitors of the RET Lung Cancer Oncoprotein Discovered by a Fragment Optimization Approach. ChemMedChem 2021; 16:1605-1608. [PMID: 33559353 PMCID: PMC9969764 DOI: 10.1002/cmdc.202100013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/01/2021] [Indexed: 12/24/2022]
Abstract
A fragment-based drug-discovery approach was used on a pyrazoloadenine fragment library to uncover new molecules that target the RET (REarranged during Transfection) oncoprotein, which is a driver oncoprotein in ∼2 % of non-small-cell lung cancers. The fragment library was screened against the RET kinase and LC-2/ad (RET-driven), KM-12 (TRKA-driven matched control) and A549 (cytotoxic control) cells to identify selective scaffolds that could inhibit RET-driven growth. An unsubstituted pyrazoloadenine fragment was found to be active on RET in a biochemical assay, but reduced cell viability in non-RET-driven cell lines (EC50 =1 and 3 μM, respectively). To increase selectivity for RET, the pyrazoloadenine was modeled in the RET active site, and two domains were identified that were probed with pyrazoloadenine fragment derivatives to improve RET affinity. Scaffolds at each domain were merged to generate a novel lead compound, 8 p, which exhibited improved activity and selectivity for the RET oncoprotein (A549 EC50 =5.92 μM, LC-2/ad EC50 =0.016 μM, RET IC50 =0.000326 μM).
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Affiliation(s)
- Debasmita Saha
- Department of Pharmaceutical Sciences, College of Pharm
acy, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Katie Rose Ryan
- Department of Biochemistry and Molecular Biology, College
of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Naga Rajiv Lakkaniga
- Department of Pharmaceutical Sciences, College of Pharm
acy, University of Arkansas for Medical Sciences, Little Rock, AR USA,SmartBio Labs, Chennai, India
| | - Erica Lane Smith
- Department of Pharmaceutical Sciences, College of Pharm
acy, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Brendan Frett
- Department of Pharmaceutical Sciences, College of Pharm
acy, University of Arkansas for Medical Sciences, Little Rock, AR USA
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Esmael A, Elsherief M, Eltoukhy K. Predictive Value of the Alberta Stroke Program Early CT Score (ASPECTS) in the Outcome of the Acute Ischemic Stroke and Its Correlation with Stroke Subtypes, NIHSS, and Cognitive Impairment. Stroke Res Treat 2021; 2021:5935170. [PMID: 33575025 PMCID: PMC7864728 DOI: 10.1155/2021/5935170] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 12/03/2020] [Accepted: 01/16/2021] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES This study is aimed at correlating ASPECTS with mortality and morbidity in patients with acute middle cerebral artery territory infarction and at determining the cutoff value of ASPECTS that may predict the outcome. METHODS 150 patients diagnosed with acute middle cerebral artery territory infarction were involved in this study. Risk factors, initial NIHSS, and GCS were determined. An initial or follow-up noncontrast CT brain was done and assessed by ASPECTS. Outcomes were determined by mRS during the follow-up of cases after 3 months. Correlations of ASPECTS and outcome variables were done by Spearman correlation. Logistic regression analysis and ROC curve were done to detect the cutoff value of ASPECTS that predicts unfavorable outcomes. RESULTS The most common subtypes of ischemic strokes were lacunar stroke in 66 patients (44%), cardioembolic stroke in 39 patients (26%), and LAA stroke in 30 cases (20%). The cardioembolic stroke had a statistically significant lower ASPECT score than other types of ischemic strokes (P < 0.05). Spearman correlation showed that lower ASPECTS values (worse outcome) were more in older patients and associated with lower initial GCS. ASPECTS values were inversely correlated with initial NIHSS, inpatient stay, inpatient complications, mortality, and mRS. The ASPECTS cutoff value determined for the prediction of unfavorable outcomes was equal to ≤7. The binary logistic regression analysis detected that patients with ASPECTS ≤ 7 were significantly associated with about fourfold increased risk of poor outcomes (OR 3.95, 95% CI 2.09-11.38, and P < 0.01). CONCLUSIONS ASPECTS is a valuable and appropriate technique for the evaluation of the prognosis in acute ischemic stroke. Patients with high ASPECTS values are more likely to attain favorable outcomes, and the cutoff value of ASPECTS is a strong predictor for unfavorable outcomes. This trial is registered with ClinicalTrials.gov NCT04235920.
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Affiliation(s)
- Ahmed Esmael
- Neurology Department, Faculty of Medicine, Mansoura University, Egypt
| | | | - Khaled Eltoukhy
- Neurology Department, Faculty of Medicine, Mansoura University, Egypt
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7
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Automated Estimation of Acute Infarct Volume from Noncontrast Head CT Using Image Intensity Inhomogeneity Correction. Int J Biomed Imaging 2019; 2019:1720270. [PMID: 31531008 PMCID: PMC6719274 DOI: 10.1155/2019/1720270] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/15/2019] [Accepted: 07/31/2019] [Indexed: 11/25/2022] Open
Abstract
Identification of early ischemic changes (EIC) on noncontrast head CT scans performed within the first few hours of stroke onset may have important implications for subsequent treatment, though early stroke is poorly delimited on these studies. Lack of sharp lesion boundary delineation in early infarcts precludes manual volume measures, as well as measures using edge-detection or region-filling algorithms. We wished to test a hypothesis that image intensity inhomogeneity correction may provide a sensitive method for identifying the subtle regional hypodensity which is characteristic of early ischemic infarcts. A digital image analysis algorithm was developed using image intensity inhomogeneity correction (IIC) and intensity thresholding. Two different IIC algorithms (FSL and ITK) were compared. The method was evaluated using simulated infarcts and clinical cases. For synthetic infarcts, measured infarct volumes demonstrated strong correlation to the true lesion volume (for 20% decreased density “infarcts,” Pearson r = 0.998 for both algorithms); both algorithms demonstrated improved accuracy with increasing lesion size and decreasing lesion density. In clinical cases (41 acute infarcts in 30 patients), calculated infarct volumes using FSL IIC correlated with the ASPECTS scores (Pearson r = 0.680) and the admission NIHSS (Pearson r = 0.544). Calculated infarct volumes were highly correlated with the clinical decision to treat with IV-tPA. Image intensity inhomogeneity correction, when applied to noncontrast head CT, provides a tool for image analysis to aid in detection of EIC, as well as to evaluate and guide improvements in scan quality for optimal detection of EIC.
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8
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Zhang XH, Liang HM. Systematic review with network meta-analysis: Diagnostic values of ultrasonography, computed tomography, and magnetic resonance imaging in patients with ischemic stroke. Medicine (Baltimore) 2019; 98:e16360. [PMID: 31348236 PMCID: PMC6709059 DOI: 10.1097/md.0000000000016360] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Ischemic stroke is a foremost cause for disability and death worldwide. This study is conducted in order to compare the diagnostic values between transcranial Doppler ultrasound (ultrasonography), computed tomography (CT), and magnetic resonance imaging (MRI) in patients suffering from ischemic stroke by performing a network meta-analysis. METHODS We made use of Cochrane Library, PubMed, and Embase in order to obtain literature and papers. The combination analysis of both direct and indirect evidence in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy was conducted so as to assess the odds ratios (ORs) and surface under the cumulative ranking curve (SUCRA) values of the seven different imaging methods. These imaging techniques include ultrasonography, computed tomography (traditional CT, computed tomography angiography [CTA], computed tomography perfusion [CTP]), and MRI (traditional MRI, diffusion-weighted imaging [DWI], magnetic resonance angiography), in order to properly diagnose ischemic stroke patients. RESULTS Thirteen eligible diagnostic trials were enrolled into this network meta-analysis. The results of the traditional meta-analysis showed that among CT methods, CTP showed higher sensitivity, NPV, and accuracy; among MRI methods, DWI had relatively higher sensitivity, NPV, and accuracy. The results of network meta-analysis showed that DWI had relatively higher sensitivity, NPV, and accuracy when compared with traditional CT, CTA, magnetic resonance angiography and traditional MRI. CTP showed higher SUCRA among CT methods while DWI showed higher SUCRA among MRI methods. A cluster analysis revealed that DWI had the highest diagnostic value in terms of sensitivity, PPV, NPV, and accuracy amongst the aforementioned seven imaging techniques. CONCLUSION This network meta-analysis provides supporting evidence to the idea that DWI has a higher diagnostic value regarding ischemic stroke among MRI methods, and CTP has a poor diagnostic value among CT methods, which provide therapeutic considerations for Ischemic stroke intervention.
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Affiliation(s)
| | - Hui-Min Liang
- Department of Neurology, Huaihe Hospital of Henan University, Kaifeng, P. R. China
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Leiva-Salinas C, Jiang B, Wintermark M. Computed Tomography, Computed Tomography Angiography, and Perfusion Computed Tomography Evaluation of Acute Ischemic Stroke. Neuroimaging Clin N Am 2018; 28:565-572. [DOI: 10.1016/j.nic.2018.06.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Carlos Leiva-Salinas
- Division of Neuroradiology, Department of Radiology, University of Missouri, One Hospital Drive, Columbia, MO 65212, USA
| | - Bin Jiang
- Division of Neuroradiology, Department of Radiology, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Max Wintermark
- Division of Neuroradiology, Department of Radiology, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA.
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10
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Nagel S, Wang X, Carcel C, Robinson T, Lindley RI, Chalmers J, Anderson CS. Clinical Utility of Electronic Alberta Stroke Program Early Computed Tomography Score Software in the ENCHANTED Trial Database. Stroke 2018; 49:1407-1411. [DOI: 10.1161/strokeaha.117.019863] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/20/2018] [Accepted: 01/30/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Simon Nagel
- From the Department of Neurology, Heidelberg University Hospital, Germany (S.N.)
| | - Xia Wang
- Neurological and Mental Health Division, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., R.I.L., J.C., C.S.A.)
| | | | - Thompson Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, United Kingdom (T.R.)
| | - Richard I. Lindley
- Neurological and Mental Health Division, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., R.I.L., J.C., C.S.A.)
- Sydney Medical School, Westmead Hospital, University of Sydney, New South Wales, Australia (R.I.L.)
| | - John Chalmers
- Neurological and Mental Health Division, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., R.I.L., J.C., C.S.A.)
| | - Craig S. Anderson
- Neurological and Mental Health Division, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., R.I.L., J.C., C.S.A.)
- the George Institute China at Peking University Health Science Center, Beijing (C.S.A.)
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Multivariate Prognostic Model of Acute Stroke Combining Admission Infarct Location and Symptom Severity: A Proof-of-Concept Study. J Stroke Cerebrovasc Dis 2017; 27:936-944. [PMID: 29198948 DOI: 10.1016/j.jstrokecerebrovasdis.2017.10.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 10/23/2017] [Accepted: 10/29/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The information on topographic distribution of acute ischemic infarct can contribute to prediction of functional outcome. We aimed to develop a multivariate model for stroke prognostication, combining admission clinical and imaging variables, including the infarct topology. METHODS Acute ischemic stroke patients without baseline functional disability who had magnetic resonance imaging within 24 hours of onset or last-seen-well were included. The admission stroke severity was determined using the National Institutes of Health Stroke Scale (NIHSS) score. The relation between infarct location and outcome was assessed using both voxel-based and visual atlas-based analyses. The disability/death was defined by a modified Rankin Scale score greater than 2 at 3-month follow-up. RESULTS Among 198 patients included in this study, higher admission NIHSS score (P < .001), larger infarct volume (P < .001), and major arterial occlusions (P < .001) were associated with disability/death in univariate analyses. On voxel-based analysis, infarcts in the middle centrum semiovale, insula, and midbrain/pons were associated with higher rates of disability/death. In multivariate analysis, admission NIHSS score (P < .001), infarction of insula (P = .005), and midbrain/pons (P = .006) were independent predictors of disability/death. In receiver operating characteristics analysis, a simple 0-to-3 scoring system using these 3 variables had an area under the curve of .812 for prediction of disability/death (P < .001). CONCLUSIONS Admission symptom severity, infarction of insula, and midbrain/pons were independent predictors of clinical outcome in acute ischemic stroke patients. The methodology of this hypothesis-generating study can help conceive quantitative population-based probabilistic models for prognostication or treatment triage in stroke patients, combining admission clinical and imaging findings-including infarct topography.
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12
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Heiss WD. Contribution of Neuro-Imaging for Prediction of Functional Recovery after Ischemic Stroke. Cerebrovasc Dis 2017; 44:266-276. [PMID: 28869961 DOI: 10.1159/000479594] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 07/18/2017] [Indexed: 12/23/2022] Open
Abstract
Prediction measures of recovery and outcome after stroke perform with only modest levels of accuracy if based only on clinical data. Prediction scores can be improved by including morphologic imaging data, where size, location, and development of the ischemic lesion is best documented by magnetic resonance imaging. In addition to the primary lesion, the involvement of fiber tracts contributes to prognosis, and consequently the use of diffusion tensor imaging (DTI) to assess primary and secondary pathways improves the prediction of outcome and of therapeutic effects. The recovery of ischemic tissue and the progression of damage are dependent on the quality of blood supply. Therefore, the status of the supplying arteries and of the collateral flow is not only crucial for determining eligibility for acute interventions, but also has an impact on the potential to integrate areas surrounding the lesion that are not typically part of a functional network into the recovery process. The changes in these functional networks after a localized lesion are assessed by functional imaging methods, which additionally show altered pathways and activated secondary centers related to residual functions and demonstrate changes in activation patterns within these networks with improved performance. These strategies in some instances record activation in secondary centers of a network, for example, also in homolog contralateral areas, which might be inhibitory to the recovery of primary centers. Such findings might have therapeutic consequences, for example, image-guided inhibitory stimulation of these areas. In the future, a combination of morphological imaging including DTI of fiber tracts and activation studies during specific tasks might yield the best information on residual function, reserve capacity, and prospects for recovery after ischemic stroke.
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13
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Schröder J, Thomalla G. A Critical Review of Alberta Stroke Program Early CT Score for Evaluation of Acute Stroke Imaging. Front Neurol 2017; 7:245. [PMID: 28127292 PMCID: PMC5226934 DOI: 10.3389/fneur.2016.00245] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 12/29/2016] [Indexed: 01/19/2023] Open
Abstract
Assessment of ischemic stroke lesions on computed tomography (CT) or MRI using the Alberta Stroke Program Early CT Score (ASPECTS) is widely used to guide acute stroke treatment. We aimed to review the current evidence on ASPECTS. Originally, the score was developed for standardized lesion assessment on non-contrast CT (NCCT). Early studies described ASPECTS as a predictor of functional outcome and symptomatic intracranial hemorrhage after iv-thrombolysis with a threshold of ≤7 suggested to identify patients at high risk. Following studies rather pointed toward a linear relationship between ASPECTS and functional outcome. ASPECTS has also been applied to assess perfusion CT and diffusion-weighted MRI (DWI). Cerebral blood volume ASPECTS proved to be the best predictor of outcome, outperforming NCCT-ASPECTS in some studies. For DWI-ASPECTS varying thresholds to identify patients at risk for poor outcome were reported. ASPECTS has been used for patient selection in three of the five groundbreaking trials proving efficacy of mechanical thrombectomy published in 2015. ASPECTS values predict functional outcome after thrombectomy. Moreover, treatment effect of thrombectomy appears to depend on ASPECTS values being smaller or not present in low ASPECTS, while patients with ASPECTS 5–10 do clearly benefit from mechanical thrombectomy. However, as patients with low ASPECTS values were excluded from recent trials data on this subgroup is limited. There are several limitations to ASPECTS addressed in a growing number of studies. The score is limited to the anterior circulation, the template is unequally weighed and correlation with lesion volume depends on lesion location. Overall ASPECTS is a useful and easily applicable tool for assessment of prognosis in acute stroke treatment and to help guide acute treatment decisions regardless whether MRI or CT is used. Patients with low ASPECTS values are unlikely to achieve good outcome. However, methodological constraints of ASPECTS have to be considered, and based on present data, a clear cutoff value to define “low ASPECTS values” cannot be given.
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Affiliation(s)
- Julian Schröder
- Department of Neurology, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
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14
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Brown MD, Burton JH, Nazarian DJ, Promes SB. Clinical Policy: Use of Intravenous Tissue Plasminogen Activator for the Management of Acute Ischemic Stroke in the Emergency Department. Ann Emerg Med 2016; 66:322-333.e31. [PMID: 26304253 DOI: 10.1016/j.annemergmed.2015.06.031] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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15
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Abstract
Acute ischemic stroke is common and often treatable, but treatment requires reliable information on the state of the brain that may be provided by modern neuroimaging. Critical information includes: the presence of hemorrhage; the site of arterial occlusion; the size of the early infarct "core"; and the size of underperfused, potentially threatened brain parenchyma, commonly referred to as the "penumbra." In this chapter we review the major determinants of outcomes in ischemic stroke patients, and the clinical value of various advanced computed tomography and magnetic resonance imaging methods that may provide key physiologic information in these patients. The focus is on major strokes due to occlusions of large arteries of the anterior circulation, the most common cause of a severe stroke syndrome. The current evidence-based approach to imaging the acute stroke patient at the Massachusetts General Hospital is presented, which is applicable for all stroke types. We conclude with new information on time and stroke evolution that imaging has revealed, and how it may open the possibilities of treating many more patients.
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Affiliation(s)
- R Gilberto González
- Neuroradiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Ang TE, Bivard A, Levi C, Ma H, Hsu CY, Campbell B, Donnan G, Davis SM, Parsons M. Multi-Modal CT in Acute Stroke: Wait for a Serum Creatinine before Giving Intravenous Contrast? No! Int J Stroke 2015; 10:1014-7. [DOI: 10.1111/ijs.12605] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 05/28/2015] [Indexed: 10/23/2022]
Abstract
Background Multi-modal CT (MMCT) to guide decision making for reperfusion treatment is increasingly used, but there remains a perceived risk of contrast-induced nephropathy (CIN). At our center, MMCT is used empirically without waiting for serum-creatinine (sCR) or renal profiling. Aims To determine the incidence of CIN, examine the risk factors predisposing to its development, and investigate its effects on clinical outcome in the acute stroke population. Methods An institution-wide protocol was implemented for acute stroke presentations to have MMCT (100–150 ml nonionic tri-iodinated contrast, perfusion CT and CT angiography) without waiting for serum-creatinine to minimize delays. Intravenous saline is routinely infused (80–125 ml/h) for at least 24-h after MMCT. Serial creatinine levels were measured at baseline, risk period, and follow-up. Renal profiles and clinical progress were reviewed up to 90 days. Results We analyzed 735 consecutive patients who had MMCT for the evaluation of acute ischemic or hemorrhagic stroke during the last five-years. A total of 623 patients met the inclusion criteria for analysis: 16 cases (2·6%) biochemically qualified as CIN; however, the risk period serum-creatinine for 15 of these cases was confounded by dehydration, urinary tract infection, or medications. None of the group had progression to chronic kidney disease or required dialysis. Conclusions The incidence of CIN is low when MMCT is used routinely to assess acute stroke patients. In this population, CIN was a biochemical phenomenon that did not have clinical manifestations, cause chronic kidney disease, require dialysis, or negatively impact on 90-day mRS outcomes. Renal profiling and waiting for a baseline serum-creatinine are an unnecessary delay to emergency reperfusion treatment.
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Affiliation(s)
- Timothy E. Ang
- Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia
- Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Andrew Bivard
- Hunter Medical Research Institute, Newcastle, New South Wales, Australia
- University of Newcastle, Newcastle, New South Wales, Australia
| | - Christopher Levi
- Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia
- University of Newcastle, Newcastle, New South Wales, Australia
| | - Henry Ma
- Neurology, Monash Medical Centre, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Chung Y. Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Bruce Campbell
- Royal Melbourne Hospital, Melbourne, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Geoffrey Donnan
- University of Melbourne, Melbourne, Victoria, Australia
- The Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
| | - Stephen M. Davis
- Royal Melbourne Hospital, Melbourne, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Mark Parsons
- Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia
- University of Newcastle, Newcastle, New South Wales, Australia
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Fisher M, Saver JL. Future directions of acute ischaemic stroke therapy. Lancet Neurol 2015; 14:758-67. [DOI: 10.1016/s1474-4422(15)00054-x] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 03/28/2015] [Accepted: 04/21/2015] [Indexed: 12/22/2022]
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Rai AT, Evans K, Riggs JE, Hobbs GR. Intravenous thrombolysis of large vessel occlusions is associated with higher hospital costs than small vessel strokes: a rationale for developing stroke severity-based financial models. J Neurointerv Surg 2015; 8:423-8. [PMID: 25665984 DOI: 10.1136/neurintsurg-2014-011632] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 01/22/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Owing to their severity, large vessel occlusion (LVO) strokes may be associated with higher costs that are not reflected in current coding systems. This study aimed to determine whether intravenous thrombolysis costs are related to the presence or absence of LVO. METHODS Patients who had undergone intravenous thrombolysis over a 9-year period were divided into LVO and no LVO (nLVO) groups based on admission CT angiography. The primary outcome was hospital cost per admission. Secondary outcomes included admission duration, 90-day clinical outcome, and discharge destination. RESULTS 119 patients (53%) had LVO and 104 (47%) had nLVO. Total mean±SD cost per LVO patient was $18,815±14,262 compared with $15,174±11,769 per nLVO patient (p=0.04). Hospital payments per admission were $17,338±13,947 and $15,594±16,437 for LVO and nLVO patients, respectively (p=0.4). A good outcome was seen in 33 LVO patients (27.7%) and in 69 nLVO patients (66.4%) (OR 0.2, 95% CI 0.1 to 0.3, p<0.0001). Hospital mortality occurred in 31 LVO patients (26.1%) and in 7 nLVO patients (6.7%) (OR 0.2, 95% CI 0.08 to 0.5, p<0.0001). 31 LVO patients (32.6%) were discharged to home versus 64 nLVO patients (61.5%) (OR 4.5, 95% CI 2.6 to 8, p<0.0001). Admission duration was 7.5±6.9 days in LVO patients versus 4.9±4.2 days in nLVO patients (p=0.0009). Multivariate regression analysis after controlling for comorbidities showed the presence of LVO to be an independent predictor of higher total hospital costs. CONCLUSIONS The presence or absence of LVO is associated with significant differences in hospital costs, outcomes, admission duration, and home discharge. These differences can be important when developing systems of care models for acute ischemic stroke.
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Affiliation(s)
- Ansaar T Rai
- Department of Neuroradiology, Neurosurgery and Neurology West Virginia University Healthcare Room 2278, Morgantown, West Virginia, USA
| | - Kim Evans
- Decision Support, West Virginia University Healthcare, Morgantown, West Virginia, USA
| | - Jack E Riggs
- Department of Neurology, Morgantown, West Virginia, USA
| | - Gerald R Hobbs
- Department of Statistics, HSCS, Morgantown, West Virginia, USA
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The predictive value of the Boston Acute Stroke Imaging Scale (BASIS) in acute ischemic stroke patients among Chinese population. PLoS One 2014; 9:e113967. [PMID: 25531102 PMCID: PMC4273951 DOI: 10.1371/journal.pone.0113967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 11/01/2014] [Indexed: 11/19/2022] Open
Abstract
Objective Evaluate the predictive value of Boston Acute Stroke Imaging Scale (BASIS) in acute ischemic stroke in Chinese population. Methods This was a retrospective study. 566 patients of acute ischemic stroke were classified as having a major stroke or minor stroke based on BASIS. We compared short-term outcome (death, occurrence of complications, admission to intensive care unit [ICU] or neurological intensive care unit [NICU]), long-term outcome (death, recurrence of stroke, myocardial infarction, modified Rankin scale) and economic index including in-hospital cost and length of hospitalization. Continuous variables were compared by using the Student t test or Kruskal-Wallis test. Categorical variables were tested with the Chisquare test. Cox regression analysis was applied to identify whether BASIS was the independent predictive variable of death. Results During hospitalization, 9 patients (4.6%) died in major stroke group while no patients died in minor stroke group (p<0.001), 12 patients in the major stroke group and 5 patients in minor stroke group were admitted to ICU/NICU (p = 0.001). There were more complications (cerebral hernia, pneumonia, urinary tract infection) in major stroke group than minor stroke group (p<0.05). Meanwhile, the average cost of hospitalization in major stroke group was 3,100 US$ and 1,740 US$ in minor stroke group (p<0.001); the average length of stay in major and minor stroke group was 21.3 days and 17.3 days respectively (p<0.001). Results of the follow-up showed that 52 patients (26.7%) died in major stroke group while 56 patients (15.1%) died in minor stroke group (P<0.001). 62.2% of the patients in major stroke group and 80.4% of the patients in minor stroke group were able to live independently (P = 0.002). The survival analysis showed that patients with major stroke had 80% higher of risk of death than patients with minor stroke even after adjusting traditional atherosclerotic factors and NIHSS at baseline (HR = 1.8, 95% CI: 1.1–3.1). Conclusion BASIS can predict in-hospital mortality, occurrence of complication, length of stay and hospitalization cost of the acute ischemic stroke patients and can also estimate the long term outcome (death and the dependency). BASIS could and should be used as a dichotomous stroke classification system in the daily practice.
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Yeo LLL, Paliwal PR, Wakerley B, Khoo CM, Teoh HL, Ahmad A, Ting EY, Seet RC, Ong V, Chan BP, Yohanna K, Gopinathan A, Rathakrishnan R, Sharma VK. External validation of the Boston Acute Stroke Imaging Scale and M1-BASIS in thrombolyzed patients. Stroke 2014; 45:2942-7. [PMID: 25169951 DOI: 10.1161/strokeaha.114.006776] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Radiological findings play an essential role in therapeutic decision making and prognostication in acute ischemic stroke (AIS). The Boston Acute Stroke Imaging Scale (BASIS) and Middle Cerebral Artery-BASIS (M1-BASIS) methodologies are rapid purely radiological instruments and easily applicable for patients with AIS. We validated these methods in patients with AIS treated with intravenous tissue-type plasminogen activator. METHODS For BASIS, patients were labeled as having major stroke if there was occlusion of distal internal carotid artery, proximal (both M1 and M2 segments) of middle cerebral artery or the basilar artery, or an Alberta Stroke Program Early CT Score≤7. M1-BASIS differs from BASIS by classifying AIS patients with M2 occlusion as a minor stroke. We evaluated these classification systems for predicting functional outcomes (modified Rankin Scale score 0-1) at 3 months. RESULTS Two hundred sixty-five consecutive AIS patients treated with intravenous tissue-type plasminogen activator were included. On multivariate analysis, younger age (odds ratio, 1.039, 95% confidence interval, 1.009-1.070; P=0.011), lower National Institutes of Health Stroke Scale score (odds ratio, 1.140; 95% confidence interval, 1.073-1.210; P<0.001), and minor stroke by M1-BASIS (odds ratio, 2.376; 95% confidence interval, 1.047-5.393; P=0.039) were independent predictors of good functional outcome. When compared with National Institutes of Health Stroke Scale, the receiver operating characteristic curves for both BASIS (area under the curve, 0.721) and M1-BASIS (area under the curve, 0.795) correlated well with clinical severity scores. M1-BASIS has an additive effect with the National Institutes of Health Stroke Scale score to predict good outcomes. CONCLUSIONS The purely radiological M1-BASIS correlates well with the clinical severity of stroke and can be a reliable prognostication tool in thrombolyzed AIS patients. This system might find an important place in the current era of telestroke.
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Affiliation(s)
- Leonard L L Yeo
- From the Divisions of Neurology (L.L.L.Y., P.R.P., B.W., H.L.T., A.A., R.C.S., B.P.C., R.R., V.K.S.), Endocrinology (C.M.K.), Respiratory and Critical Care Medicine (V.O.), and Department of Diagnostic Imaging (E.Y.T., A.G.), National University Health System, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (R.C.S., V.K.S.); and National Brain Center, Indonesia (K.Y.).
| | - Prakash R Paliwal
- From the Divisions of Neurology (L.L.L.Y., P.R.P., B.W., H.L.T., A.A., R.C.S., B.P.C., R.R., V.K.S.), Endocrinology (C.M.K.), Respiratory and Critical Care Medicine (V.O.), and Department of Diagnostic Imaging (E.Y.T., A.G.), National University Health System, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (R.C.S., V.K.S.); and National Brain Center, Indonesia (K.Y.)
| | - Benjamin Wakerley
- From the Divisions of Neurology (L.L.L.Y., P.R.P., B.W., H.L.T., A.A., R.C.S., B.P.C., R.R., V.K.S.), Endocrinology (C.M.K.), Respiratory and Critical Care Medicine (V.O.), and Department of Diagnostic Imaging (E.Y.T., A.G.), National University Health System, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (R.C.S., V.K.S.); and National Brain Center, Indonesia (K.Y.)
| | - Chin M Khoo
- From the Divisions of Neurology (L.L.L.Y., P.R.P., B.W., H.L.T., A.A., R.C.S., B.P.C., R.R., V.K.S.), Endocrinology (C.M.K.), Respiratory and Critical Care Medicine (V.O.), and Department of Diagnostic Imaging (E.Y.T., A.G.), National University Health System, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (R.C.S., V.K.S.); and National Brain Center, Indonesia (K.Y.)
| | - Hock L Teoh
- From the Divisions of Neurology (L.L.L.Y., P.R.P., B.W., H.L.T., A.A., R.C.S., B.P.C., R.R., V.K.S.), Endocrinology (C.M.K.), Respiratory and Critical Care Medicine (V.O.), and Department of Diagnostic Imaging (E.Y.T., A.G.), National University Health System, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (R.C.S., V.K.S.); and National Brain Center, Indonesia (K.Y.)
| | - Aftab Ahmad
- From the Divisions of Neurology (L.L.L.Y., P.R.P., B.W., H.L.T., A.A., R.C.S., B.P.C., R.R., V.K.S.), Endocrinology (C.M.K.), Respiratory and Critical Care Medicine (V.O.), and Department of Diagnostic Imaging (E.Y.T., A.G.), National University Health System, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (R.C.S., V.K.S.); and National Brain Center, Indonesia (K.Y.)
| | - Eric Y Ting
- From the Divisions of Neurology (L.L.L.Y., P.R.P., B.W., H.L.T., A.A., R.C.S., B.P.C., R.R., V.K.S.), Endocrinology (C.M.K.), Respiratory and Critical Care Medicine (V.O.), and Department of Diagnostic Imaging (E.Y.T., A.G.), National University Health System, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (R.C.S., V.K.S.); and National Brain Center, Indonesia (K.Y.)
| | - Raymond C Seet
- From the Divisions of Neurology (L.L.L.Y., P.R.P., B.W., H.L.T., A.A., R.C.S., B.P.C., R.R., V.K.S.), Endocrinology (C.M.K.), Respiratory and Critical Care Medicine (V.O.), and Department of Diagnostic Imaging (E.Y.T., A.G.), National University Health System, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (R.C.S., V.K.S.); and National Brain Center, Indonesia (K.Y.)
| | - Venetia Ong
- From the Divisions of Neurology (L.L.L.Y., P.R.P., B.W., H.L.T., A.A., R.C.S., B.P.C., R.R., V.K.S.), Endocrinology (C.M.K.), Respiratory and Critical Care Medicine (V.O.), and Department of Diagnostic Imaging (E.Y.T., A.G.), National University Health System, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (R.C.S., V.K.S.); and National Brain Center, Indonesia (K.Y.)
| | - Bernard P Chan
- From the Divisions of Neurology (L.L.L.Y., P.R.P., B.W., H.L.T., A.A., R.C.S., B.P.C., R.R., V.K.S.), Endocrinology (C.M.K.), Respiratory and Critical Care Medicine (V.O.), and Department of Diagnostic Imaging (E.Y.T., A.G.), National University Health System, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (R.C.S., V.K.S.); and National Brain Center, Indonesia (K.Y.)
| | - Kusama Yohanna
- From the Divisions of Neurology (L.L.L.Y., P.R.P., B.W., H.L.T., A.A., R.C.S., B.P.C., R.R., V.K.S.), Endocrinology (C.M.K.), Respiratory and Critical Care Medicine (V.O.), and Department of Diagnostic Imaging (E.Y.T., A.G.), National University Health System, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (R.C.S., V.K.S.); and National Brain Center, Indonesia (K.Y.)
| | - Anil Gopinathan
- From the Divisions of Neurology (L.L.L.Y., P.R.P., B.W., H.L.T., A.A., R.C.S., B.P.C., R.R., V.K.S.), Endocrinology (C.M.K.), Respiratory and Critical Care Medicine (V.O.), and Department of Diagnostic Imaging (E.Y.T., A.G.), National University Health System, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (R.C.S., V.K.S.); and National Brain Center, Indonesia (K.Y.)
| | - Rahul Rathakrishnan
- From the Divisions of Neurology (L.L.L.Y., P.R.P., B.W., H.L.T., A.A., R.C.S., B.P.C., R.R., V.K.S.), Endocrinology (C.M.K.), Respiratory and Critical Care Medicine (V.O.), and Department of Diagnostic Imaging (E.Y.T., A.G.), National University Health System, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (R.C.S., V.K.S.); and National Brain Center, Indonesia (K.Y.)
| | - Vijay K Sharma
- From the Divisions of Neurology (L.L.L.Y., P.R.P., B.W., H.L.T., A.A., R.C.S., B.P.C., R.R., V.K.S.), Endocrinology (C.M.K.), Respiratory and Critical Care Medicine (V.O.), and Department of Diagnostic Imaging (E.Y.T., A.G.), National University Health System, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (R.C.S., V.K.S.); and National Brain Center, Indonesia (K.Y.)
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Barlinn K, Seibt J, Engellandt K, Gerber J, Puetz V, Kepplinger J, Wunderlich O, Pallesen LP, Bodechtel U, Koch R, von Kummer R, Dzialowski I. Multimodal Computed Tomography Based Definition of Cerebral Imaging Profiles for Acute Stroke Reperfusion Therapy (CT-DEFINE): Results of a Prospective Observational Study. Clin Neuroradiol 2014; 25:403-10. [PMID: 25150187 DOI: 10.1007/s00062-014-0320-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 06/17/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE To prospectively evaluate the prognostic impact of multimodal computed tomography-based imaging in ischemic stroke patients potentially eligible for reperfusion therapy. METHODS Anterior circulation stroke patients underwent non-contrast CT (NCCT), CT-angiography, and CT-perfusion within 12 h from symptom-onset. Patients could be treated with intravenous-tissue plasminogen activator (IV-tPA), endovascular or combined reperfusion therapies. Cerebral imaging profiles (IP) were NCCT-Alberta Stroke Program Early CT Score (ASPECTS) > 7 (IP1); NCCT-ASPECTS > 5 and proximal occlusion on CT-angiography (IP2); CT-perfusion mismatch between cerebral blood volume (CBV)-ASPECTS, and cerebral blood flow (CBF)-ASPECTS ≥ 2 (IP3). Favorable outcome was defined as modified Rankin Scale ≤ 2 at 3 months. RESULTS Of 102 included patients, 62 (61%) received any reperfusion therapy. In IP2 and IP3, favorable outcome was more frequent in patients with reperfusion therapy than in those without; however, this did not reach statistical significance (IP2: 39% vs 15%, p = 0.26; IP3: 50% vs 17 %; p = 0.31). No difference was seen in IP1 (58% vs 58%, p = 1.0). In IP2, patients with IV-tPA alone achieved better functional outcome (50% vs 11%, p = 0.03) and lower mortality (0% vs 28%, p = 0.045) than those without. CONCLUSIONS Our results suggest a benefit with imaging profile selection based upon the combination of a small-to-moderate-sized infarction and a visible intracranial occlusion in patients receiving IV-tPA. Reperfusion therapy may be futile in patients without proven vessel occlusion.
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Affiliation(s)
- K Barlinn
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - J Seibt
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - K Engellandt
- Division of Neuroradiology, University Hospital Dresden, Dresden, Germany
| | - J Gerber
- Division of Neuroradiology, University Hospital Dresden, Dresden, Germany
| | - V Puetz
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - J Kepplinger
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - O Wunderlich
- Division of Neuroradiology, University Hospital Dresden, Dresden, Germany
| | - L-P Pallesen
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - U Bodechtel
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - R Koch
- Institute for Medical Informatics and Biometry, University Hospital Dresden, Dresden, Germany
| | - R von Kummer
- Division of Neuroradiology, University Hospital Dresden, Dresden, Germany
| | - I Dzialowski
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- Elblandklinikum Meissen, Department of Neurology, Academic Teaching Hospital of the University of Technology Dresden, Meissen, Germany
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Beitzke D, Nolz R, Unterhumer S, Plank C, Weber M, Schernthaner R, Schöpf V, Wolf F, Loewe C. Low-dose high-pitch CT angiography of the supraaortic arteries using sinogram-affirmed iterative reconstruction. PLoS One 2014; 9:e99832. [PMID: 24919195 PMCID: PMC4053523 DOI: 10.1371/journal.pone.0099832] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 05/19/2014] [Indexed: 11/18/2022] Open
Abstract
Objective To prospectively evaluate image quality and radiation dose using a low-dose computed tomography angiography protocol and iterative image reconstruction for high-pitch dual-source CT-angiography (DSCTA) of the supraaortic arteries. Material and Methods DSCTA was performed in 42 patients, using either 120 kVp tube voltage, 120 mAS tube current, 2.4 pitch and filtered back projection, or 100 kVp tube voltage, 100 mAs tube current, 3.2 pitch, and sinogram affirmed iterative reconstruction. Measurements of vessel attenuation, of the contrast-to-noise ratio (CNR) and the signal-to-noise ratio (SNR) were performed to objectively evaluate image quality. Two readers evaluated subjective image quality and image noise, using a four-point scale. Effective dose was used to compare the differences in radiation dose. Results Low-dose protocol application showed significantly higher vessel opacification (p = 0.013), and non-significantly higher CNR and SNR values. There was no difference in the subjective image quality and image noise reading between the protocols. Effective dose was significantly lower using the low-dose protocol (1.29±0.21 mSv vs. 2.92±0.72 mSv; p<0.001). Conclusion The combined use of reduced tube voltage, reduced tube current, and iterative reconstruction reduces radiation dose by 55.4% in high-pitch DSCTA of the supraaortic arteries without impairment of image quality.
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Affiliation(s)
- Dietrich Beitzke
- Department of Biomedical Imaging and Image-guided Therapy, Division of Cardiovascular and Interventional Radiology, Medical University Vienna, Vienna, Austria
- * E-mail:
| | - Richard Nolz
- Department of Biomedical Imaging and Image-guided Therapy, Division of Cardiovascular and Interventional Radiology, Medical University Vienna, Vienna, Austria
| | - Sylvia Unterhumer
- Department of Biomedical Imaging and Image-guided Therapy, Division of Cardiovascular and Interventional Radiology, Medical University Vienna, Vienna, Austria
| | - Christina Plank
- Department of Biomedical Imaging and Image-guided Therapy, Division of Cardiovascular and Interventional Radiology, Medical University Vienna, Vienna, Austria
| | - Michael Weber
- Department of Biomedical Imaging and Image-guided Therapy, Division of Cardiovascular and Interventional Radiology, Medical University Vienna, Vienna, Austria
| | - Rüdiger Schernthaner
- Department of Biomedical Imaging and Image-guided Therapy, Division of Cardiovascular and Interventional Radiology, Medical University Vienna, Vienna, Austria
| | - Veronika Schöpf
- Department of Biomedical Imaging and Image-guided Therapy, Division of Neuroradiology and Musculoskeletal Radiology, Medical University Vienna, Vienna, Austria
| | - Florian Wolf
- Department of Biomedical Imaging and Image-guided Therapy, Division of Cardiovascular and Interventional Radiology, Medical University Vienna, Vienna, Austria
| | - Christian Loewe
- Department of Biomedical Imaging and Image-guided Therapy, Division of Cardiovascular and Interventional Radiology, Medical University Vienna, Vienna, Austria
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Rai A, Cline B, Williams E, Carpenter J, Roberts T. Intravenous thrombolysis outcomes in patients presenting with large vessel acute ischemic strokes--CT angiography-based prognosis. J Neuroimaging 2014; 25:238-242. [PMID: 24888428 DOI: 10.1111/jon.12126] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 01/29/2014] [Accepted: 03/02/2014] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE To establish outcome rates for patients receiving intravenous thrombolysis based on vascular occlusion site. METHODS This is a retrospective analysis of 225 patients who had received intravenous-rt-PA for anterior circulation strokes. The occlusion-site was prospectively determined on the admission computed tomographic angiography (CTA) and divided into: large vessel occlusion (LVO) including patients with an internal carotid artery terminus or middle cerebral artery (M1/proximal M2) occlusions and no large vessel occlusion (No-LVO; distal M2/M3/ACA) including patients with either distal or no occlusions. The primary outcome was the modified Rankin score (mRS) at 90-days with a good outcome defined by mRS of 0-2.000. RESULTS There were 114 (50.7%) patients in the LVO and 111 (49.3%) in the No-LVO group. A good outcome was seen in 28 (24.6%) patients in the LVO and 77 (69.4%) patients in the No-LVO group (OR .14; 95% CI: .08-.26; P < .0001). Mortality was observed in 13 (11.7%) patients in the No-LVO group and 48 (42.1%) patients in the LVO group (OR .18; 95% CI: .09-.36; P < .0001). Significant hemorrhage was seen in 14 (12.5%) patients in the LVO and 0 (0%) patients in the No-LVO group (P < .0001). Older age (OR .96; 95% CI: .93-.98; P = .002) and presence of LVO (OR .29; 95% CI: .12-.68; P = .004) were significant independent predictors of poor outcome. CONCLUSION CTA identification of proximal occlusions is associated with significantly poor outcomes in patients receiving intravenous stroke thrombolysis.
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Affiliation(s)
- Ansaar Rai
- Radiology & Neurology, West Virginia University, Morgantown, WV
| | - Brendan Cline
- Neuroradiology, West Virginia University, Morgantown, WV
| | - Eric Williams
- Neuroradiology, West Virginia University, Morgantown, WV
| | | | - Thomas Roberts
- Neuroradiology, West Virginia University, Morgantown, WV
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24
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Ntaios G, Papavasileiou V, Faouzi M, Vanacker P, Wintermark M, Michel P. Acute Imaging Does Not Improve ASTRAL Score's Accuracy despite Having a Prognostic Value. Int J Stroke 2014; 9:926-31. [DOI: 10.1111/ijs.12304] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 04/29/2014] [Indexed: 11/27/2022]
Abstract
Background The ASTRAL score was recently shown to reliably predict three-month functional outcome in patients with acute ischemic stroke. Aim The study aims to investigate whether information from multimodal imaging increases ASTRAL score's accuracy. Methods All patients registered in the ASTRAL registry until March 2011 were included. In multivariate logistic-regression analyses, we added covariates derived from parenchymal, vascular, and perfusion imaging to the 6-parameter model of the ASTRAL score. If a specific imaging covariate remained an independent predictor of three-month modified Rankin score > 2, the area-under-the-curve (AUC) of this new model was calculated and compared with ASTRAL score's AUC. We also performed similar logistic regression analyses in arbitrarily chosen patient subgroups. Results When added to the ASTRAL score, the following covariates on admission computed tomography/magnetic resonance imaging-based multimodal imaging were not significant predictors of outcome: any stroke-related acute lesion, any nonstroke-related lesions, chronic/subacute stroke, leukoaraiosis, significant arterial pathology in ischemic territory on computed tomography angiography/magnetic resonance angiography/Doppler, significant intracranial arterial pathology in ischemic territory, and focal hypoperfusion on perfusion-computed tomography. The Alberta Stroke Program Early CT score on plain imaging and any significant extracranial arterial pathology on computed tomography angiography/magnetic resonance angiography/Doppler were independent predictors of outcome (odds ratio: 0·93, 95% CI: 0·87–0·99 and odds ratio: 1·49, 95% CI: 1·08–2·05, respectively) but did not increase ASTRAL score's AUC (0·849 vs. 0·850, and 0·8563 vs. 0·8564, respectively). In exploratory analyses in subgroups of different prognosis, age or stroke severity, no covariate was found to increase ASTRAL score's AUC, either. Conclusions The addition of information derived from multimodal imaging does not increase ASTRAL score's accuracy to predict functional outcome despite having an independent prognostic value. More selected radiological parameters applied in specific subgroups of stroke patients may add prognostic value of multimodal imaging.
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Affiliation(s)
- George Ntaios
- Department of Medicine, University of Thessaly, Larissa, Greece
| | | | - Mohamed Faouzi
- Institute of Social and Preventive Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Peter Vanacker
- Department of Neurology, University Hospital Antwerp, Edegem, Belgium
| | - Max Wintermark
- Department of Radiology, Division of Neuroradiology, University of Virginia, Charlottesville, VA, USA
| | - Patrik Michel
- Stroke Center, Neurology Service, Department of Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
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25
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Matías-Guiu J, Serna-Candel C, Espejo-Domínguez J, Fernández-Matarrubia M, Simal P, Matías-Guiu J. Large artery occlusion diagnosed by computed tomography angiography in acute ischaemic stroke: Frequency, predictive factors, and safety. NEUROLOGÍA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.nrleng.2013.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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26
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Hinduja A. Imaging predictors of outcome following intravenous thrombolysis in acute stroke. Acta Neurol Belg 2014; 114:81-6. [PMID: 24357040 DOI: 10.1007/s13760-013-0270-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 12/11/2013] [Indexed: 11/25/2022]
Abstract
Intravenous tissue plasminogen activator is the only approved medical treatment for patients with acute ischemic stroke. While it is associated with excellent clinical outcome in about 30 %, even with timely thrombolysis administration, certain strokes continue to evolve and lead to poor outcomes. Several studies have attempted to identify predictors of outcome despite timely thrombolysis. Persistence of a proximal clot burden and large vessel occlusion following thrombolysis are markers for patients who may potentially benefit from advanced treatment modalities like intra-arterial thrombolysis and thrombectomy. Timely brain imaging and interpretation play a crucial role in providing these treatment decisions. In this review, various imaging predictors of poor outcome among patients with acute ischemic stroke treated with intravenous thrombolysis are outlined. Despite identification of these imaging predictors, thrombolysis should not be withheld, as it may still be beneficial in a subset of patients. Knowledge of these predictors may set benchmarks for selecting candidates who may potentially benefit from advanced management strategies in future trials.
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Affiliation(s)
- Archana Hinduja
- Department of Neurology, University of Arkansas for Medical Sciences, 4301 West Markham Street, Slot 500, Little Rock, AR, 72205, USA,
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27
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Oclusión arterial de gran vaso diagnosticada por angiografía por tomografía computarizada en el ictus isquémico agudo: frecuencia, factores predictores y seguridad. Neurologia 2014; 29:261-6. [DOI: 10.1016/j.nrl.2013.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 06/17/2013] [Indexed: 11/21/2022] Open
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28
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Heiss WD, Kidwell CS. Imaging for prediction of functional outcome and assessment of recovery in ischemic stroke. Stroke 2014; 45:1195-201. [PMID: 24595589 DOI: 10.1161/strokeaha.113.003611] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Wolf-Dieter Heiss
- From the Max Planck Institute for Neurological Research, Cologne, Germany (W.-D.H.); and Departments of Neurology and Medical Imaging, University of Arizona, Tucson (C.S.K.)
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29
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Rai AT, Evans K. Hospital-based financial analysis of endovascular therapy and intravenous thrombolysis for large vessel acute ischemic strokes: the 'bottom line'. J Neurointerv Surg 2014; 7:150-6. [PMID: 24476964 DOI: 10.1136/neurintsurg-2013-011085] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Economic viability is important to any hospital striving to be a comprehensive stroke center. An inability to recover cost can strain sustained delivery of advanced stroke care. OBJECTIVE To carry out a comparative financial analysis of intravenous (IV) recombinant tissue plasminogen activator and endovascular (EV) therapy in treating large vessel strokes from a hospital's perspective. METHODOLOGY Actual hospital's charges, costs, and payments were analyzed for 265 patients who received treatment for large vessel strokes. The patients were divided into an EV (n=141) and an IV group (n=124). The net gain/loss was calculated as the difference between payments received and the total cost. RESULTS The charges, costs, and payments were significantly higher for the EV than the IV group (p<0.0001 for all). Medicare A was the main payer. Length of stay was inversely related to net gain/loss (p<0.0001). Favorable outcome was associated with a net gain of $3853 (±$21,155) and poor outcome with a net deficit of $2906 (±$15,088) (p=0.003). The hospital showed a net gain for the EV group versus a net deficit for the IV group in patients who survived the admission (p=0.04), had a favorable outcome (p=0.1), or were discharged to home (p=0.03). There was no difference in the time in hospital based on in-hospital mortality for the EV group but patients who died in the IV group had a significantly shorter length of stay than those who survived (p=0.04). The favorable outcome of 42.3% in the EV group was significantly higher than the 29.4% in the IV group (p=0.03). CONCLUSIONS Endovascular therapy was associated with better outcomes and higher cost-recovery than IV thrombolysis in patients with large vessel strokes.
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Affiliation(s)
- Ansaar T Rai
- Department of Radiology and Neurosurgery and Neurology, West Virginia University Healthcare, Morgantown, West Virginia, USA
| | - Kim Evans
- Decision Support West Virginia University Healthcare, Morgantown, West Virginia, USA
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30
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Ibatullin MM, Kalinin MN, Kurado AT, Valeeva AA, Khasanova DR. [Multimodal imaging protocols and their predictive role in acute stroke functional outcome]. Zh Nevrol Psikhiatr Im S S Korsakova 2014; 114:9-15. [PMID: 25726796 DOI: 10.17116/jnevro20141141229-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Brain imaging plays a central role in the assessment of patients with acute ischemic stroke. Within a few minutes, modern multimodal imaging protocols can provide one with comprehensive information about prognosis, management, and outcome of the disease, and may detect changes in the intracranial structures reflecting severity of the ischemic injury depicted by four Ps: parenchyma (of the brain), pipes (i.e., the cerebral blood vessels), penumbra, and permeability (of the blood brain barrier). In this article, we have reviewed neuroradiological predictors of stroke functional outcome in the light of the aforementioned four Ps.
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Affiliation(s)
- M M Ibatullin
- GBOU VPO "Kazanskiĭ gosudarstvennyĭ meditsinskiĭ universitet"
| | - M N Kalinin
- GBOU VPO "Kazanskiĭ gosudarstvennyĭ meditsinskiĭ universitet"
| | - A T Kurado
- GAUZ "Mezhregional'nyĭ kliniko-diagnosticheskiĭ tsentr", Kazan'
| | - A A Valeeva
- GBOU VPO "Kazanskiĭ gosudarstvennyĭ meditsinskiĭ universitet"
| | - D R Khasanova
- GBOU VPO "Kazanskiĭ gosudarstvennyĭ meditsinskiĭ universitet"
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31
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Karaman B, Selph J, Burdine J, Graham CB, Sen S. CT Angiography and Presentation NIH stroke Scale in Predicting TIA in Patients Presenting with Acute Stroke Symptoms. JOURNAL OF NEUROLOGICAL DISORDERS 2013; 2:140. [PMID: 24851234 PMCID: PMC4025925 DOI: 10.4172/2329-6895.1000140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Patient candidacy for acute stroke intervention, is currently assessed using brain computed tomography angiography (CTA) evidence of significant stenosis/occlusion (SSO) with a high National Institutes of Health Stroke Scale (NIHSS) (>6). This study examined the association between CTA without significant stenosis/occlusion (NSSO) and lower NIHSS (≤ 6) with transient ischemic attack (TIA) and other good clinical outcomes at discharge. Patients presenting <8 hours from stroke symptom onset, had an NIHSS assessment and brain CTA performed at presentation. Good clinical outcomes were defined as: discharge diagnosis of TIA, modified Rankin Score [mRS] ≤ 1, and home as the discharge disposition. Eighty-five patients received both an NIHSS at presentation and a CTA at 4.2 ± 2.2 hours from stroke symptom onset. Patients with NSSO on CTA as well as those with NIHSS≤6 had better outcomes at discharge (p<0.001). NIHSS ≤ 6 were more likely than NSSO (p=0.01) to have a discharge diagnosis of TIA (p<0.001). NSSO on CTA and NIHSS ≤ 6 also correlated with fewer deaths (p<0.001). Multivariable analyses showed NSSO on CTA (Adjusted OR: 5.8 95% CI: 1.2-27.0, p=0.03) independently predicted the discharge diagnosis of TIA. Addition of NIHSS ≤ 6 to NSSO on CTA proved to be a stronger independent predictor of TIA (Adjusted OR 18.7 95% CI: 3.5-98.9, p=0.001).
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Affiliation(s)
- Bedriye Karaman
- Ege University Medical School, Department of Neurology, Izmir, Turkey
| | - James Selph
- University of South Carolina School of Medicine, Department of Neurology Columbia, South Carolina, USA
| | - Joselyn Burdine
- University of South Carolina School of Medicine, Department of Neurology Columbia, South Carolina, USA
| | - Cole Blease Graham
- University of South Carolina School of Medicine, Department of Neurology Columbia, South Carolina, USA
| | - Souvik Sen
- University of South Carolina School of Medicine, Department of Neurology Columbia, South Carolina, USA
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32
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Affiliation(s)
- Ramón Gilberto González
- From the Neuroradiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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33
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González RG, Furie KL, Goldmacher GV, Smith WS, Kamalian S, Payabvash S, Harris GJ, Halpern EF, Koroshetz WJ, Camargo ECS, Dillon WP, Lev MH. Good outcome rate of 35% in IV-tPA-treated patients with computed tomography angiography confirmed severe anterior circulation occlusive stroke. Stroke 2013; 44:3109-13. [PMID: 24003051 DOI: 10.1161/strokeaha.113.001938] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE To determine the effect of intravenous tissue plasminogen activator (IV-tPA) on outcomes in patients with severe major anterior circulation ischemic stroke. METHODS Prospectively, 649 patients with acute stroke had admission National Institutes of Health stroke scale (NIHSS) scores, noncontrast computed tomography (CT), CT angiography (CTA), and 6-month outcome assessed using modified Rankin scale. IV-tPA treatment decisions were made before CTA, at the time of noncontrast CT scanning, as per routine clinical protocol. Severe symptoms were defined as NIHSS>10. Poor outcome was defined as modified Rankin scale >2. Major occlusions were identified on CTA. Univariate and multivariate stepwise-forward logistic regression analyses of the full cohort were performed. RESULTS Of 649 patients, 188 (29%) patients presented with NIHSS>10, and 64 out of 188 (34%) patients received IV-tPA. Admission NIHSS, large artery occlusion, and IV-tPA all independently predicted good outcomes; however, a significant interaction existed between IV-tPA and occlusion (P<0.001). Of the patients who presented with NIHSS>10 with anterior circulation occlusion, twice the percentage had good outcomes if they received IV-tPA (17 out of 49 patients, 35%) than if they did not (13 out of 77 patients, 17%; P=0.031). The number needed to treat was 7 (95% confidence interval, 3-60). CONCLUSIONS IV-tPA treatment resulted in significantly better outcomes in patients with severely symptomatic stroke with major anterior circulation occlusions. The 35% good outcome rate was similar to rates found in endovascular therapy trials. Vascular imaging may help in patient selection and stratification for trials of IV-thrombolytic and endovascular therapies.
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Affiliation(s)
- R Gilberto González
- From the Department of Radiology (R.G.G., K.L.F., G.V.G., S.K., S.P., G.J.H., E.F.H., E.C.S.C., M.H.L.), and Department of Radiology and Institute for Technology Assessment (E.F.H.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; ICON Medical Imaging (Beacon Bioscience), North Wales, PA (G.V.G.); Department of Neurology (W.S.S.), and Department of Radiology (W.P.D.), University of California at San Francisco, CA; Department of Radiology, University of Minnesota, Minneapolis (S.P.); National Institutes of Neurological Disorders and Stroke, Bethesda, MD (W.J.K.); Department of Neurology, Boston University Medical Center, MA (E.C.S.C.); and Department of Neurology, Rhode Island Hospital and Warren Alpert Medical School, Brown University, Providence, RI (K.L.F.)
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34
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Dubey P, Pandey S, Moonis G. Acute stroke imaging: recent updates. Stroke Res Treat 2013; 2013:767212. [PMID: 23970999 PMCID: PMC3732599 DOI: 10.1155/2013/767212] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 06/17/2013] [Indexed: 11/17/2022] Open
Abstract
Acute ischemic stroke imaging is one of the leading causes of death and disability worldwide. Neuroimaging plays a crucial role in early diagnosis and yields essential information regarding tissue integrity, a factor that remains a key therapeutic determinant. Given the widespread public health implications of stroke and central role of neuroimaging in overall management, acute stroke imaging remains a heavily debated, extensively researched, and rapidly evolving subject. There has been recent debate in the scientific community due to divided opinions on the use of CT perfusion and access-related limitations of MRI. In this paper we review and summarize recent updates relevant to acute stroke imaging and propose an imaging paradigm based on the recently available evidence.
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Affiliation(s)
- Prachi Dubey
- Department of Radiology, University of Massachusetts Medical School, Worcestor, MA 01655, USA
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Sachin Pandey
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Gul Moonis
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
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35
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Zhu G, Michel P, Aghaebrahim A, Patrie JT, Xin W, Eskandari A, Zhang W, Wintermark M. Computed Tomography Workup of Patients Suspected of Acute Ischemic Stroke. Stroke 2013; 44:1049-55. [DOI: 10.1161/strokeaha.111.674705] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
To determine whether perfusion computed tomography (PCT) adds value to noncontrast head CT (NCT), CT angiogram (CTA), and clinical assessment in patients suspected of acute ischemic stroke.
Methods—
We retrospectively reviewed 165 patients with acute ischemic stroke. PCT was used to calculate the volumes of infarct core and ischemic penumbra on admission. Other imaging data included Alberta Score Program Early CT Score, site of occlusion, and collateral flow. Clinical data included age, time, National Institutes of Health Stroke Scale at baseline, treatment type, and modified Rankin score (mRS) at 90 days. Recanalization status was assessed on follow-up imaging. In a first multivariate regression analysis, we assessed whether volumes of PCT penumbra and infarct core could be predicted from clinical variables, NCT, or CTA, or whether they represented independent information. In a second multivariate regression analysis, we used mRS at 90 days as outcome and determined which variables predicted it best.
Results—
Of 165 patients identified, 76 had a mRS score of 0 to 2 at 90 days, 89 had a mRS score >2. PCT infarct could be predicted by clinical data, NCT, CTA, and combinations of this data (
P
<0.05). PCT penumbra could not be predicted by clinical data, NCT, and CTA. All of the variables but NCT and CTA were significantly associated with 90-day mRS outcome. The single most important predictor was recanalization status (
P
<0.001). PCT penumbra volume (
P
=0.001) was also a predictor of clinical outcome, especially when considered in conjunction with recanalization through an interaction term (
P
<0.001).
Conclusions—
PCT penumbra represents independent information, which cannot be predicted by clinical, NCT, and CTA data. PCT penumbra is an important determinant of clinical outcome and adds relevant clinical information compared with a stroke CT workup, including NCT and CTA.
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Affiliation(s)
- Guangming Zhu
- From the Department of Radiology, Neuroradiology Division, University of Virginia, Charlottesville, VA (G.Z., M.W.); Department of Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (M.W.); Department of Public Health Sciences, University of Virginia, Charlottesville, VA (J.T.P, W.X.); Department of Neurology, Military General Hospital of Beijing PLA, Beijing, China (G.Z., W.Z.); Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (P.M., A
| | - Patrik Michel
- From the Department of Radiology, Neuroradiology Division, University of Virginia, Charlottesville, VA (G.Z., M.W.); Department of Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (M.W.); Department of Public Health Sciences, University of Virginia, Charlottesville, VA (J.T.P, W.X.); Department of Neurology, Military General Hospital of Beijing PLA, Beijing, China (G.Z., W.Z.); Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (P.M., A
| | - Amin Aghaebrahim
- From the Department of Radiology, Neuroradiology Division, University of Virginia, Charlottesville, VA (G.Z., M.W.); Department of Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (M.W.); Department of Public Health Sciences, University of Virginia, Charlottesville, VA (J.T.P, W.X.); Department of Neurology, Military General Hospital of Beijing PLA, Beijing, China (G.Z., W.Z.); Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (P.M., A
| | - James T. Patrie
- From the Department of Radiology, Neuroradiology Division, University of Virginia, Charlottesville, VA (G.Z., M.W.); Department of Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (M.W.); Department of Public Health Sciences, University of Virginia, Charlottesville, VA (J.T.P, W.X.); Department of Neurology, Military General Hospital of Beijing PLA, Beijing, China (G.Z., W.Z.); Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (P.M., A
| | - Wenjun Xin
- From the Department of Radiology, Neuroradiology Division, University of Virginia, Charlottesville, VA (G.Z., M.W.); Department of Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (M.W.); Department of Public Health Sciences, University of Virginia, Charlottesville, VA (J.T.P, W.X.); Department of Neurology, Military General Hospital of Beijing PLA, Beijing, China (G.Z., W.Z.); Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (P.M., A
| | - Ashraf Eskandari
- From the Department of Radiology, Neuroradiology Division, University of Virginia, Charlottesville, VA (G.Z., M.W.); Department of Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (M.W.); Department of Public Health Sciences, University of Virginia, Charlottesville, VA (J.T.P, W.X.); Department of Neurology, Military General Hospital of Beijing PLA, Beijing, China (G.Z., W.Z.); Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (P.M., A
| | - Weiwei Zhang
- From the Department of Radiology, Neuroradiology Division, University of Virginia, Charlottesville, VA (G.Z., M.W.); Department of Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (M.W.); Department of Public Health Sciences, University of Virginia, Charlottesville, VA (J.T.P, W.X.); Department of Neurology, Military General Hospital of Beijing PLA, Beijing, China (G.Z., W.Z.); Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (P.M., A
| | - Max Wintermark
- From the Department of Radiology, Neuroradiology Division, University of Virginia, Charlottesville, VA (G.Z., M.W.); Department of Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (M.W.); Department of Public Health Sciences, University of Virginia, Charlottesville, VA (J.T.P, W.X.); Department of Neurology, Military General Hospital of Beijing PLA, Beijing, China (G.Z., W.Z.); Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (P.M., A
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Mortimer AM, Simpson E, Bradley MD, Renowden SA. Computed tomography angiography in hyperacute ischemic stroke: prognostic implications and role in decision-making. Stroke 2013; 44:1480-8. [PMID: 23493735 DOI: 10.1161/strokeaha.111.679522] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alex M Mortimer
- Department of Neuroradiology, Frenchay Hospital, Frenchay Park Rd, Bristol, BS161LE, United Kingdom.
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37
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González RG, Copen WA, Schaefer PW, Lev MH, Pomerantz SR, Rapalino O, Chen JW, Hunter GJ, Romero JM, Buchbinder BR, Larvie M, Hirsch JA, Gupta R. The Massachusetts General Hospital acute stroke imaging algorithm: an experience and evidence based approach. J Neurointerv Surg 2013; 5 Suppl 1:i7-12. [PMID: 23493340 PMCID: PMC3623036 DOI: 10.1136/neurintsurg-2013-010715] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The Massachusetts General Hospital Neuroradiology Division employed an experience and evidence based approach to develop a neuroimaging algorithm to best select patients with severe ischemic strokes caused by anterior circulation occlusions (ACOs) for intravenous tissue plasminogen activator and endovascular treatment. Methods found to be of value included the National Institutes of Health Stroke Scale (NIHSS), non-contrast CT, CT angiography (CTA) and diffusion MRI. Perfusion imaging by CT and MRI were found to be unnecessary for safe and effective triage of patients with severe ACOs. An algorithm was adopted that includes: non-contrast CT to identify hemorrhage and large hypodensity followed by CTA to identify the ACO; diffusion MRI to estimate the core infarct; and NIHSS in conjunction with diffusion data to estimate the clinical penumbra.
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Affiliation(s)
- Ramon Gilberto González
- Neuroradiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
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