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Migdady I, Johnson-Black PH, Leslie-Mazwi T, Malhotra R. Current and Emerging Endovascular and Neurocritical Care Management Strategies in Large-Core Ischemic Stroke. J Clin Med 2023; 12:6641. [PMID: 37892779 PMCID: PMC10607145 DOI: 10.3390/jcm12206641] [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: 09/16/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
The volume of infarcted tissue in patients with ischemic stroke is consistently associated with increased morbidity and mortality. Initial studies of endovascular thrombectomy for large-vessel occlusion excluded patients with established large-core infarcts, even when large volumes of salvageable brain tissue were present, due to the high risk of hemorrhagic transformation and reperfusion injury. However, recent retrospective and prospective studies have shown improved outcomes with endovascular thrombectomy, and several clinical trials were recently published to evaluate the efficacy of endovascular management of patients presenting with large-core infarcts. With or without thrombectomy, patients with large-core infarcts remain at high risk of in-hospital complications such as hemorrhagic transformation, malignant cerebral edema, seizures, and others. Expert neurocritical care management is necessary to optimize blood pressure control, mitigate secondary brain injury, manage cerebral edema and elevated intracranial pressure, and implement various neuroprotective measures. Herein, we present an overview of the current and emerging evidence pertaining to endovascular treatment for large-core infarcts, recent advances in neurocritical care strategies, and their impact on optimizing patient outcomes.
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Affiliation(s)
- Ibrahim Migdady
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Phoebe H. Johnson-Black
- Department of Neurosurgery, Division of Neurocritical Care, UCLA David Geffen School of Medicine, Ronald Reagan Medical Center, Los Angeles, CA 90095, USA;
| | | | - Rishi Malhotra
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
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Neurological Functional Independence After Endovascular Thrombectomy and Different Imaging Modalities for Large Infarct Core Assessment : A Systematic Review and Meta-analysis. Clin Neuroradiol 2023; 33:21-29. [PMID: 35920865 DOI: 10.1007/s00062-022-01202-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 07/10/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To investigate the rate of neurological functional independence (NFI) at 90 days in patients with large infarct core (LIC), which was evaluated by different imaging modalities before endovascular thrombectomy (EVT). METHODS PubMed and EMBASE were searched for original studies on clinical functional outcomes at 90 days in LIC patients who received EVT treatment from inception to 28 September 2021. The pooled NFI rates were calculated using random effects model according to different imaging modalities and criteria. RESULTS We included 34 studies enrolling 2997 LIC patients. The NFI rates were 23% (95% confidence interval, CI 15-32%) and 24% (95% CI 10-38%) when LIC was defined as core volume ≥50 ml and ≥ 70 ml separately on computed tomography perfusion, 36% (95% CI 23-48%) and 21% (95% CI 17-25%) when LIC was defined as core volume ≥ 50 ml and ≥ 70 ml separately on magnetic resonance diffusion-weighted imaging (DWI), 28% (95% CI 24-32%) and 37% (95% CI 21-53%) when LIC was defined as DWI-ASPECTS ≤ 5 and ≤ 6 separately, 23% (95% CI 19-27%) and 32% (95% CI 18-46%) when LIC was defined as NCCT-ASPECTS ≤ 5 and ≤ 6 separately. CONCLUSION Similar NFI rates could be obtained after EVT in LIC patients if proper LIC criteria were select according to the imaging modality.
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Katyal A, Bhaskar SMM. Value of pre-intervention computed tomography perfusion imaging in the assessment of tissue outcome and long-term clinical prognosis in patients with anterior circulation acute ischemic stroke receiving reperfusion therapy: a systematic review. Acta Radiol 2022; 63:1243-1254. [PMID: 34342497 DOI: 10.1177/02841851211035892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Computed tomography perfusion (CTP) imaging has emerged as an important adjunct to the current armamentarium of acute ischemic stroke (AIS) workflow. However, its adoption in routine clinical practice is far from optimal. PURPOSE To investigate the putative association of CTP imaging biomarkers in the assessment of prognosis in acute ischemic stroke. MATERIAL AND METHODS We performed a systematic review of the literature using MEDLINE, EMBASE, and Cochrane Central Register of Clinical Trials focusing on CTP biomarkers, tissue-based and clinical-based patient outcomes. We included randomized controlled trials, prospective cohort studies, and case-controlled studies published from January 2005 to 28 August 2020. Two independent reviewers conducted the study appraisal, data extraction, and quality assessment of the studies. RESULTS A total of 60 full-text studies were included in the final systematic review analysis. Increasing infarct core volume is associated with reduced odds of achieving functional independence (modified Rankin score 0-2) at 90 days and is correlated with the final infarct volume when reperfusion is achieved. CONCLUSION CTP has value in assessing tissue perfusion status in the hyperacute stroke setting and the long-term clinical prognosis of patients with AIS receiving reperfusion therapy. However, the prognostic use of CTP requires optimization and further validation.
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Affiliation(s)
- Anubhav Katyal
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW, Australia.,University of New South Wales (UNSW), South West Sydney Clinical School, Sydney, NSW, Australia
| | - Sonu Menachem Maimonides Bhaskar
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW, Australia.,Liverpool Hospital & South West Sydney Local Health District (SWSLHD), Department of Neurology & Neurophysiology, Sydney, NSW, Australia.,NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW, Australia.,Thrombolysis and Endovascular WorkFLOw Network (TEFLON), Sydney, NSW, Australia
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Hoving JW, Koopman MS, Tolhuisen ML, van Voorst H, Brehm M, Berkhemer OA, Coutinho JM, Beenen LFM, Marquering HA, Emmer BJ, Majoie CBLM. Accuracy of CT perfusion ischemic core volume and location estimation: A comparison between four ischemic core estimation approaches using syngo.via. PLoS One 2022; 17:e0272276. [PMID: 35917382 PMCID: PMC9345340 DOI: 10.1371/journal.pone.0272276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 07/15/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Computed tomography perfusion (CTP) is widely used in the evaluation of acute ischemic stroke patients for endovascular thrombectomy (EVT). The stability of CTP core estimation is suboptimal and varies between software packages. We aimed to quantify the volumetric and spatial agreement between the CTP ischemic core and follow-up infarct for four ischemic core estimation approaches using syngo.via. METHODS We included successfully reperfused, EVT-treated patients with baseline CTP and 24h follow-up diffusion weighted magnetic resonance imaging (DWI) (November 2017-September 2020). Data were processed with syngo.via VB40 using four core estimation approaches based on: cerebral blood volume (CBV)<1.2mL/100mL with and without smoothing filter, relative cerebral blood flow (rCBF)<30%, and rCBF<20%. The follow-up infarct was segmented on DWI. RESULTS In 59 patients, median estimated CTP core volumes for four core estimation approaches ranged from 12-39 mL. Median 24h follow-up DWI infarct volume was 11 mL. The intraclass correlation coefficient (ICC) showed moderate-good volumetric agreement for all approaches (range 0.61-0.76). Median Dice was low for all approaches (range 0.16-0.21). CTP core overestimation >10mL occurred least frequent (14/59 [24%] patients) using the CBV-based core estimation approach with smoothing filter. CONCLUSIONS In successfully reperfused patients who underwent EVT, syngo.via CTP ischemic core estimation showed moderate volumetric and spatial agreement with the follow-up infarct on DWI. In patients with complete reperfusion after EVT, the volumetric agreement was excellent. A CTP core estimation approach based on CBV<1.2 mL/100mL with smoothing filter least often overestimated the follow-up infarct volume and is therefore preferred for clinical decision making using syngo.via.
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Affiliation(s)
- Jan W. Hoving
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- * E-mail:
| | - Miou S. Koopman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Manon L. Tolhuisen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus Brehm
- Siemens Healthcare GmbH, Computed Tomography, Forchheim, Germany
| | - Olvert A. Berkhemer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Jonathan M. Coutinho
- Department of Neurology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Ludo F. M. Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Henk A. Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Bart J. Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Charles B. L. M. Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
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Malikova H, Weichet J. Diagnosis of Ischemic Stroke: As Simple as Possible. Diagnostics (Basel) 2022; 12:diagnostics12061452. [PMID: 35741262 PMCID: PMC9221735 DOI: 10.3390/diagnostics12061452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/06/2022] [Accepted: 06/10/2022] [Indexed: 11/29/2022] Open
Abstract
The absolute majority of strokes in high-income countries, roughly 91%, are of ischemic origin. This review is focused on acute ischemic stroke (AIS) with large vessel occlusion (LVO) in the anterior circulation, which is considered the most devastating subtype of AIS. Moreover, stroke survivors impose substantial direct and indirect costs of care as well as costs due to productivity loss. We review of diagnostic possibilities of individual imaging methods such as computed tomography and magnetic resonance imaging, and discuss their pros and cons in the imaging of AIS. The goals of non-invasive imaging in AIS are as follows: (a) to rule out intracranial hemorrhage and to quickly exclude hemorrhagic stroke and contraindications for intravenous thrombolysis; (b) to identify potential LVO and its localization and to quickly provide guidance for endovascular treatment; (c) to assess/estimate the volume or size of the ischemic core. We suggest fast diagnostic management, which is able to quickly satisfy the above-mentioned diagnostic goals in AIS with LVO.
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Affiliation(s)
- Hana Malikova
- Correspondence: ; Tel.: +420-267-162-400; Fax: +420-267-162-409
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Vagal A, Saba L. Artificial Intelligence in "Code Stroke"-A Paradigm Shift: Do Radiologists Need to Change Their Practice? Radiol Artif Intell 2022; 4:e210204. [PMID: 35391761 DOI: 10.1148/ryai.210204] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 12/27/2021] [Accepted: 12/29/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Achala Vagal
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH 45267-0525 (A.V.); and Department of Diagnostic Imaging and Radiology, University of Cagliari, Cagliari, Italy (L.S.)
| | - Luca Saba
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH 45267-0525 (A.V.); and Department of Diagnostic Imaging and Radiology, University of Cagliari, Cagliari, Italy (L.S.)
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Potreck A, Falbesaner A, Seker F, Weyland CS, Mundiyanapurath S, Heiland S, Bendszus M, Pfaff JAR. Accuracy and reliability of PBV ASPECTS, CBV ASPECTS and NCCT ASPECTS in acute ischaemic stroke: a matched-pair analysis. Neuroradiol J 2021; 34:585-592. [PMID: 34014792 PMCID: PMC8649194 DOI: 10.1177/19714009211015771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE To investigate the reliability and accuracy of Alberta Stroke Program Early Computed Tomography Scores (ASPECTS) derived from flatpanel detector computed tomography pooled blood volume maps compared to non-contrast computed tomography and multidetector computed tomography perfusion cerebral blood volume maps. METHODS ASPECTS from pooled blood volume maps were evaluated retrospectively by two experienced readers for 37 consecutive patients with acute middle cerebral artery (MCA) M1 occlusion who underwent flatpanel detector computed tomography perfusion imaging before mechanical thrombectomy between November 2016 and February 2019. For comparison with ASPECTS from non-contrast computed tomography and cerebral blood volume maps, a matched-pair analysis according to pre-stroke modified Rankin scale, age, stroke severity, site of occlusion, time from stroke onset to imaging and final modified thrombolysis in cerebral infarction (mTICI) was performed in a separate group of patients who underwent multimodal computed tomography prior to mechanical thrombectomy between June 2015 and February 2019. Follow-up ASPECTS were derived from either non-contrast computed tomography or from magnetic resonance imaging (in seven patients) one day after mechanical thrombectomy. RESULTS Interrater agreement was best for non-contrast computed tomography ASPECTS (w-kappa = 0.74, vs. w-kappa = 0.63 for cerebral blood volume ASPECTS and w-kappa = 0.53 for pooled blood volume ASPECTS). Also, accuracy, defined as correlation between acute and follow-up ASPECTS, was best for non-contrast computed tomography ASPECTS (Spearman ρ = 0.86 (0.65-0.97), P < 0.001), while it was lower and comparable for pooled blood volume ASPECTS (ρ = 0.58 (0.32-0.79), P < 0.001) and cerebral blood volume ASPECTS (ρ = 0.52 (0.17-0.80), P = 0.001). It was noteworthy that cases of relevant infarct overestimation by two or more ASPECTS regions (compared to follow-up imaging) were observed for both acute pooled blood volume and cerebral blood volume ASPECTS but occurred more often for acute pooled blood volume ASPECTS (25% vs. 5%, P = 0.02). CONCLUSION Non-contrast computed tomography ASPECTS outperformed both pooled blood volume ASPECTS and cerebral blood volume ASPECTS in accuracy and reliability. Importantly, relevant infarct overestimation was observed more often in pooled blood volume ASPECTS than cerebral blood volume ASPECTS, limiting its present clinical applicability for acute stroke imaging.
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Affiliation(s)
- Arne Potreck
- Department of Neuroradiology,
University Hospital Heidelberg, Heidelberg, Germany
| | - Alina Falbesaner
- Department of Neuroradiology,
University Hospital Heidelberg, Heidelberg, Germany
| | - Fatih Seker
- Department of Neuroradiology,
University Hospital Heidelberg, Heidelberg, Germany
| | - Charlotte S Weyland
- Department of Neuroradiology,
University Hospital Heidelberg, Heidelberg, Germany
| | | | - Sabine Heiland
- Department of Neuroradiology,
University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology,
University Hospital Heidelberg, Heidelberg, Germany
| | - Johannes AR Pfaff
- Department of Neuroradiology,
University Hospital Heidelberg, Heidelberg, Germany
- Department of Neuroradiology,
University Hospital Salzburg, Christian-Doppler-Klinik, Salzburg, Austria
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8
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Almallouhi E, Al Kasab S, Hubbard Z, Bass EC, Porto G, Alawieh A, Chalhoub R, Jabbour PM, Starke RM, Wolfe SQ, Arthur AS, Samaniego E, Maier I, Howard BM, Rai A, Park MS, Mascitelli J, Psychogios M, De Leacy R, Dumont T, Levitt MR, Polifka A, Osbun J, Crosa R, Kim JT, Casagrande W, Yoshimura S, Matouk C, Kan PT, Williamson RW, Gory B, Mokin M, Fragata I, Zaidat O, Yoo AJ, Spiotta AM. Outcomes of Mechanical Thrombectomy for Patients With Stroke Presenting With Low Alberta Stroke Program Early Computed Tomography Score in the Early and Extended Window. JAMA Netw Open 2021; 4:e2137708. [PMID: 34878550 PMCID: PMC8655598 DOI: 10.1001/jamanetworkopen.2021.37708] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
IMPORTANCE Limited data are available about the outcomes of mechanical thrombectomy (MT) for real-world patients with stroke presenting with a large core infarct. OBJECTIVE To investigate the safety and effectiveness of MT for patients with large vessel occlusion and an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 2 to 5. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which combines the prospectively maintained databases of 28 thrombectomy-capable stroke centers in the US, Europe, and Asia. The study included 2345 patients presenting with an occlusion in the internal carotid artery or M1 segment of the middle cerebral artery from January 1, 2016, to December 31, 2020. Patients were followed up for 90 days after intervention. The ASPECTS is a 10-point scoring system based on the extent of early ischemic changes on the baseline noncontrasted computed tomography scan, with a score of 10 indicating normal and a score of 0 indicating ischemic changes in all of the regions included in the score. EXPOSURE All patients underwent MT in one of the included centers. MAIN OUTCOMES AND MEASURES A multivariable regression model was used to assess factors associated with a favorable 90-day outcome (modified Rankin Scale score of 0-2), including interaction terms between an ASPECTS of 2 to 5 and receiving MT in the extended window (6-24 hours from symptom onset). RESULTS A total of 2345 patients who underwent MT were included (1175 women [50.1%]; median age, 72 years [IQR, 60-80 years]; 2132 patients [90.9%] had an ASPECTS of ≥6, and 213 patients [9.1%] had an ASPECTS of 2-5). At 90 days, 47 of the 213 patients (22.1%) with an ASPECTS of 2 to 5 had a modified Rankin Scale score of 0 to 2 (25.6% [45 of 176] of patients who underwent successful recanalization [modified Thrombolysis in Cerebral Ischemia score ≥2B] vs 5.4% [2 of 37] of patients who underwent unsuccessful recanalization; P = .007). Having a low ASPECTS (odds ratio, 0.60; 95% CI, 0.38-0.85; P = .002) and presenting in the extended window (odds ratio, 0.69; 95% CI, 0.55-0.88; P = .001) were associated with worse 90-day outcome after controlling for potential confounders, without significant interaction between these 2 factors (P = .64). CONCLUSIONS AND RELEVANCE In this cohort study, more than 1 in 5 patients presenting with an ASPECTS of 2 to 5 achieved 90-day functional independence after MT. A favorable outcome was nearly 5 times more likely for patients with low ASPECTS who had successful recanalization. The association of a low ASPECTS with 90-day outcomes did not differ for patients presenting in the early vs extended MT window.
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Affiliation(s)
- Eyad Almallouhi
- Department of Neurosurgery, Medical University of South Carolina, Charleston
- Department of Neurology, Medical University of South Carolina, Charleston
| | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, Charleston
- Department of Neurology, Medical University of South Carolina, Charleston
| | - Zachary Hubbard
- Department of Neurosurgery, Medical University of South Carolina, Charleston
| | - Eric C. Bass
- Department of Radiology, Medical University of South Carolina, Charleston
| | - Guilherme Porto
- Department of Neurosurgery, Medical University of South Carolina, Charleston
| | - Ali Alawieh
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Reda Chalhoub
- Department of Neurosurgery, Medical University of South Carolina, Charleston
| | - Pascal M. Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Robert M. Starke
- Department of Neurosurgery, University of Miami Health System, Miami, Florida
| | - Stacey Q. Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Adam S. Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Science Center, Memphis
| | - Edgar Samaniego
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Brian M. Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Ansaar Rai
- Department of Radiology, West Virginia School of Medicine, Morgantown
| | - Min S. Park
- Department of Neurosurgery, University of Virginia, Charlottesville
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio
| | | | - Reade De Leacy
- Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | - Travis Dumont
- Department of Neurosurgery, University of Arizona, Tuscon
| | | | - Adam Polifka
- Department of Neurosurgery, University of Florida, Gainesville
| | - Joshua Osbun
- Department of Neurological Surgery, Washington University, St Louis, Missouri
| | - Roberto Crosa
- Department of Neurosurgery, Endovascular Neurological Center, Montevideo, Uruguay
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Walter Casagrande
- Department of Cerebrovascular and Endovascular Neurosurgery, Hospital Juan Fernandez, Buenos Aires, Argentina
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Peter T Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston
| | | | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa
| | - Isabel Fragata
- Neuroradiology Department, Hospital São José Centro Hospitalar, Lisboa, Portugal
| | - Osama Zaidat
- Neuroscience Department, Bon Secours Mercy Health St Vincent Medical Center, Toledo, Ohio
| | - Albert J. Yoo
- Department of Radiology, Texas Stroke Institute, Dallas–Fort Worth
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9
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Jing M, Yeo JYP, Holmin S, Andersson T, Arnberg F, Bhogal P, Yang C, Gopinathan A, Tu TM, Tan BYQ, Sia CH, Teoh HL, Paliwal PR, Chan BPL, Sharma V, Yeo LLL. Preprocedural Imaging : A Review of Different Radiological Factors Affecting the Outcome of Thrombectomy. Clin Neuroradiol 2021; 32:13-24. [PMID: 34709411 DOI: 10.1007/s00062-021-01095-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 08/25/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Endovascular treatment (EVT) has strong evidence for its effectiveness in treatment of acute ischemic stroke (AIS); however, up to half of the patients who undergo EVT still do not have good functional outcomes. Various prethrombectomy radiological factors have been shown to be associated with good clinical outcomes and may be the key to better functional outcomes, reduced complications, and reduced mortality. In this paper, we reviewed the current literature on these imaging parameters so they can be employed to better estimate the probability of procedural success, therefore allowing for more effective preprocedural planning of EVT strategies. We reviewed articles in the literature related to imaging factors which have been shown to be associated with EVT success. The factors which are reviewed in this paper included: anatomical factors such as 1) the type of aortic arch and its characteristics, 2) the characteristics of the thrombus such as length, clot burden, permeability, location, 3) the middle cerebral artery features including the tortuosity and underlying intracranial stenosis, 4) perfusion scans estimating the volume of infarct and the penumbra and 5) the effect of collaterals on the procedure. The prognostic effect of each factor on the successful outcome of EVT is described. The identification of preprocedural thrombectomy imaging factors can help to improve the chances of recanalization, functional outcomes, and mortality. It allows the interventionist to make time-sensitive decisions in the treatment of acute ischemic stroke.
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Affiliation(s)
- Mingxue Jing
- Division of Neurology, Department of Medicine, National University Health System, 1 E Kent Ridge Road, 119228, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Joshua Y P Yeo
- Department of Medicine, National University Health System, Singapore, Singapore
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Tommy Andersson
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, 171 76, Stockholm, Sweden
- Department of Medical Imaging, AZ Groeninge, 8500, Kortrijk, Belgium
| | - Fabian Arnberg
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Paul Bhogal
- Department of Neuroradiology, St.Bartholomew's and the Royal London Hospital, London, UK
| | - Cunli Yang
- Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Anil Gopinathan
- Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tian Ming Tu
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Benjamin Yong Qiang Tan
- Division of Neurology, Department of Medicine, National University Health System, 1 E Kent Ridge Road, 119228, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ching Hui Sia
- National University Heart Centre, National University Health System, Singapore, Singapore
| | - Hock Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, 1 E Kent Ridge Road, 119228, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Prakash R Paliwal
- Division of Neurology, Department of Medicine, National University Health System, 1 E Kent Ridge Road, 119228, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bernard P L Chan
- Division of Neurology, Department of Medicine, National University Health System, 1 E Kent Ridge Road, 119228, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Vijay Sharma
- Division of Neurology, Department of Medicine, National University Health System, 1 E Kent Ridge Road, 119228, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Leonard L L Yeo
- Division of Neurology, Department of Medicine, National University Health System, 1 E Kent Ridge Road, 119228, Singapore, Singapore.
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, 171 76, Stockholm, Sweden.
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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10
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Ren Z, Huo X, Ma G, Tong X, Kumar J, Pressman E, Chen W, Yuan G, Wang AYC, Wei M, Zhang J, Nan G, Zhu Q, Liu Y, Zhang L, Song W, Zhou Z, Wang G, Li T, Luo J, Wang E, Ling W, Ju D, Song C, Liu SD, Gui L, Li T, Liu Y, Zhao J, Guo Z, Zheng H, Sun Y, Xu N, Wang YJ, Miao Z. Selection criteria for large core trials: rationale for the ANGEL-ASPECT study design. J Neurointerv Surg 2021; 14:107-110. [PMID: 34326195 PMCID: PMC8785010 DOI: 10.1136/neurintsurg-2021-017798] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2021] [Indexed: 02/05/2023]
Affiliation(s)
- Zeguang Ren
- Department of Neurosurgery, Cleveland Clinic Martin Health, Port St Lucie, Florida, USA
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Gaoting Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Jay Kumar
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Elliot Pressman
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, Fujian, China
| | - Guangxiong Yuan
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, Hunan, China
| | - Alvin Yi-Chou Wang
- Department of Neurosurgery, Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, Guangdong, China
| | - Ming Wei
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Jiangang Zhang
- Department of Neurology, Anyang People's Hospital, Anyang, Henan, China
| | - Guangxian Nan
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Qiyi Zhu
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Yajie Liu
- Department of Neurosurgery, Shenzhen Hospital of Southern Medical University, Shenzhen, Guangdong, China
| | - Liyong Zhang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong, China
| | - Weigen Song
- Department of Neurology, Yancheng Third People's Hospital, Yancheng, Jiangsu, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Guoqing Wang
- Department of Neurology, Bin zhou People's Hospital, Binzhou, Shandong, China
| | - Tianxiao Li
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Jun Luo
- Department of Neurology, Sichuan Mianyang 404 Hospital, Mianyang, Sichuan, China
| | - En Wang
- Department of Neurology, Taizhou Hospital of Zhejiang Province, Linhai, Zhejiang, China
| | - Wentong Ling
- Department of Neurology, ZhongShan City People's Hospital, Zhongshan, China
| | - Dongsheng Ju
- Department of Neurology, Songyuan Jilin oil Field Hospital, Songyuan, Jilin, China
| | - Cunfeng Song
- Department of Interventional Neuroradiology, Liaocheng 3rd People's Hospital, Liaocheng, Shandong, China
| | - Shu-Dong Liu
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Liqiang Gui
- Emergency and Critical Stroke Ambulance Center, Langfang Changzheng Hospital, Langfang, Hebei, China
| | - Tong Li
- Department of Neurosurgery, Nanning Second Peoples Hospital, Nanning, Guangxi, China
| | - Yan Liu
- Department of Neurology, Jingjiang People's Hospital, Jingjiang, Jiangsu, China
| | - Junfeng Zhao
- Department of Neurology, SiPing Central People's Hospital, Siping, Jilin, China
| | - Zaiyu Guo
- Department of Neurology, Tianjin teda Hospital, Tianjin, China
| | - Hongbo Zheng
- Department of Neurology, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Yaxuan Sun
- Department of Neurology, Shanxi Provincial Peoples Hospital, Taiyuan, Shanxi, China
| | - Na Xu
- Department of Neurology, Xiamen Medical College Affiliated Second Hospital, Xiamen, Fujian, China
| | - Yong Jun Wang
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
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11
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Abdelkhaleq R, Kim Y, Khose S, Kan P, Salazar-Marioni S, Giancardo L, Sheth SA. Automated prediction of final infarct volume in patients with large-vessel occlusion acute ischemic stroke. Neurosurg Focus 2021; 51:E13. [PMID: 34198252 DOI: 10.3171/2021.4.focus21134] [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: 03/01/2021] [Accepted: 04/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In patients with large-vessel occlusion (LVO) acute ischemic stroke (AIS), determinations of infarct size play a key role in the identification of candidates for endovascular stroke therapy (EVT). An accurate, automated method to quantify infarct at the time of presentation using widely available imaging modalities would improve screening for EVT. Here, the authors aimed to compare the performance of three measures of infarct core at presentation, including an automated method using machine learning. METHODS Patients with LVO AIS who underwent successful EVT at four comprehensive stroke centers were identified. Patients were included if they underwent concurrent noncontrast head CT (NCHCT), CT angiography (CTA), and CT perfusion (CTP) with Rapid imaging at the time of presentation, and MRI 24 to 48 hours after reperfusion. NCHCT scans were analyzed using the Alberta Stroke Program Early CT Score (ASPECTS) graded by neuroradiology or neurology expert readers. CTA source images were analyzed using a previously described machine learning model named DeepSymNet (DSN). Final infarct volume (FIV) was determined from diffusion-weighted MRI sequences using manual segmentation. The primary outcome was the performance of the three infarct core measurements (NCHCT-ASPECTS, CTA with DSN, and CTP-Rapid) to predict FIV, which was measured using area under the receiver operating characteristic (ROC) curve (AUC) analysis. RESULTS Among 76 patients with LVO AIS who underwent EVT and met inclusion criteria, the median age was 67 years (IQR 54-76 years), 45% were female, and 37% were White. The median National Institutes of Health Stroke Scale score was 16 (IQR 12-22), and the median NCHCT-ASPECTS on presentation was 8 (IQR 7-8). The median time between when the patient was last known to be well and arrival was 156 minutes (IQR 73-303 minutes), and between NCHCT/CTA/CTP to groin puncture was 73 minutes (IQR 54-81 minutes). The AUC was obtained at three different cutoff points: 10 ml, 30 ml, and 50 ml FIV. At the 50-ml FIV cutoff, the AUC of ASPECTS was 0.74; of CTP core volume, 0.72; and of DSN, 0.82. Differences in AUCs for the three predictors were not significant for the three FIV cutoffs. CONCLUSIONS In a cohort of patients with LVO AIS in whom reperfusion was achieved, determinations of infarct core at presentation by NCHCT-ASPECTS and a machine learning model analyzing CTA source images were equivalent to CTP in predicting FIV. These findings have suggested that the information to accurately predict infarct core in patients with LVO AIS was present in conventional imaging modalities (NCHCT and CTA) and accessible by machine learning methods.
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Affiliation(s)
| | | | | | - Peter Kan
- 2Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas
| | | | - Luca Giancardo
- 3Center for Precision Health, UTHealth School of Biomedical Informatics, UTHealth McGovern Medical School, Houston; and
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12
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Jadhav AP, Hacke W, Dippel DWJ, Simonsen CZ, Costalat V, Fiehler J, Thomalla G, Bendszus M, Andersson T, Mattle HP, Leslie-Mazwi TM, Mokin M, Yoo AJ, Zaidat OO, Sheth SA, Jovin TG, Liebeskind D. Select wisely: the ethical challenge of defining large core with perfusion in the early time window. J Neurointerv Surg 2021; 13:497-499. [PMID: 33875552 DOI: 10.1136/neurintsurg-2021-017386] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 02/01/2023]
Affiliation(s)
| | - Werner Hacke
- Neurology, University of Heidelberg, Heidelberg, Germany
| | | | | | - Vincent Costalat
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, Montepellier, France
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Goetz Thomalla
- Neurology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Tommy Andersson
- Departments of Radiology and Neurology, AZ Groeninge, Kortrijk, Belgium.,Department of Neuroradiology; Department of Clinical Neuroscience, Karolinska University Hospital; Karolinska Institutet, Stockholm, Sweden
| | | | | | - Maxim Mokin
- Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Albert J Yoo
- Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Osama O Zaidat
- Neuroscience, St Vincent Mercy Hospital, Toledo, Ohio, USA
| | - Sunil A Sheth
- Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Tudor G Jovin
- Neurology, Cooper University Hospital, Camden, New Jersey, USA
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13
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Bouslama M, Barreira CM, Haussen DC, Rodrigues GM, Pisani L, Frankel MR, Nogueira RG. Endovascular reperfusion outcomes in patients with a stroke and low ASPECTS is highly dependent on baseline infarct volumes. J Neurointerv Surg 2021; 14:117-121. [PMID: 33722970 DOI: 10.1136/neurintsurg-2020-017184] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/12/2021] [Accepted: 02/13/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients with large vessel occlusion stroke (LVOS) and a low Alberta Stroke Program Early CT Score (ASPECTS) are often not offered endovascular therapy (ET) as they are thought to have a poor prognosis. OBJECTIVE To compare the outcomes of patients with low and high ASPECTS undergoing ET based on baseline infarct volumes. METHODS Review of a prospectively collected endovascular database at a tertiary care center between September 2010 and March 2020. All patients with anterior circulation LVOS and interpretable baseline CT perfusion (CTP) were included. Subjects were divided into groups with low ASPECTS (0-5) and high ASPECTS (6-10) and subsequently into limited and large CTP-core volumes (cerebral blood flow 30% >70 cc). The primary outcome measure was the difference in rates of 90-day good outcome as defined by a modified Rankin Scale (mRS) score of 0 to 2 across groups. RESULTS 1248 patients fit the inclusion criteria. 125 patients had low ASPECTS, of whom 16 (12.8%) had a large core (LC), whereas 1123 patients presented with high ASPECTS, including 29 (2.6%) patients with a LC. In the category with a low ASPECTS, there was a trend towards lower rates of functional independence (90-day modified Rankin Scale (mRS) score 0-2) in the LC group (18.8% vs 38.9%, p=0.12), which became significant after adjusting for potential confounders in multivariable analysis (aOR=0.12, 95% CI 0.016 to 0.912, p=0.04). Likewise, LC was associated with significantly lower rates of functional independence (31% vs 51.9%, p=0.03; aOR=0.293, 95% CI 0.095 to 0.909, p=0.04) among patients with high ASPECTS. CONCLUSIONS Outcomes may vary significantly in the same ASPECTS category depending on infarct volume. Patients with ASPECTS ≤5 but baseline infarct volumes ≤70 cc may achieve independence in nearly 40% of the cases and thus should not be excluded from treatment.
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Affiliation(s)
- Mehdi Bouslama
- Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Clara M Barreira
- Department of Neurology, Neurosurgery and Radiology, Emory University, Atlanta, Georgia, USA
| | - Diogo C Haussen
- Department of Neurology, Neurosurgery and Radiology, Emory University, Atlanta, Georgia, USA
| | | | - Leonardo Pisani
- Department of Radiology, Georgetown University Medical Center, Washington, District of Columbia, USA
| | | | - Raul G Nogueira
- Department of Neurology and Interventional Neuroradiology, Emory University, Atlanta, Georgia, USA
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14
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García-Tornel Á, Campos D, Rubiera M, Boned S, Olivé-Gadea M, Requena M, Ciolli L, Muchada M, Pagola J, Rodriguez-Luna D, Deck M, Juega J, Rodríguez-Villatoro N, Sanjuan E, Tomasello A, Piñana C, Hernández D, Álvarez-Sabin J, Molina CA, Ribó M. Ischemic Core Overestimation on Computed Tomography Perfusion. Stroke 2021; 52:1751-1760. [PMID: 33682453 DOI: 10.1161/strokeaha.120.031800] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Álvaro García-Tornel
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Daniel Campos
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Marta Rubiera
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Sandra Boned
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Marta Olivé-Gadea
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Manuel Requena
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Ludovico Ciolli
- Stroke Unit, Neurology Unit, Department of Neuroscience, Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Italy (L.C.)
| | - Marian Muchada
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Jorge Pagola
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - David Rodriguez-Luna
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Matias Deck
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Jesus Juega
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Noelia Rodríguez-Villatoro
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Estela Sanjuan
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Alejandro Tomasello
- Department of Interventional Neurorradiology (A.T., C.P., D.H.), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Carlos Piñana
- Department of Interventional Neurorradiology (A.T., C.P., D.H.), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - David Hernández
- Department of Interventional Neurorradiology (A.T., C.P., D.H.), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - José Álvarez-Sabin
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Carlos A Molina
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
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Recanalization Therapy for Acute Ischemic Stroke with Large Vessel Occlusion: Where We Are and What Comes Next? Transl Stroke Res 2021; 12:369-381. [PMID: 33409732 PMCID: PMC8055567 DOI: 10.1007/s12975-020-00879-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/15/2020] [Accepted: 11/18/2020] [Indexed: 12/18/2022]
Abstract
In the past 5 years, the success of multiple randomized controlled trials of recanalization therapy with endovascular thrombectomy has transformed the treatment of acute ischemic stroke with large vessel occlusion. The evidence from these trials has now established endovascular thrombectomy as standard of care. This review will discuss the chronological evolution of large vessel occlusion treatment from early medical therapy with tissue plasminogen activator to the latest mechanical thrombectomy. Additionally, it will highlight the potential areas in endovascular thrombectomy for acute ischemic stroke open to exploration and further progress in the next decade.
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16
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Automated CT Perfusion Imaging to Aid in the Selection of Patients With Acute Ischemic Stroke for Mechanical Thrombectomy: A Health Technology Assessment. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2020; 20:1-87. [PMID: 33240454 PMCID: PMC7668535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Stroke is a sudden interruption in the blood supply to a part of the brain, causing loss of neurological function. It is the third leading cause of death in Canada and affects mainly older people. In the acute setting, neuroimaging is integral to stroke evaluation and decision-making. The neuroimaging results guide patient selection for mechanical thrombectomy. Using automated image processing techniques facilitates efficient review of this information and communication between centres. We conducted a health technology assessment of automated CT perfusion imaging as a tool for selecting stroke patients with anterior circulation occlusion for mechanical thrombectomy. This assessment included an evaluation of clinical effectiveness, cost-effectiveness, and the budget impact of publicly funding automated CT perfusion imaging. METHODS We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each study using QUADAS-2 or the Cochrane risk-of-bias tool, and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and approximated cost-effectiveness based on previous analyses. We also analyzed the budget impact of publicly funding automated CT perfusion imaging to evaluate people with acute ischemic stroke in Ontario. RESULTS Automated CT perfusion imaging had a sensitivity of 84% for identifying the infarct core (dead tissue that does not recover despite restoring blood flow with mechanical thrombectomy), compared with diffusion-weighted MRI imaging at 24 hours. One study reported that 7% of patients were misclassified with respect to eligibility for mechanical thrombectomy (either erroneously classified as eligible or erroneously classified non-eligible). Two randomized controlled trials (DEFUSE 3 and DAWN) demonstrated the efficacy of mechanical thrombectomy up to 24 hours after stroke onset, with patient selection guided by automated CT perfusion imaging. These data showed that a significantly higher proportion of patients in the mechanical thrombectomy group achieved functional independence compared with the standard care group (DEFUSE 3: risk ratio: 2.67 [95% confidence interval 1.60-4.48]; DAWN: adjusted rate difference: 33% [95% credible interval 21%-44%]; GRADE: Moderate).A previous health technology assessment in stroke patients presenting at 0 to 6 hours after stroke symptom onset and the results from recent randomized controlled trials for patients presenting at 6 to 24 hours informed the evaluation of cost-effectiveness. Mechanical thrombectomy informed by automated CT perfusion imaging to assess eligibility is likely to be cost-effective for patients presenting at 6 to 24 hours after stroke symptom onset. The annual budget impact of publicly funding automated CT perfusion imaging in Ontario over the next 5 years would be $1.3 million in year 1 and $0.9 million each year thereafter. Some of the costs of automated CT perfusion imaging could be offset by avoiding unnecessary patient transfers between hospitals. CONCLUSIONS Automated CT perfusion imaging has an acceptable sensitivity and specificity for detecting brain areas that have been affected by stroke. In patients selected for mechanical thrombectomy using automated CT perfusion imaging, there was significant improvement in functional independence. Mechanical thrombectomy informed by automated CT perfusion imaging is likely to be cost-effective. We estimate that publicly funding automated CT perfusion imaging in Ontario would result in additional costs of $1.3 million in year 1 and $0.9 million per year thereafter.
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17
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Kremenova K, Holesta M, Peisker T, Girsa D, Weichet J, Lukavsky J, Malikova H. Is limited-coverage CT perfusion helpful in treatment decision-making in patients with acute ischemic stroke? Quant Imaging Med Surg 2020; 10:1908-1916. [PMID: 33014724 DOI: 10.21037/qims-20-555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background The initial core infarct volume predicts treatment outcome in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). According to the literature, CT perfusion (CTP) is able to evaluate cerebral parenchymal viability and assess the initial core in AIS. We prospectively studied whether limited-coverage CTP with automated core calculation correlates with the final infarct volume on follow-up non-enhanced CT (NECT) in patients successfully treated by mechanical thrombectomy. Methods We enrolled 31 stroke patients (20 women aged 74.4±12.9 years and 11 men aged 66±15.4 years; median initial NIHSS score 15.5) with occlusion of the medial cerebral artery and/or the internal carotid artery that were treated by successful mechanical thrombectomy. CTP performed in a 38.6 mm slab at the level of basal ganglia was included in the CT stroke protocol, but was not used to determine indication for mechanical thrombectomy. The infarction core volume based on CTP was automatically calculated using dedicated software with a threshold defined as cerebral blood flow <30% of the value in the contralateral healthy hemisphere. The final infarction volume was measured on 24-hour follow-up NECT in the same slab with respect to CTP. Pearson and Spearman correlation coefficients and robust linear regression were used for comparison of both volumes, P values <0.05 were considered as statistically significant. Results The median time from stroke onset to CT was 77 minutes (range, 31-284 minutes), and the median time from CT to vessel recanalization was 95 minutes (range, 55-215 minutes). The mean CTP-calculated core infarct volume was 24.3±19.2 mL (median 19 mL, range 1-79 mL), while the mean final infarct volume was 21.5±39.5 mL (median 8 mL; range 0-210 mL). Only a weak relationship was found between the CTP-calculated core and final infarct volume [Pr(29) =0.32, P=0.078; rho =0.40, P=0.028]. Regression analysis showed CTP significantly overestimated lower volumes. Conclusions In our prospective study, the infarction core calculated using limited-coverage CTP only weakly correlated with the final infarction volume measured on 24-hour follow-up NECT; moreover, CTP significantly overestimated lower volumes. Our results do not support the use of limited-coverage CTP for guiding treatment recommendations in patients with AIS.
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Affiliation(s)
- Karin Kremenova
- Department of Radiology, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, Prague, Czech Rep
| | - Michal Holesta
- Department of Radiology, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, Prague, Czech Rep
| | - Tomas Peisker
- Department of Neurology, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, Prague, Czech Rep
| | - David Girsa
- Department of Radiology, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, Prague, Czech Rep
| | - Jiri Weichet
- Department of Radiology, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, Prague, Czech Rep
| | - Jiří Lukavsky
- Psychology Department, Faculty of Arts, Charles University, Prague, Czech Rep
| | - Hana Malikova
- Department of Radiology, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, Prague, Czech Rep.,Institute of Anatomy, Second Medical Faculty, Charles University, Prague, Czech Rep
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18
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Wake-up Stroke: New Opportunities for Acute Stroke Treatment. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2020. [DOI: 10.1007/s40138-020-00205-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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19
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Nael K, Sakai Y, Khatri P, Prestigiacomo CJ, Puig J, Vagal A. Imaging-based Selection for Endovascular Treatment in Stroke. Radiographics 2019; 39:1696-1713. [DOI: 10.1148/rg.2019190030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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20
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Sheth SA, Lopez-Rivera V, Barman A, Grotta JC, Yoo AJ, Lee S, Inam ME, Savitz SI, Giancardo L. Machine Learning-Enabled Automated Determination of Acute Ischemic Core From Computed Tomography Angiography. Stroke 2019; 50:3093-3100. [PMID: 31547796 DOI: 10.1161/strokeaha.119.026189] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- The availability of and expertise to interpret advanced neuroimaging recommended in the guideline-based endovascular stroke therapy (EST) evaluation are limited. Here, we develop and validate an automated machine learning-based method that evaluates for large vessel occlusion (LVO) and ischemic core volume in patients using a widely available modality, computed tomography angiogram (CTA). Methods- From our prospectively maintained stroke registry and electronic medical record, we identified patients with acute ischemic stroke and stroke mimics with contemporaneous CTA and computed tomography perfusion (CTP) with RAPID (IschemaView) post-processing as a part of the emergent stroke workup. A novel convolutional neural network named DeepSymNet was created and trained to identify LVO as well as infarct core from CTA source images, against CTP-RAPID definitions. Model performance was measured using 10-fold cross validation and receiver-operative curve area under the curve (AUC) statistics. Results- Among the 297 included patients, 224 (75%) had acute ischemic stroke of which 179 (60%) had LVO. Mean CTP-RAPID ischemic core volume was 23±42 mL. LVO locations included internal carotid artery (13%), M1 (44%), and M2 (21%). The DeepSymNet algorithm autonomously learned to identify the intracerebral vasculature on CTA and detected LVO with AUC 0.88. The method was also able to determine infarct core as defined by CTP-RAPID from the CTA source images with AUC 0.88 and 0.90 (ischemic core ≤30 mL and ≤50 mL). These findings were maintained in patients presenting in early (0-6 hours) and late (6-24 hours) time windows (AUCs 0.90 and 0.91, ischemic core ≤50 mL). DeepSymNet probabilities from CTA images corresponded with CTP-RAPID ischemic core volumes as a continuous variable with r=0.7 (Pearson correlation, P<0.001). Conclusions- These results demonstrate that the information needed to perform the neuroimaging evaluation for endovascular therapy with comparable accuracy to advanced imaging modalities may be present in CTA, and the ability of machine learning to automate the analysis.
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Affiliation(s)
- Sunil A Sheth
- From the Departments of Neurology (S.A.S., V.L.-R., S.L., S.I.S.), UTHealth McGovern Medical School, Houston, TX.,Institute for Stroke and Cerebrovascular Diseases (S.I.S., S.A.S., A.B., L.G.), UTHealth McGovern Medical School, Houston, TX
| | - Victor Lopez-Rivera
- From the Departments of Neurology (S.A.S., V.L.-R., S.L., S.I.S.), UTHealth McGovern Medical School, Houston, TX
| | - Arko Barman
- Institute for Stroke and Cerebrovascular Diseases (S.I.S., S.A.S., A.B., L.G.), UTHealth McGovern Medical School, Houston, TX.,Center for Precision Health, UTHealth School of Biomedical Informatics, Houston, TX (A.B., L.G.)
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital, Texas Medical Center, Houston (J.C.G.)
| | - Albert J Yoo
- Texas Stroke Institute, Dallas-Fort Worth (A.J.Y.)
| | - Songmi Lee
- From the Departments of Neurology (S.A.S., V.L.-R., S.L., S.I.S.), UTHealth McGovern Medical School, Houston, TX
| | - Mehmet E Inam
- Neurosurgery (M.E.I.), UTHealth McGovern Medical School, Houston, TX
| | - Sean I Savitz
- From the Departments of Neurology (S.A.S., V.L.-R., S.L., S.I.S.), UTHealth McGovern Medical School, Houston, TX.,Institute for Stroke and Cerebrovascular Diseases (S.I.S., S.A.S., A.B., L.G.), UTHealth McGovern Medical School, Houston, TX
| | - Luca Giancardo
- Diagnostic and Interventional Imaging (L.G.), UTHealth McGovern Medical School, Houston, TX.,Institute for Stroke and Cerebrovascular Diseases (S.I.S., S.A.S., A.B., L.G.), UTHealth McGovern Medical School, Houston, TX.,Center for Precision Health, UTHealth School of Biomedical Informatics, Houston, TX (A.B., L.G.)
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21
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Sakai Y, Delman BN, Fifi JT, Tuhrim S, Wheelwright D, Doshi AH, Mocco J, Nael K. Estimation of Ischemic Core Volume Using Computed Tomographic Perfusion. Stroke 2019; 49:2345-2352. [PMID: 30355089 DOI: 10.1161/strokeaha.118.021952] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background and Purpose- Estimation of infarction based on computed tomographic perfusion (CTP) has been challenging, mainly because of noise associated with CTP data. The Bayesian method is a robust probabilistic method that minimizes effects of oscillation, tracer delay, and noise during residue function estimation compared with other deconvolution methods. This study compares CTP-estimated ischemic core volume calculated by the Bayesian method and by the commonly used block-circulant singular value deconvolution technique. Methods- Patients were included if they had (1) anterior circulation ischemic stroke, (2) baseline CTP, (3) successful recanalization defined by thrombolysis in cerebral infarction ≥IIb, and (4) minimum infarction volume of >5 mL on follow-up magnetic resonance imaging (MRI). CTP data were processed with circulant singular value deconvolution and Bayesian methods. Two established CTP methods for estimation of ischemic core volume were applied: cerebral blood flow (CBF) method (relative CBF, <30% within the region of delay >2 seconds) and cerebral blood volume method (<2 mL per 100 g within the region of relative mean transit time >145%). Final infarct volume was determined on MRI (fluid-attenuated inversion recovery images). CTP and MRI-derived ischemic core volumes were compared by univariate and Bland-Altman analysis. Results- Among 35 patients included, the mean/median (mL) difference for CTP-estimated ischemic core volume against MRI was -4/-7 for Bayesian CBF ( P=0.770), 20/12 for Bayesian cerebral blood volume ( P=0.041), 21/10 for circulant singular value deconvolution CBF ( P=0.006), and 35/18 for circulant singular value deconvolution cerebral blood volume ( P<0.001). Among all methods, Bayesian CBF provided the narrowest limits of agreement (-28 to 19 mL) in comparison with MRI. Conclusions- Despite existing variabilities between CTP postprocessing methods, Bayesian postprocessing increases accuracy and limits variability in CTP estimation of ischemic core.
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Affiliation(s)
- Yu Sakai
- From the Department of Radiology (Y.S., B.N.D., A.H.D., K.N.), Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Bradley N Delman
- From the Department of Radiology (Y.S., B.N.D., A.H.D., K.N.), Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Johanna T Fifi
- Department of Neurology (J.T.F., S.T., D.W.), Icahn School of Medicine at Mount Sinai, New York City, NY.,Department of Neurosurgery (J.T.F., J.M.), Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Stanley Tuhrim
- Department of Neurology (J.T.F., S.T., D.W.), Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Danielle Wheelwright
- Department of Neurology (J.T.F., S.T., D.W.), Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Amish H Doshi
- From the Department of Radiology (Y.S., B.N.D., A.H.D., K.N.), Icahn School of Medicine at Mount Sinai, New York City, NY
| | - J Mocco
- Department of Neurosurgery (J.T.F., J.M.), Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Kambiz Nael
- From the Department of Radiology (Y.S., B.N.D., A.H.D., K.N.), Icahn School of Medicine at Mount Sinai, New York City, NY
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22
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Hoving JW, Marquering HA, Majoie CBLM, Yassi N, Sharma G, Liebeskind DS, van der Lugt A, Roos YB, van Zwam W, van Oostenbrugge RJ, Goyal M, Saver JL, Jovin TG, Albers GW, Davalos A, Hill MD, Demchuk AM, Bracard S, Guillemin F, Muir KW, White P, Mitchell PJ, Donnan GA, Davis SM, Campbell BCV. Volumetric and Spatial Accuracy of Computed Tomography Perfusion Estimated Ischemic Core Volume in Patients With Acute Ischemic Stroke. Stroke 2019; 49:2368-2375. [PMID: 30355095 DOI: 10.1161/strokeaha.118.020846] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background and Purpose- The volume of estimated ischemic core using computed tomography perfusion (CTP) imaging can identify ischemic stroke patients who are likely to benefit from reperfusion, particularly beyond standard time windows. We assessed the accuracy of pretreatment CTP estimated ischemic core in patients with successful endovascular reperfusion. Methods- Patients from the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) and EXTEND-IA TNK (Tenecteplase Versus Alteplase Before Endovascular Therapy for Ischemic Stroke) databases who had pretreatment CTP, >50% angiographic reperfusion, and follow-up magnetic resonance imaging at 24 hours were included. Ischemic core volume on baseline CTP data was estimated using relative cerebral blood flow <30% (RAPID, iSchemaView). Follow-up diffusion magnetic resonance imaging was registered to CTP, and the diffusion lesion was outlined using a semiautomated algorithm. Volumetric and spatial agreement (using Dice similarity coefficient, average Hausdorff distance, and precision) was assessed, and expert visual assessment of quality was performed. Results- In 120 patients, median CTP estimated ischemic core volume was 7.8 mL (IQR, 1.8-19.9 mL), and median diffusion lesion volume at 24 hours was 30.8 mL (IQR, 14.9-67.6 mL). Median volumetric difference was 4.4 mL (IQR, 1.2-12.0 mL). Dice similarity coefficient was low (median, 0.24; IQR, 0.15-0.37). The median precision (positive predictive value) of 0.68 (IQR, 0.40-0.88) and average Hausdorff distance (median, 3.1; IQR, 1.8-5.7 mm) indicated reasonable spatial agreement for regions estimated as ischemic core at baseline. Overestimation of total ischemic core volume by CTP was uncommon. Expert visual review revealed overestimation predominantly in white matter regions. Conclusions- CTP estimated ischemic core volumes were substantially smaller than follow-up diffusion-weighted imaging lesions at 24 hours despite endovascular reperfusion within 2 hours of imaging. This may be partly because of infarct growth. Volumetric CTP core overestimation was uncommon and not related to imaging-to-reperfusion time. Core overestimation in white matter should be a focus of future efforts to improve CTP accuracy.
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Affiliation(s)
- Jan W Hoving
- From the Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (J.W.H., N.Y., G.S., S.M.D., B.C.V.C.), University of Melbourne, Parkville, Australia.,Department of Radiology and Nuclear Medicine (J.W.H., H.A.M., C.B.L.M.M.), Amsterdam UMC (Universitair Medische Centra), University of Amsterdam, the Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine (J.W.H., H.A.M., C.B.L.M.M.), Amsterdam UMC (Universitair Medische Centra), University of Amsterdam, the Netherlands.,Department of Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC (Universitair Medische Centra), University of Amsterdam, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine (J.W.H., H.A.M., C.B.L.M.M.), Amsterdam UMC (Universitair Medische Centra), University of Amsterdam, the Netherlands
| | - Nawaf Yassi
- From the Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (J.W.H., N.Y., G.S., S.M.D., B.C.V.C.), University of Melbourne, Parkville, Australia.,The Florey Institute of Neuroscience and Mental Health (N.Y., G.A.D.), University of Melbourne, Parkville, Australia
| | - Gagan Sharma
- From the Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (J.W.H., N.Y., G.S., S.M.D., B.C.V.C.), University of Melbourne, Parkville, Australia
| | - David S Liebeskind
- Neurovascular Imaging Research Core, Department of Neurology (D.S.L.), University of California at Los Angeles
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.)
| | - Yvo B Roos
- Department of Neurology (Y.B.R.), Amsterdam UMC (Universitair Medische Centra), University of Amsterdam, the Netherlands
| | - Wim van Zwam
- Department of Radiology (W.v.Z.), Cardiovascular Research Institute (CARIM), Maastricht University Medical Center, the Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology (R.J.v.O.), Cardiovascular Research Institute (CARIM), Maastricht University Medical Center, the Netherlands
| | - Mayank Goyal
- Department of Radiology, University of Calgary, Foothills Hospital, AB, Canada (M.G.)
| | - Jeffrey L Saver
- Department of Neurology (J.L.S.), University of California at Los Angeles
| | - Tudor G Jovin
- Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, CA (T.G.J.)
| | | | - Antoni Davalos
- Department of Neuroscience, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Spain (A.D.)
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, AB, Canada (M.D.H., A.M.D.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, AB, Canada (M.D.H., A.M.D.)
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, INSERM U 947 (S.B.), University of Lorraine and University Hospital of Nancy, France
| | - Francis Guillemin
- INSERM CIC-EC 1433 Clinical Epidemiology (F.G.), University of Lorraine and University Hospital of Nancy, France
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Scotland, United Kingdom (K.W.M.)
| | - Philip White
- Institute of Neuroscience, Newcastle University (P.W.), Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom.,Department of Neuroradiology (P.W.), Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Australia (P.J.M.)
| | - Geoffrey A Donnan
- The Florey Institute of Neuroscience and Mental Health (N.Y., G.A.D.), University of Melbourne, Parkville, Australia
| | - Stephen M Davis
- From the Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (J.W.H., N.Y., G.S., S.M.D., B.C.V.C.), University of Melbourne, Parkville, Australia
| | - Bruce C V Campbell
- From the Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (J.W.H., N.Y., G.S., S.M.D., B.C.V.C.), University of Melbourne, Parkville, Australia
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23
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Bhuva P, Yoo AJ, Jadhav AP, Jovin TG, Haussen DC, Bonafe A, Budzik RJ, Yavagal DR, Hanel RA, Hassan AE, Ribo M, Cognard C, Sila CA, Morgan PM, Zhang Y, Shields R, Smith W, Saver JL, Liebeskind DS, Nogueira RG. Noncontrast Computed Tomography Alberta Stroke Program Early CT Score May Modify Intra-Arterial Treatment Effect in DAWN. Stroke 2019; 50:2404-2412. [DOI: 10.1161/strokeaha.118.024583] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
It is unknown whether noncontrast computed tomography (NCCT) can identify patients who will benefit from intra-arterial treatment (IAT) in the extended time window. We sought to characterize baseline Alberta Stroke Program Early CT Score (ASPECTS) in DAWN (DWI or CTP Assessment With Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention With Trevo) and to assess whether ASPECTS modified IAT effect.
Methods—
Core lab adjudicated ASPECTS scores were analyzed. The trial cohort was divided into 2 groups by qualifying imaging (computed tomography versus magnetic resonance imaging). ASPECTS-by-treatment interaction was tested for the trial coprimary end points (90-day utility-weighted modified Rankin Scale (mRS) score and mRS, 0–2), mRS 0 to 3, and ordinal mRS. ASPECTS was evaluated separately as an ordinal and a dichotomized (0–6 versus 7–10) variable.
Results—
Of 205 DAWN subjects, 123 (60%) had NCCT ASPECTS, and 82 (40%) had diffusion weighted imaging ASPECTS. There was a significant ordinal NCCT ASPECTS-by-treatment interaction for 90-day utility-weighted mRS (interaction
P
=0.04) and mRS 0 to 2 (interaction
P
=0.02). For both end points, IAT effect was more pronounced at higher NCCT ASPECTS. The dichotomized NCCT ASPECTS-by-treatment interaction was significant only for mRS 0 to 2 (interaction
P
=0.04), where greater treatment benefit was seen in the ASPECTS 7 to 10 group (odds ratio, 7.50 [2.71–20.77] versus odds ratio, 0.48 [0.04–5.40]). A bidirectional treatment effect was observed in the NCCT ASPECTS 0 to 6 group, with treatment associated with not only more mRS 0 to 3 outcomes (50% versus 25%) but also more mRS 5 to 6 outcomes (40% versus 25%). There was no significant modification of IAT effect by diffusion weighted imaging ASPECTS.
Conclusions—
Baseline NCCT ASPECTS appears to modify IAT effect in DAWN. Higher NCCT ASPECTS was associated with greater benefit from IAT. No treatment interaction was observed for diffusion weighted imaging ASPECTS.
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Affiliation(s)
- Parita Bhuva
- From the Division of Neurointervention, Texas Stroke Institute, Dallas-Fort Worth (P.B., A.J.Y.)
| | - Albert J. Yoo
- From the Division of Neurointervention, Texas Stroke Institute, Dallas-Fort Worth (P.B., A.J.Y.)
| | - Ashutosh P. Jadhav
- The Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA (A.P.J.)
| | - Tudor G. Jovin
- Cooper University Hospital Neurological Institute, Camden, New Jersey (T.G.J.)
| | - Diogo C. Haussen
- The Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (D.C.H., R.G.N.)
| | - Alain Bonafe
- Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.)
| | - Ronald J. Budzik
- Department of Interventional Neuroradiology, Riverside Methodist Hospital/Ohio Health Research Institute, Columbus (R.J.B.)
| | - Dileep R. Yavagal
- Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine–Jackson Memorial Hospital, Miami, FL (D.R.Y.)
| | | | - Ameer E. Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Valley Baptist Hospital, Harlingen (A.E.H.)
| | - Marc Ribo
- Stroke Unit, Hospital Vall d’Hebrón, Barcelona, Spain (M.R.)
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.)
| | | | | | | | - Ryan Shields
- Stryker Neurovascular, Fremont, CA (P.M.M., Y.S., R.S.)
| | - Wade Smith
- Department of Neurology, University of California, San Francisco (W.S.)
| | - Jeffrey L. Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles (UCLA) (J.L.S., D.S.L.)
| | - David S. Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles (UCLA) (J.L.S., D.S.L.)
| | - Raul G. Nogueira
- The Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA (D.C.H., R.G.N.)
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24
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Nael K, Tadayon E, Wheelwright D, Metry A, Fifi JT, Tuhrim S, De Leacy RA, Doshi AH, Chang HL, Mocco J. Defining Ischemic Core in Acute Ischemic Stroke Using CT Perfusion: A Multiparametric Bayesian-Based Model. AJNR Am J Neuroradiol 2019; 40:1491-1497. [PMID: 31413007 DOI: 10.3174/ajnr.a6170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/07/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE The Bayesian probabilistic method has shown promising results to offset noise-related variability in perfusion analysis. Using CTP, we aimed to find optimal Bayesian-estimated thresholds based on multiparametric voxel-level models to estimate the ischemic core in patients with acute ischemic stroke. MATERIALS AND METHODS Patients with anterior circulation acute ischemic stroke who had baseline CTP and achieved successful recanalization were included. In a subset of patients, multiparametric voxel-based models were constructed between Bayesian-processed CTP maps and follow-up MRIs to identify pretreatment CTP parameters that were predictive of infarction using robust logistic regression. Subsequently CTP-estimated ischemic core volumes from our Bayesian model were compared against routine clinical practice oscillation singular value decomposition-relative cerebral blood flow <30%, and the volumetric accuracy was assessed against final infarct volume. RESULTS In the constructed multivariate voxel-based model, 4 variables were identified as independent predictors of infarction: TTP, relative CBF, differential arterial tissue delay, and differential mean transit time. At an optimal cutoff point of 0.109, this model identified infarcted voxels with nearly 80% accuracy. The limits of agreement between CTP-estimated ischemic core and final infarct volume ranged from -25 to 27 mL for the Bayesian model, compared with -61 to 52 mL for oscillation singular value decomposition-relative CBF. CONCLUSIONS We established thresholds for the Bayesian model to estimate the ischemic core. The described multiparametric Bayesian-based model improved consistency in CTP estimation of the ischemic core compared with the methodology used in current clinical routine.
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Affiliation(s)
- K Nael
- From the Department of Radiology (K.N., E.T., A.M., A.H.D.), Neuroimaging Advanced and Exploratory Lab
| | - E Tadayon
- From the Department of Radiology (K.N., E.T., A.M., A.H.D.), Neuroimaging Advanced and Exploratory Lab
| | | | - A Metry
- From the Department of Radiology (K.N., E.T., A.M., A.H.D.), Neuroimaging Advanced and Exploratory Lab
| | - J T Fifi
- Departments of Neurology (D.W., J.F., S.T.).,Neurosurgery (J.F., R.A.D.L., J.M.)
| | - S Tuhrim
- Departments of Neurology (D.W., J.F., S.T.)
| | | | - A H Doshi
- From the Department of Radiology (K.N., E.T., A.M., A.H.D.), Neuroimaging Advanced and Exploratory Lab
| | - H L Chang
- Population Health Science and Policy (H.C.), Icahn School of Medicine at Mount Sinai, New York, New York
| | - J Mocco
- Neurosurgery (J.F., R.A.D.L., J.M.)
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25
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Yu W, Jiang WJ. A Simple Imaging Guide for Endovascular Thrombectomy in Acute Ischemic Stroke: From Time Window to Perfusion Mismatch and Beyond. Front Neurol 2019; 10:502. [PMID: 31178813 PMCID: PMC6543836 DOI: 10.3389/fneur.2019.00502] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/25/2019] [Indexed: 01/01/2023] Open
Affiliation(s)
- Wengui Yu
- Department of Neurology, University of California Irvine, Irvine, CA, United States
| | - Wei-Jian Jiang
- New Era Stroke Care and Research Institute, The Rocket Force General Hospital, Beijing, China
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26
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Shaker H, Khan M, Mulderink T, Koehler TJ, Scurek R, Tubergen T, Packard L, Singer J, Mazaris P, Min J, Wees N, Khan N, Abdelhak T. The Role of CT Perfusion in Defining the Clinically Relevant Core Infarction to Guide Thrombectomy Selection in Patients with Acute Stroke. J Neuroimaging 2019; 29:331-334. [DOI: 10.1111/jon.12599] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/09/2019] [Accepted: 01/10/2019] [Indexed: 11/29/2022] Open
Affiliation(s)
- Hussam Shaker
- Neuroscience Institute, Division of NeurologySpectrum Health
- Michgan State University
| | - Muhib Khan
- Neuroscience Institute, Division of NeurologySpectrum Health
- Michgan State University
| | - Todd Mulderink
- Department of RadiologySpectrum Health
- Division of RadiologyMichigan State University
- Advanced Radiology ServicesPC
| | - Tracy J. Koehler
- Scholarly Activity SupportSpectrum Health Office of Medical Education
| | - Raymond Scurek
- Michgan State University
- Emergency Care Specialists
- Central Michigan University
| | | | | | - Justin Singer
- Michgan State University
- Neuroscience Institute, Division of NeurosurgerySpectrum Health
| | - Paul Mazaris
- Michgan State University
- Neuroscience Institute, Division of NeurosurgerySpectrum Health
| | - Jiangyong Min
- Neuroscience Institute, Division of NeurologySpectrum Health
- Michgan State University
| | - Nabil Wees
- Neuroscience Institute, Division of NeurologySpectrum Health
- Michgan State University
| | - Nadeem Khan
- Neuroscience Institute, Division of NeurologySpectrum Health
- Michgan State University
| | - Tamer Abdelhak
- Neuroscience Institute, Division of NeurologySpectrum Health
- Michgan State University
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Haranhalli N, Mbabuike N, Grewal SS, Hasan TF, Heckman MG, Freeman WD, Gupta V, Vibhute P, Brown BL, Miller DA, Jahromi BS, Tawk RG. Topographic correlation of infarct area on CT perfusion with functional outcome in acute ischemic stroke. J Neurosurg 2019; 132:33-41. [PMID: 30641833 DOI: 10.3171/2018.8.jns181095] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 08/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The role of CT perfusion (CTP) in the management of patients with acute ischemic stroke (AIS) remains a matter of debate. The primary aim of this study was to evaluate the correlation between the areas of infarction and penumbra on CTP scans and functional outcome in patients with AIS. METHODS This was a retrospective review of 100 consecutively treated patients with acute anterior circulation ischemic stroke who underwent CT angiography (CTA) and CTP at admission between February 2011 and October 2014. On CTP, the volume of ischemic core and penumbra was measured using the Alberta Stroke Program Early CT Score (ASPECTS). CTA findings were also noted, including the site of occlusion and regional leptomeningeal collateral (rLMC) score. Functional outcome was defined by modified Rankin Scale (mRS) score obtained at discharge. Associations of CTP and CTA parameters with mRS scores at discharge were assessed using multivariable proportional odds logistic regression models. RESULTS The median age was 67 years (range 19-95 years), and the median NIH Stroke Scale score was 16 (range 2-35). In a multivariable analysis adjusting for potential confounding variables, having an infarct on CTP scans in the following regions was associated with a worse mRS score at discharge: insula ribbon (p = 0.043), perisylvian fissure (p < 0.001), motor strip (p = 0.007), M2 (p < 0.001), and M5 (p = 0.023). A worse mRS score at discharge was more common in patients with a greater volume of infarct core (p = 0.024) and less common in patients with a greater rLMC score (p = 0.004). CONCLUSIONS The results of this study provide evidence that several CTP parameters are independent predictors of functional outcome in patients with AIS and have potential to identify those patients most likely to benefit from reperfusion therapy in the treatment of AIS.
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Affiliation(s)
| | | | | | | | | | | | - Vivek Gupta
- 4Department of Radiology, Mayo Clinic, Jacksonville, Florida; and
| | - Prasanna Vibhute
- 4Department of Radiology, Mayo Clinic, Jacksonville, Florida; and
| | | | | | - Babak S Jahromi
- 5Departments of Neurologic Surgery and Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Affiliation(s)
| | - Katharina Schregel
- From the Department of Neuroradiology, University Medical Center Goettingen, Germany
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Etherton MR, Barreto AD, Schwamm LH, Wu O. Neuroimaging Paradigms to Identify Patients for Reperfusion Therapy in Stroke of Unknown Onset. Front Neurol 2018; 9:327. [PMID: 29867736 PMCID: PMC5962731 DOI: 10.3389/fneur.2018.00327] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 04/25/2018] [Indexed: 12/17/2022] Open
Abstract
Despite the proven efficacy of intravenous alteplase or endovascular thrombectomy for the treatment of patients with acute ischemic stroke, only a minority receive these treatments. This low treatment rate is due in large part to delay in hospital arrival or uncertainty as to the exact time of onset of ischemic stroke, which renders patients outside the current guideline-recommended window of eligibility for receiving these therapeutics. However, recent pivotal clinical trials of late-window thrombectomy now force us to rethink the value of a simplistic chronological formulation that “time is brain.” We must recognize a more nuanced concept that the rate of tissue death as a function of time is not invariant, that still salvageable tissue at risk of infarction may be present up to 24 h after last-known well, and that those patients may strongly benefit from reperfusion. Multiple studies have sought to address this clinical dilemma using neuroimaging methods to identify a radiographic time-stamp of stroke onset or evidence of salvageable ischemic tissue and thereby increase the number of patients eligible for reperfusion therapies. In this review, we provide a critical analysis of the current state of neuroimaging techniques to select patients with unwitnessed stroke for revascularization therapies and speculate on the future direction of this clinically relevant area of stroke research.
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Affiliation(s)
- Mark R Etherton
- Department of Neurology, JPK Stroke Research Center, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, MA, United States
| | - Andrew D Barreto
- Stroke Division, Department of Neurology, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Lee H Schwamm
- Department of Neurology, JPK Stroke Research Center, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, MA, United States
| | - Ona Wu
- Department of Neurology, JPK Stroke Research Center, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, MA, United States.,Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital (MGH), Charlestown, MA, United States
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30
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Abstract
The Alberta Stroke Program Early CT score (ASPECTS) is a 10-point semiquantitative topographic scoring system developed for the assessment of early ischemic changes (EICs) on noncontrast-enhanced computed tomography (NCCT) in patients with acute ischemic stroke involving the middle cerebral artery (MCA) territory. One point is subtracted from a total score of 10, if an EIC is present in any part of each of the ASPECTS regions. Higher ASPECTS has been associated with better outcomes and a lower risk of symptomatic intracerebral hemorrhage. To date, there are still controversies regarding the utility of ASPECTS for selecting patients for intravenous and intra-arterial therapies. This article provides a comprehensive review regarding methodology, limitations, and interobserver reproducibility of ASPECTS, as well as application of ASPECTS in clinical care. The focus of this review is ASPECTS evaluation on NCCT. The application of ASPECTS on multimodal computed tomography and magnetic resonance imaging (MRI) is briefly described.
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Affiliation(s)
- Supada Prakkamakul
- *Department of Radiology, King Chulalongkorn Memorial Hospital the Thai Red Cross Society, Bangkok, Thailand †Division of Neurointervention, Texas Stroke Institute, Plano, TX
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31
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Maier IL, Behme D, Schnieder M, Tsogkas I, Schregel K, Bähr M, Knauth M, Liman J, Psychogios MN. Early computed tomography-based scores to predict decompressive hemicraniectomy after endovascular therapy in acute ischemic stroke. PLoS One 2017; 12:e0173737. [PMID: 28282456 PMCID: PMC5345861 DOI: 10.1371/journal.pone.0173737] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 02/24/2017] [Indexed: 11/18/2022] Open
Abstract
Background Identification of patients requiring decompressive hemicraniectomy (DH) after endovascular therapy (EVT) is crucial as clinical signs are not reliable and early DH has been shown to improve clinical outcome. The aim of our study was to identify imaging-based scores to predict the risk for space occupying ischemic stroke and DH. Methods Prospectively derived data from patients with acute large artery occlusion within the anterior circulation and EVT was analyzed in this monocentric study. Predictive value of non-contrast cranial computed tomography (ncCT) and cerebral blood volume (CBV) Alberta Stroke Program Early CT score (ASPECTS) were investigated for DH using logistic regression models and Receiver Operating Characteristic Curve analysis. Results From 218 patients with EVT, DH was performed in 20 patients (9.2%). Baseline- (7 vs. 9; p = 0.009) and follow-up ncCT ASPECTS (1 vs. 7, p<0.001) as well as baseline CBV ASPECTS (5 vs. 7, p<0.001) were significantly lower in patients with DH. ncCT (baseline: OR 0.71, p = 0.018; follow-up: OR 0.32, p = <0.001) and CBV ASPECTS (OR 0.63, p = 0.008) predicted DH. Cut-off ncCT-ASPECTS on baseline was 7-, ncCT-ASPECTS on follow-up was 4- and CBV ASPECTS on baseline was 5 points. Conclusions ASPECTS could be useful to early identify patients requiring DH after EVT for acute large vessel occlusion.
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Affiliation(s)
- Ilko L Maier
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Daniel Behme
- Department of Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Marlena Schnieder
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Ioannis Tsogkas
- Department of Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Katharina Schregel
- Department of Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Mathias Bähr
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Michael Knauth
- Department of Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Jan Liman
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
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