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Ahmed RA, Hirsch JA, Leslie-Mazwi TM, Patel AB, Regenhardt RW. Penultimate proof for posterior occlusions: a commentary on "Focused update to guidelines for endovascular therapy for emergent large vessel occlusion: basilar artery occlusion patients". J Neurointerv Surg 2024:jnis-2024-021870. [PMID: 38729744 DOI: 10.1136/jnis-2024-021870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 05/12/2024]
Affiliation(s)
- Rashid A Ahmed
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Ahmed RA, Dmytriw AA, Regenhardt RW, Leslie-Mazwi TM, Hirsch JA. Posterior circulation cerebral infarction: A review of clinical, imaging features, management, and outcomes. Eur J Radiol Open 2023; 11:100523. [PMID: 37745629 PMCID: PMC10511775 DOI: 10.1016/j.ejro.2023.100523] [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: 05/09/2023] [Accepted: 09/11/2023] [Indexed: 09/26/2023] Open
Abstract
Objective This narrative review discusses posterior circulation cerebral infarcts (PCCI) and provides an update given recent randomized trials in the management of basilar artery occlusion (BAO). We examine clinical characteristics, imaging protocols, management updates, and outcomes of PCCI. Methods The following databases were searched: MEDLINE, Scopus, Google Scholar, and Web of Science for articles on PCCI. We included randomized trials and observational studies in humans. We also reviewed relevant references from the literature identified. Results PCCI and BAO is associated with high morbidity and mortality. Early assessment and accurate diagnosis of PCCI remains a clinical challenge. Neuroimaging advances have improved early detection, but barriers remain due to costs and availability. Recent randomized trials provide new insights for BAO patients and support the efficacy of endovascular thrombectomy. Discussion PCCI requires specific diagnostic and management that is distinct from anterior circulation stroke. While further studies are needed in varied populations and in the subset of BAO patients presenting with milder deficits, growing randomized data support the treatment of BAO patients with endovascular thrombectomy.
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Affiliation(s)
- Rashid A. Ahmed
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
| | - Adam A. Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, USA
| | - Robert W. Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, USA
| | - Thabele M. Leslie-Mazwi
- Department of Neurology, Neurosciences Institute, University of Washington, Seattle, WA, USA
| | - Joshua A. Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, USA
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Ahmed RA, Dmytriw AA, Patel AB, Stapleton CJ, Vranic JE, Rabinov JD, Leslie-Mazwi TM, Rost NS, Hirsch JA, Regenhardt RW. Basilar artery occlusion: A review of clinicoradiologic features, treatment selection, and endovascular techniques. Interv Neuroradiol 2023; 29:748-758. [PMID: 35695210 PMCID: PMC10680956 DOI: 10.1177/15910199221106049] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/17/2022] [Accepted: 05/15/2022] [Indexed: 12/20/2022] Open
Abstract
Basilar artery occlusion (BAO) is an infrequent but often fatal subtype of stroke. Predicting outcomes and selecting patients for endovascular therapy (EVT) remains challenging. Advances in neuroimaging and the development of prognostic scoring systems have augmented clinical decision-making over time. Recent randomized trials, BEST (Basilar Artery Occlusion Endovascular Intervention vs. Standard Medical Treatment), BASICS (Basilar Artery International Cooperation Study), BAOCHE (Basilar Artery Occlusion CHinese Endovascular Trial) and ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion), compared EVT and medical management for patients with BAO. These trials yielded mixed results. The former two suggested unclear benefit while the latter two supported a benefit of EVT. While all had limitations, most providers agree caution should be exercised when excluding patients from EVT who may stand to benefit. Further studies are therefore needed to determine the effectiveness, safety, selection criteria, and optimal technical approach for EVT among patients with BAO. Hyperacute-phase advanced imaging can offer several benefits to aid decision making. It is reasonable to exclude patients with low National Institutes of Health Stroke Scale (NIHSS), large imaging-proven cores, and evidence of perforator occlusion by branch atheromatous disease. Herein, we review the clinical presentation, imaging work-up, treatments, and clinical outcomes for BAO, while highlighting knowledge gaps in treatment selection and technique.
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Affiliation(s)
- Rashid A Ahmed
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam A Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Justin E Vranic
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James D Rabinov
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thabele M Leslie-Mazwi
- Department of Neurology, Neurosciences Institute, University of Washington, Seattle, WA, USA
| | - Natalia S Rost
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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4
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Li J, Peng Y, Liu J, Wu J, Yao Y, Gu S, Zhang Z, Li Y, Wang J, Li Y. Estimation of ischemic core in acute ischemic stroke with CT angiography and non-contrast CT: Attenuation changes in ASPECTS regions vs. automated ASPECTS scoring. Front Neurosci 2022; 16:933753. [PMID: 35958990 PMCID: PMC9360489 DOI: 10.3389/fnins.2022.933753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/28/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose Reperfusion therapies for acute ischemic stroke due to large-vessel occlusion (AIS-LVO) are highly time-dependent, and large infarction is related to poor outcomes and risk of symptomatic hemorrhage. It is of significance to investigate and optimize the screening means and selection criteria for reperfusion therapies to identify more appropriate patients with better outcomes. This study aimed to compare the performance of attenuation changes vs. automated Alberta Stroke Program Early CT Score (ASPECTS) and using CT angiography (CTA) source images vs. non-contrast CT (NCCT) in distinguishing the infarction extent of ischemic core volumes ≥ 70 ml within different time windows. Methods A total of 73 patients with AIS-LVO who received multimodal CT were analyzed. The automated software was used to calculate ASPECTS. Attenuation change was defined as the sum of products of relative Hounsfield unit (rHU) values times weighting factors of all 10 ASPECTS regions. rHU value of each region was the HU of the ischemic side over that of the contralateral. The corresponding weighting factors were the regression coefficients derived from a multivariable linear regression model which was used to correlate regional rHU with ischemic core volumes, because each region in the ASPECTS template is weighted disproportionally in the ASPECTS system. Automated ASPECTS and attenuation changes were both calculated using CTA and NCCT, respectively. Results Attenuation changes were correlated with ischemic core volumes within different time windows (Rho ranging from 0.439 to 0.637). In classification of the ischemic core ≥ 70 ml, the performances of attenuation changes were comparable with ASPECTS (area under the curve [AUC] ranging from 0.799 to 0.891), with DeLong’s test (P = 0.079, P = 0.373); using CTA (AUC = 0.842) was not different from NCCT (AUC = 0.838). Conclusion Attenuation changes in ASPECTS regions were correlated with ischemic core volumes. In the classification of infarction volumes, attenuation changes had a high diagnostic ability comparable with automated ASPECTS. Measurement of attenuation changes is not involved in complicated scoring algorithms. This measurement can be used as an available, rapid, reliable, and accurate means to evaluate infarction extent within different time windows. The usefulness of infarction volumes measured by attenuation changes to identify more appropriate patients for reperfusion therapies can be validated in future clinical trials.
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Affiliation(s)
- Jing Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Medical Imaging Center, Central Hospital of Shaoyang, Shaoyang, China
| | - Yuling Peng
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiayang Liu
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiajing Wu
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yunzhuo Yao
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Sirun Gu
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhiwei Zhang
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yi Li
- Artificial Intelligence and Clinical Innovation Research, Neusoft Research of Intelligent Healthcare Technology, Co., Ltd., Shanghai, China
| | - Jingjie Wang
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- *Correspondence: Jingjie Wang,
| | - Yongmei Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Yongmei Li,
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Endovascular Thrombectomy for Acute Basilar Artery Occlusion: Latest Findings and Critical Thinking on Future Study Design. Transl Stroke Res 2022; 13:913-922. [PMID: 35349051 DOI: 10.1007/s12975-022-01008-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
Randomized controlled trials (RCTs) have demonstrated powerful efficacy of endovascular thrombectomy (EVT) for large vessel occlusion in the anterior circulation. The effect of EVT for acute basilar artery occlusion (BAO) in the posterior circulation remains unproven. Here, we highlight the latest findings of observational studies and RCTs of EVT for BAO, with a focus on the predictors of functional outcomes, the limitations of recent RCTs, and critical thinking on future study design. Pooled data from large retrospective studies showed 36.4% favorable outcome at 3 months and 4.6% symptomatic intracranial hemorrhage (sICH). Multivariate logistic regression analysis revealed that higher baseline NIHSS score, pc-ASPECTS < 8, extensive baseline infarction, large pontine infarct, and sICH were independent predictors of poor outcome. Two recent randomized trial BEST (Endovascular treatment vs. standard medical treatment for vertebrobasilar artery occlusion) and BASICS (Basilar Artery International Cooperation Study) failed to demonstrate significant benefit of EVT within 6 or 8 h after stroke symptom onset. The limitations of these studies include slow enrollment, selection bias, high crossover rate, and inclusion of patients with mild deficit. To improve enrollment and minimize risk of diluting the overall treatment effect, futile recanalization and re-occlusion, optimal inclusion/exclusion criteria, including enrollment within 24 h of last known well, NIHSS score ≥ 10, pc-ASPECTS ≥ 8, no large pontine infarct, and the use of rescue therapy for underlying atherosclerotic stenosis, should be considered for future clinical trials.
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Imaging-based outcome prediction in posterior circulation stroke. J Neurol 2022; 269:3800-3809. [PMID: 35257203 PMCID: PMC9217773 DOI: 10.1007/s00415-022-11010-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 02/03/2022] [Accepted: 02/03/2022] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND PURPOSE We developed a machine learning model to allow early functional outcome prediction for patients presenting with posterior circulation (pc)-stroke based on CT-imaging and clinical data at admission. The proposed algorithm utilizes quantitative information from automated multidimensional assessments of posterior circulation Acute Stroke Prognosis Early CT-Score (pc-ASPECTS) regions. Discriminatory power was compared to predictions based on conventional pc-ASPECTS ratings. METHODS We retrospectively analyzed non-contrast CTs and clinical data of 172 pc-stroke patients. 90 days outcome was dichotomized into good and poor using modified Rankin Scale (mRS) cut-offs. Predictive performance was assessed for outcome differentiation at mRS 2, 3, 4 and survival prediction (mRS ≤ 5) using random forest algorithms. Results were compared to conventional pc-ASPECTS and clinical parameters. Models were evaluated in a nested fivefold cross-validation approach. RESULTS Receiver operating characteristic areas under the curves (ROC-AUCs) of the test sets using conventionally rated pc-ASPECTS reached 0.63 for mRS ≤ 4 to 0.68 for mRS ≤ 5 and 0.73 for mRS ≤ 5 to 0.85 for mRS ≤ 2 if clinical data were considered. Pure imaging-based machine learning classifier ROC-AUCs were lowest for mRS ≤ 4 (0.81) and highest for mRS ≤ 5 (0.87). The combined clinical data and machine learning-based model had the highest predictive performance with ROC-AUCs reaching 0.90 for mRS ≤ 2. CONCLUSION Machine learning-based evaluation of pc-ASPECTS regions predicts functional outcome of pc-stroke patients with higher accuracy than conventional assessments. This could optimize triage for additional diagnostics and allocation of best possible medical care and might allow required arrangements of the social environment at an early point of time.
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Fang WH, Chen YC, Tsai MC, Ko PS, Wang DL, Su SL. Novel and Efficient Quantitative Posterior-Circulation-Structure-Based Scale via Noncontrast CT to Predict Ischemic Stroke Prognosis: A Retrospective Study. J Pers Med 2022; 12:jpm12020138. [PMID: 35207627 PMCID: PMC8876281 DOI: 10.3390/jpm12020138] [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: 10/04/2021] [Revised: 12/09/2021] [Accepted: 12/29/2021] [Indexed: 12/10/2022] Open
Abstract
(1) Background: Posterior circulation ischemic stroke has high mortality and disability rates and requires an early prediction prognosis to provide the basis for an interventional approach. Current quantitative measures are only able to accurately assess the prognosis of patients using magnetic resonance imaging (MRI). However, it is difficult to obtain MRI images in critically urgent cases. Therefore, the development of a noncontrast CT-based rapid-assist tool is needed to enhance the value of the clinical application. (2) Objective: This study aimed to develop an auxiliary-annotating noncontrast CT-efficient tool, which is based on a deep learning model, to provide a quantitative scale and the prognosis of posterior circulation ischemic stroke patients. (3) Methods: A total of 31 patients with posterior circulation ischemic stroke, diagnosed in the stroke registry at the Tri-Service General Hospital from November 2019 to July 2020, were included in the study, with a total of 578 CT images collected from noncontrast CT and MRI that were ≤ 3 days apart. A 5-fold cross validation was used to develop an image segmentation model to identify nine posterior circulation structures, and intersection over union (IoU) was used to assess the ability of the model to identify each structure. A quantitative score was integrated to assess the importance of the proportion of ischemic lesions in each posterior circulation structure, and the ROC curve was compared with the semiquantitative score for prognostic power. The prognoses of the patients were defined into two groups of 18 patients. An mRS score of 0–2 at discharge was defined as a good prognosis, while an mRS score of 3–6 was deemed to be a poor prognosis. (4) Results: The performance of the image segmentation model for identifying the nine posterior circulation structures in noncontrast CT images was evaluated. The IoU of the left cerebellum was 0.78, the IoU of the right cerebellum was 0.79, the IoU of the left occipital lobe was 0.74, the IoU of the right occipital lobe was 0.68, the IoU of the left thalamus was 0.73, the IoU of the right thalamus was 0.75, the IoU of the medulla oblongata was 0.82, and the IoU of the midbrain was 0.83. The prognostic AUC of posterior circulation patients predicted using a quantitative integrated score was 0.74, which was significantly higher than that of the pc-ASPECTS (AUC = 0.63, p = 0.035), with a sensitivity of 0.67 and a specificity of 0.72. (5) Conclusions: In this study, a deep learning model was used to develop a noncontrast CT-based quantitative integrated score tool, which is an effective tool for clinicians to assess the prognosis of posterior circulation ischemic stroke.
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Affiliation(s)
- Wen-Hui Fang
- Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan;
| | - Ying-Chu Chen
- School of Public Health, National Defense Medical Center, Taipei 11490, Taiwan; (Y.-C.C.); (P.-S.K.); (D.-L.W.)
| | - Ming-Chen Tsai
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan;
| | - Pi-Shao Ko
- School of Public Health, National Defense Medical Center, Taipei 11490, Taiwan; (Y.-C.C.); (P.-S.K.); (D.-L.W.)
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei 11490, Taiwan
| | - Ding-Lian Wang
- School of Public Health, National Defense Medical Center, Taipei 11490, Taiwan; (Y.-C.C.); (P.-S.K.); (D.-L.W.)
| | - Sui-Lung Su
- School of Public Health, National Defense Medical Center, Taipei 11490, Taiwan; (Y.-C.C.); (P.-S.K.); (D.-L.W.)
- Correspondence:
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Dias BA, Bezerra KB, Bezerra ASDA, Santana VG, Borges RR, Reinaux JCDF, Souza DL, Maluf FB. Importance of computed tomography angiography in acute/hyperacute ischemic stroke. Radiol Bras 2021; 54:360-366. [PMID: 34866695 PMCID: PMC8630949 DOI: 10.1590/0100-3984.2020.0168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/11/2021] [Indexed: 08/30/2023] Open
Abstract
Objective To evaluate the importance of computed tomography and computed tomography angiography (CTA) in stroke protocols, as well as their impact on endovascular treatment and on the determination of the etiology. Materials and Methods Were evaluated 28 patients with acute/hyperacute stroke in the anterior circulation who underwent intracranial and cervical CTA between April 2018 and August 2019. The parameters evaluated were the degree of stenosis, plaque characteristics, type of infarct, treatment, etiology, and the Alberta Stroke Program Early CT Score (ASPECTS). Results Of the 28 patients evaluated, 16 (57.1%) had an ASPECTS of 10 (the maximum score, indicative of normality). Four patients (14.3%) underwent thrombolytic treatment, and seven (25.0%) underwent mechanical thrombectomy. The etiology was atherosclerosis in 32.1% of the patients, cerebral small-vessel disease in 7.1%, cardioembolic in 7.1%, and undetermined in 53.6%. Regarding plaque, 17.9% of the patients presented stenosis ≥ 50%, 21.4% presented stable plaques, and 42.9% presented vulnerable plaques. Patients with a lower ASPECTS were more likely to have relevant stenosis and were more likely to have a total infarct. Conclusion In the evaluation of patients with acute/hyperacute strokes, CTA provides important information, identifying occlusion, as well as helping define the etiology and inform decisions regarding treatment.
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Affiliation(s)
- Bruna Arrais Dias
- Hospital Santa Marta (HSM), Brasília, DF, Brazil.,Hospital Universitário de Brasília, Brasília, DF, Brazil
| | | | - Alexandre Sérgio de Araújo Bezerra
- Hospital Santa Marta (HSM), Brasília, DF, Brazil.,Hospital Universitário de Brasília, Brasília, DF, Brazil.,Universidade de Brasília (UnB), Brasília, DF, Brazil
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Affiliation(s)
- Jared B Cooper
- Department of Neurosurgery, New York Medical College at Westchester Medical Center, Valhalla
| | - Haris Kamal
- Department of Neurosurgery, New York Medical College at Westchester Medical Center, Valhalla
| | - Katarina B Dakay
- Department of Neurosurgery, New York Medical College at Westchester Medical Center, Valhalla
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Liu C, Xie J, Sun S, Li H, Li T, Jiang C, Chen X, Wang J, Le A, Wang J, Li Z, Wang J, Wang W. Hemorrhagic Transformation After Tissue Plasminogen Activator Treatment in Acute Ischemic Stroke. Cell Mol Neurobiol 2020; 42:621-646. [PMID: 33125600 DOI: 10.1007/s10571-020-00985-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/22/2020] [Indexed: 12/17/2022]
Abstract
Hemorrhagic transformation (HT) is a common complication after thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) in ischemic stroke. In this article, recent research progress of HT in vivo and in vitro studies was reviewed. We have discussed new potential mechanisms and possible experimental models of HT development, as well as possible biomarkers and treatment methods. Meanwhile, we compared and analyzed rodent models, large animal models and in vitro BBB models of HT, and the limitations of these models were discussed. The molecular mechanism of HT was investigated in terms of BBB disruption, rt-PA neurotoxicity and the effect of neuroinflammation, matrix metalloproteinases, reactive oxygen species. The clinical features to predict HT were represented including blood biomarkers and clinical factors. Recent progress in neuroprotective strategies to improve HT after stroke treated with rt-PA is outlined. Further efforts need to be made to reduce the risk of HT after rt-PA therapy and improve the clinical prognosis of patients with ischemic stroke.
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Affiliation(s)
- Chengli Liu
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Jie Xie
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Shanshan Sun
- Department of Ultrasound Imaging, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Hui Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Tianyu Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Chao Jiang
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
| | - Xuemei Chen
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Henan, 450000, People's Republic of China
| | - Junmin Wang
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Henan, 450000, People's Republic of China
| | - Anh Le
- Washington University in St. Louis, Saint Louis, MO, 63130, USA
| | - Jiarui Wang
- The Johns Hopkins University, Baltimore, MD, 21218, USA
| | - Zhanfei Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Jian Wang
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Henan, 450000, People's Republic of China.
| | - Wei Wang
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China.
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Abstract
ABSTRACT:Background and Purpose:Large prospective observational studies have cast doubt on the common assumption that endovascular thrombectomy (EVT) is superior to intravenous thrombolysis for patients with acute basilar artery occlusion (BAO). The purpose of this study was to retrospectively review our experience for patients with BAO undergoing EVT with modern endovascular devices.Methods:All consecutive patients undergoing EVT with either a second-generation stent retriever or direct aspiration thrombectomy for BAO at our regional stroke center from January 1, 2013 to March 1, 2019 were included. The primary outcome measure was functional outcome at 1 month using the modified Rankin Scale (mRS) score. Multivariable logistic regression was used to assess the association between patient characteristics and dichotomized mRS.Results:A total of 43 consecutive patients underwent EVT for BAO. The average age was 67 years with 61% male patients. Overall, 37% (16/43) of patients achieved good functional outcome. Successful reperfusion was achieved in 72% (31/43) of cases. The median (interquartile range) stroke onset to treatment time was 420 (270–639) minutes (7 hours) for all patients. The procedure-related complication rate was 9% (4/43). On multivariate analysis, posterior circulation Alberta stroke program early computed tomography score and Basilar Artery on Computed Tomography Angiography score were associated with improved functional outcome.Conclusion:EVT appears to be safe and feasible in patients with BAO. Our finding that time to treatment and successful reperfusion were not associated with improved outcome is likely due to including patients with established infarcts. Given the variability of collaterals in the posterior circulation, the paradigm of utilizing a tissue window may assist in patient selection for EVT. Magnetic resonance imaging may be a reasonable option to determine the extent of ischemia in certain situations.
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Posterior Circulation Thrombectomy—pc-ASPECT Score Applied to Preintervention Magnetic Resonance Imaging Can Accurately Predict Functional Outcome. World Neurosurg 2019; 129:e566-e571. [DOI: 10.1016/j.wneu.2019.05.217] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/25/2019] [Accepted: 05/27/2019] [Indexed: 11/19/2022]
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13
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Valor de la escala ASPECTS de circulación posterior y del índice puente-mesencéfalo en imágenes de TC sin contraste y angiografía por TC en pacientes con oclusiones de la arteria basilar recanalizados tras trombectomía mecánica. RADIOLOGIA 2019; 61:143-152. [DOI: 10.1016/j.rx.2018.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 05/12/2018] [Accepted: 06/10/2018] [Indexed: 11/23/2022]
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Werner M, López-Rueda A, Zarco F, Blasco J, San Román L, Amaro S, Carrero E, Valero R, Oleaga L, Macho J, Bargalló N. Value of Posterior circulation ASPECTS and Pons-Midbrain Index on non-contrast CT and CT Angiography Source Images in patients with basilar artery occlusion recanalized after mechanical thrombectomy. RADIOLOGIA 2019. [DOI: 10.1016/j.rxeng.2018.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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15
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Murayama K, Suzuki S, Matsukiyo R, Takenaka A, Hayakawa M, Tsutsumi T, Fujii K, Katada K, Toyama H. Preliminary study of time maximum intensity projection computed tomography imaging for the detection of early ischemic change in patient with acute ischemic stroke. Medicine (Baltimore) 2018; 97:e9906. [PMID: 29489691 PMCID: PMC5851726 DOI: 10.1097/md.0000000000009906] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Noncontrast computed tomography (NCCT) has been used for the detection of early ischemic change (EIC); however, correct interpretation of NCCT findings requires much clinical experience. This study aimed to assess the accuracy of time maximum intensity projection computed tomography technique (tMIP), which reflects the maximum value for the time phase direction from the dynamic volume data for each projected plane, for detection of EIC, against that of NCCT.Retrospective review of NCCT, cerebral blood volume in CT perfusion (CTP-CBV), and tMIP of 186 lesions from 280 regions evaluated by Alberta Stroke Program Early CT Score (ASPECTS) in 14 patients with acute middle cerebral artery stroke who had undergone whole-brain CTP using 320-row area detector CT was performed. Four radiologists reviewed EIC on NCCT, CTP-CBV, and tMIP in each ASPECTS region at onset using the continuous certainty factor method. Receiver operating characteristic analysis was performed to compare the relative performance for detection of EIC. The correlations were evaluated.tMIP-color showed the best discriminative value for detection of EIC. There were significant differences in the area under the curve for NCCT and tMIP-color, CTP-CBV (P < .05). Scatter plots of ASPECTS showed a positive significant correlation between NCCT, tMIP-gray, tMIP-color, and the follow-up study (NCCT, r = 0.32, P = .0166; tMIP-gray, r = 0.44, P = .0007; tMIP-color, r = 0.34, P = .0104).Because tMIP provides a high contrast parenchymal image with anatomical and vascular information in 1 sequential scan, it showed greater accuracy for detection of EIC and predicted the final infarct extent more accurately than NCCT based on ASPECTS.
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Affiliation(s)
| | | | | | | | | | - Takashi Tsutsumi
- Clinical Application Research Center, Toshiba Medical Systems Corporation, Otawara
| | - Kenji Fujii
- Clinical Application Research Center, Toshiba Medical Systems Corporation, Otawara
| | - Kazuhiro Katada
- Joint Research Laboratory of Advanced Medical Imaging, Fujita Health University, Toyoake, Japan
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16
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Acute basilar thrombosis: Recanalization following intravenous thrombolysis is dependent on thrombus length. PLoS One 2018; 13:e0193051. [PMID: 29466399 PMCID: PMC5821367 DOI: 10.1371/journal.pone.0193051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 02/02/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction We investigated whether thrombus length measured in Computed Tomography Angiography (CTA) is predictive of the success rate of intravenous thrombolysis (IVT) in acute basilar occlusion and whether recanalization can be achieved by additional mechanical endovascular thrombectomy. Methods In 51 patients with acute basilar thrombosis thrombus length was measured on CTA images before intravenous thrombolysis (IVT) with rt-PA was started. After 114 minutes on average success of IVT was evaluated either by CTA or DSA. Patients with persistent basilar occlusion and no major brainstem infarction on CT underwent endovascular recanalization. Results 87% of patients had no recanalization of basilar artery after IVT alone. The average thrombus length was 15 mm in patients with persistent basilar occlusion after IVT and 7 mm in patients with recanalization after IVT. Thrombi longer than 13 mm did not resolve after IVT alone and 80% of thrombi shorter than 13 mm did not resolve either. 41 patients were transferred to endovascular recanalization; endovascular therapy was performed successfully in 90% (37 / 41). Conclusions Recanalization rates in acute basilar occlusion after IVT alone are low and dependent on thrombus length. Additional mechanical endovascular thrombectomy showed to be a very successful recanalization therapy.
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17
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Nagel S. [Stroke due to acute occlusion of the basilar artery : Diagnosis and treatment]. Med Klin Intensivmed Notfmed 2017; 112:679-686. [PMID: 28905077 DOI: 10.1007/s00063-017-0347-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 08/17/2017] [Indexed: 10/18/2022]
Abstract
Acute occlusion of the basilar artery is a rare and, if left untreated, severe neurovascular condition with a high mortality. The clinical presentation is often atypical and hence diagnosis may be delayed. Because of the devastating natural course, recanalization strategies were often more aggressive than in patients with occlusions in the anterior circulation. To date, there is no evidence-based therapy, and recent larger registry studies and meta-analyses do not show a clear superiority of endovascular approaches over systemic thrombolysis alone. The current review aims to provide an overview of the most critical aspects in clinical and radiological diagnosis and treatment of basilar artery thrombosis.
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Affiliation(s)
- S Nagel
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
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18
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Efficacy and safety of direct aspiration first pass technique versus stent-retriever thrombectomy in acute basilar artery occlusion—a retrospective single center experience. Neuroradiology 2017; 59:297-304. [DOI: 10.1007/s00234-017-1802-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 02/03/2017] [Indexed: 10/20/2022]
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19
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Mohan S, Agarwal M, Pukenas B. Computed Tomography Angiography of the Neurovascular Circulation. Radiol Clin North Am 2016; 54:147-62. [DOI: 10.1016/j.rcl.2015.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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20
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Abstract
Basilar artery occlusions (BAOs) are a subset of posterior circulation strokes. Particular issues relevant to BAOs include variable and stuttering symptoms at onset resulting in delays in diagnosis, high morbidity and mortality, and uncertain best management. Despite better imaging techniques, diagnosis, and therefore treatment, is often delayed. We will present the most common signs and symptoms of posterior circulation strokes. Data on optimal treatment strategies are gathered from multiple case series, registries, and one randomized trial, which was stopped early. Possible etiologies of BAOs, acute, and subacute treatment strategies and special topics in neuroimaging of the posterior fossa are discussed. This review may be helpful to neurohospitalists who are managing patients with acute stroke as well as emergency room physicians and neurologists.
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Affiliation(s)
- Stacie L Demel
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Joseph P Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
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21
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Ibatullin MM, Kalinin MN, Curado AT, Khasanova DR. [Neurovisualisation predictors of malignant cerebral infarction and hemorrhagic transformation]. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:3-11. [PMID: 26120991 DOI: 10.17116/jnevro2015115323-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neuroimaging plays a central role in the assessment of patients with acute ischemic stroke. Within a few minutes, modern multimodal imaging protocols can provide one with comprehensive information about prognosis, management, and outcome of the disease, and may detect changes in the intracranial structures reflecting severity of the ischemic injury depicted by four Ps: parenchyma (of the brain), pipes (i.e., the cerebral blood vessels), penumbra, and permeability (of the blood brain barrier). In this article, we have reviewed neuroradiological predictors of malignant middle cerebral artery infarction and hemorrhagic transformation in light of the aforementioned four Ps.
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Affiliation(s)
| | | | - A T Curado
- Interregional Clinical Diagnostic Center, Kazan
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22
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[Vascular assessment in stroke codes: role of computed tomography angiography]. RADIOLOGIA 2014; 57:156-66. [PMID: 25060835 DOI: 10.1016/j.rx.2013.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 10/05/2013] [Accepted: 11/18/2013] [Indexed: 11/22/2022]
Abstract
Advances in imaging studies for acute ischemic stroke are largely due to the development of new efficacious treatments carried out in the acute phase. Together with computed tomography (CT) perfusion studies, CT angiography facilitates the selection of patients who are likely to benefit from appropriate early treatment. CT angiography plays an important role in the workup for acute ischemic stroke because it makes it possible to confirm vascular occlusion, assess the collateral circulation, and obtain an arterial map that is very useful for planning endovascular treatment. In this review about CT angiography, we discuss the main technical characteristics, emphasizing the usefulness of the technique in making the right diagnosis and improving treatment strategies.
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23
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Ibatullin MM, Kalinin MN, Kurado AT, Valeeva AA, Khasanova DR. [Multimodal imaging protocols and their predictive role in acute stroke functional outcome]. Zh Nevrol Psikhiatr Im S S Korsakova 2014; 114:9-15. [PMID: 25726796 DOI: 10.17116/jnevro20141141229-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Brain imaging plays a central role in the assessment of patients with acute ischemic stroke. Within a few minutes, modern multimodal imaging protocols can provide one with comprehensive information about prognosis, management, and outcome of the disease, and may detect changes in the intracranial structures reflecting severity of the ischemic injury depicted by four Ps: parenchyma (of the brain), pipes (i.e., the cerebral blood vessels), penumbra, and permeability (of the blood brain barrier). In this article, we have reviewed neuroradiological predictors of stroke functional outcome in the light of the aforementioned four Ps.
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Affiliation(s)
- M M Ibatullin
- GBOU VPO "Kazanskiĭ gosudarstvennyĭ meditsinskiĭ universitet"
| | - M N Kalinin
- GBOU VPO "Kazanskiĭ gosudarstvennyĭ meditsinskiĭ universitet"
| | - A T Kurado
- GAUZ "Mezhregional'nyĭ kliniko-diagnosticheskiĭ tsentr", Kazan'
| | - A A Valeeva
- GBOU VPO "Kazanskiĭ gosudarstvennyĭ meditsinskiĭ universitet"
| | - D R Khasanova
- GBOU VPO "Kazanskiĭ gosudarstvennyĭ meditsinskiĭ universitet"
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24
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Mortimer AM, Simpson E, Bradley MD, Renowden SA. Computed tomography angiography in hyperacute ischemic stroke: prognostic implications and role in decision-making. Stroke 2013; 44:1480-8. [PMID: 23493735 DOI: 10.1161/strokeaha.111.679522] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alex M Mortimer
- Department of Neuroradiology, Frenchay Hospital, Frenchay Park Rd, Bristol, BS161LE, United Kingdom.
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25
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Miyagi T, Koga M, Shiokawa Y, Nakagawara J, Hasegawa Y, Furui E, Kimura K, Kario K, Okuda S, Yamagami H, Okada Y, Nezu T, Maeda K, Endo K, Minematsu K, Toyoda K. Intravenous alteplase at 0.6 mg/kg for acute stroke patients with basilar artery occlusion: the stroke acute management with urgent risk factor assessment and improvement (SAMURAI) Recombinant tissue plasminogen activator registry. J Stroke Cerebrovasc Dis 2012; 22:1098-106. [PMID: 23063059 DOI: 10.1016/j.jstrokecerebrovasdis.2012.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 08/03/2012] [Accepted: 08/22/2012] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The therapeutic efficacy of low-dose intravenous alteplase (0.6 mg/kg) for basilar artery occlusion (BAO) remains unknown. METHODS BAO patients enrolled from the Japanese multicenter registry involving 600 stroke patients treated with the low-dose intravenous alteplase were studied. RESULTS Twenty-five patients had BAO (8 women ranging from 32-92 years of age; mean baseline National Institutes of Health Stroke Scale [NIHSS] score 16). The stroke subtype was cardioembolic in 15 patients and atherothrombotic in 4 patients. BAO was recanalized during hospitalization in 18 (78%) of 23 patients undergoing follow-up angiography. Within the initial 24 hours, 14 patients (56%) had a ≥ 8-point decrease in the NIHSS score, being more common than 267 patients with middle cerebral artery occlusion (MCO) from the same registry (odds ratio [OR] 2.50; 95% confidence interval [CI] 1.06-5.97) after adjustment by sex, age, and baseline NIHSS score. In addition, 4 patients (16%) had a ≥ 4-point increase in the score, being marginally more common than MCO patients (OR 3.13; 95% CI 0.81-10.25). Symptomatic intracranial hemorrhage within the initial 36 hours (8% v 5%), independence at 3 months (modified Rankin Scale score ≤ 2, 48% v 52%), and mortality at 3 months (4% v 6%) were similar when comparing BAO and MCO patients. When compared with previous studies of BAO, vital and functional outcomes at 3 months were relatively better in our study. CONCLUSIONS The use of low-dose alteplase resulted in similar outcomes when comparing acute BAO and MCO patients.
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Affiliation(s)
- Tetsuya Miyagi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Lindsberg PJ, Sairanen T, Strbian D, Kaste M. Current treatment of basilar artery occlusion. Ann N Y Acad Sci 2012; 1268:35-44. [DOI: 10.1111/j.1749-6632.2012.06687.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hurley MC, Soltanolkotabi M, Ansari S. Neuroimaging in acute stroke: choosing the right patient for neurointervention. Tech Vasc Interv Radiol 2012; 15:19-32. [PMID: 22464299 DOI: 10.1053/j.tvir.2011.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although the non-contrast computed tomography head continues as the sole mandatory imaging technique before intravenous thrombolysis, the increased availability of advanced infarct/penumbral imaging techniques and confidence in their use have led many to adopt them into routine practice--most particularly before intra-arterial interventions. Computed tomography versus magnetic resonance-based routes to imaging the cerebral vasculature, cell death, and parenchymal perfusion have differing advantages in terms of speed, availability, exposures to contrast and radiation, sensitivity, and resolution. Continued refinement and future developments, such as the ability to quantitate perfusion, promise to lead to tailored treatment protocols that respect the individual variations in anatomy, physiology, and pathology. This should lead both to an extension of treatment to patients currently excluded by rigid time windows and the avoidance of futile therapies and their associated morbidities.
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Affiliation(s)
- Michael C Hurley
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.
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28
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Nagel S, Herweh C, Köhrmann M, Huttner HB, Poli S, Hartmann M, Hähnel S, Steiner T, Ringleb P, Hacke W. MRI in Patients with Acute Basilar Artery Occlusion – DWI Lesion Scoring is an Independent Predictor of Outcome. Int J Stroke 2011; 7:282-8. [DOI: 10.1111/j.1747-4949.2011.00705.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Aims We analyzed early diffusion-weighted magnetic resonance imaging of patients with acute basilar artery occlusion by applying different lesion scoring systems and determined their predictive value for favorable outcome. Methods Between 1998 and 2010, patients with confirmed basilar artery occlusion were entered in a local database. magnetic resonance imaging angiography was performed for diagnosis of basilar artery occlusion and/or during initiated recanalization therapy. We analyzed the patients’ clinical and radiological baseline data, recanalization, and favorable outcome modified Rankin Scale 0–2 after three-months. Diffusion weighted imaging findings were categorized into lesions in vascular territories as well as by two previously published scores for ischemic damage in the posterior circulation, the Renard score and posterior circulation Acute Stroke Prognosis Early computed tomography Score. Results Fifty patients with basilar artery occlusion received an early MRI, and in 30 of those, a follow-up MRI was performed. Median time to baseline MRI was 5·5 h (one-hour to 24 h). Median baseline Renard score and posterior circulation Acute Stroke Prognosis Early CT Score were 2·75 (0–10) and 7 (0–10), respectively. Of the patients, 82% received an acute recanalization therapy and in 78% of those, the basilar artery recanalized. Median time to therapy was five-hours (1·25–20 h). 24% of all patients had a favorable outcome (mRS 0–2). Patients with a favorable outcome had a lower Renard score and higher pcASPECTS, a lower rate of complete basilar artery occlusion, a higher Glasgow coma scale on admission, and a higher rate of successful recanalization (all P < 0·05). After logistic regression, the only independent predictor for favorable outcome was a posterior circulation Acute Stroke Prognosis Early CT Score of 8 or more points (odds ratio 3·9, 95% confidence interval 1·4–11·7, P < 0·05). Conclusion In patients with acute basilar artery occlusion, posterior circulation Acute Stroke Prognosis Early CT Score of 8 or more points on early diffusion weighted imaging is an independent predictor for favorable outcome.
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Affiliation(s)
- Simon Nagel
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Christian Herweh
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Martin Köhrmann
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Hagen B. Huttner
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Sven Poli
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Marius Hartmann
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
- Institute of Neuroradiology, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Stefan Hähnel
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Thorsten Steiner
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Peter Ringleb
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
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29
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Puetz V, Khomenko A, Hill MD, Dzialowski I, Michel P, Weimar C, Wijman CAC, Mattle HP, Engelter ST, Muir KW, Pfefferkorn T, Tanne D, Szabo K, Kappelle LJ, Algra A, von Kummer R, Demchuk AM, Schonewille WJ. Extent of hypoattenuation on CT angiography source images in basilar artery occlusion: prognostic value in the Basilar Artery International Cooperation Study. Stroke 2011; 42:3454-9. [PMID: 21960577 DOI: 10.1161/strokeaha.111.622175] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) quantifies the extent of early ischemic changes in the posterior circulation with a 10-point grading system. We hypothesized that pc-ASPECTS applied to CT angiography source images predicts functional outcome of patients in the Basilar Artery International Cooperation Study (BASICS). METHODS BASICS was a prospective, observational registry of consecutive patients with acute symptomatic basilar artery occlusion. Functional outcome was assessed at 1 month. We applied pc-ASPECTS to CT angiography source images of patients with CT angiography for confirmation of basilar artery occlusion. We calculated unadjusted and adjusted risk ratios (RRs) of pc-ASPECTS dichotomized at ≥8 versus <8. Primary outcome measure was favorable outcome (modified Rankin Scale scores 0-3). Secondary outcome measures were mortality and functional independence (modified Rankin Scale scores 0-2). RESULTS Of 158 patients included, 78 patients had a CT angiography source images pc-ASPECTS≥8. Patients with a pc-ASPECTS≥8 more often had a favorable outcome than patients with a pc-ASPECTS<8 (crude RR, 1.7; 95% CI, 0.98-3.0). After adjustment for age, baseline National Institutes of Health Stroke Scale score, and thrombolysis, pc-ASPECTS≥8 was not related to favorable outcome (RR, 1.3; 95% CI, 0.8-2.2), but it was related to reduced mortality (RR, 0.7; 95% CI, 0.5-0.98) and functional independence (RR, 2.0; 95% CI, 1.1-3.8). In post hoc analysis, pc-ASPECTS dichotomized at ≥6 versus <6 predicted a favorable outcome (adjusted RR, 3.1; 95% CI, 1.2-7.5). CONCLUSIONS pc-ASPECTS on CT angiography source images independently predicted death and functional independence at 1 month in the CT angiography subgroup of patients in the BASICS registry.
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Affiliation(s)
- Volker Puetz
- University of Technology Dresden, Dresden University Stroke Center, Department of Neurology, Fetscherstr. 74, 01307 Dresden, Germany.
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Costalat V, Machi P, Lobotesis K, Maldonado I, Vendrell JF, Riquelme C, Mourand I, Milhaud D, Héroum C, Perrigault PF, Arquizan C, Bonafé A. Rescue, Combined, and Stand-Alone Thrombectomy in the Management of Large Vessel Occlusion Stroke Using the Solitaire Device: A Prospective 50-Patient Single-Center Study. Stroke 2011; 42:1929-35. [PMID: 21597019 DOI: 10.1161/strokeaha.110.608976] [Citation(s) in RCA: 169] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Vincent Costalat
- From the CHU Montpellier Neuroradiology (V.C., P.M., K.L., I.M., J.F.V., C.R., A.B.), Montpellier, France; CHU Montpellier Neurology (I.M., D.M., C.H., C.A.), Montpellier, France; CHU Montpellier (P.F.P.), SARC, Ansesthesiology, Montpellier, France
| | - Paolo Machi
- From the CHU Montpellier Neuroradiology (V.C., P.M., K.L., I.M., J.F.V., C.R., A.B.), Montpellier, France; CHU Montpellier Neurology (I.M., D.M., C.H., C.A.), Montpellier, France; CHU Montpellier (P.F.P.), SARC, Ansesthesiology, Montpellier, France
| | - Kyriakos Lobotesis
- From the CHU Montpellier Neuroradiology (V.C., P.M., K.L., I.M., J.F.V., C.R., A.B.), Montpellier, France; CHU Montpellier Neurology (I.M., D.M., C.H., C.A.), Montpellier, France; CHU Montpellier (P.F.P.), SARC, Ansesthesiology, Montpellier, France
| | - Igor Maldonado
- From the CHU Montpellier Neuroradiology (V.C., P.M., K.L., I.M., J.F.V., C.R., A.B.), Montpellier, France; CHU Montpellier Neurology (I.M., D.M., C.H., C.A.), Montpellier, France; CHU Montpellier (P.F.P.), SARC, Ansesthesiology, Montpellier, France
| | - Jean François Vendrell
- From the CHU Montpellier Neuroradiology (V.C., P.M., K.L., I.M., J.F.V., C.R., A.B.), Montpellier, France; CHU Montpellier Neurology (I.M., D.M., C.H., C.A.), Montpellier, France; CHU Montpellier (P.F.P.), SARC, Ansesthesiology, Montpellier, France
| | - Carlos Riquelme
- From the CHU Montpellier Neuroradiology (V.C., P.M., K.L., I.M., J.F.V., C.R., A.B.), Montpellier, France; CHU Montpellier Neurology (I.M., D.M., C.H., C.A.), Montpellier, France; CHU Montpellier (P.F.P.), SARC, Ansesthesiology, Montpellier, France
| | - Isabelle Mourand
- From the CHU Montpellier Neuroradiology (V.C., P.M., K.L., I.M., J.F.V., C.R., A.B.), Montpellier, France; CHU Montpellier Neurology (I.M., D.M., C.H., C.A.), Montpellier, France; CHU Montpellier (P.F.P.), SARC, Ansesthesiology, Montpellier, France
| | - Didier Milhaud
- From the CHU Montpellier Neuroradiology (V.C., P.M., K.L., I.M., J.F.V., C.R., A.B.), Montpellier, France; CHU Montpellier Neurology (I.M., D.M., C.H., C.A.), Montpellier, France; CHU Montpellier (P.F.P.), SARC, Ansesthesiology, Montpellier, France
| | - Chérif Héroum
- From the CHU Montpellier Neuroradiology (V.C., P.M., K.L., I.M., J.F.V., C.R., A.B.), Montpellier, France; CHU Montpellier Neurology (I.M., D.M., C.H., C.A.), Montpellier, France; CHU Montpellier (P.F.P.), SARC, Ansesthesiology, Montpellier, France
| | - Pierre-François Perrigault
- From the CHU Montpellier Neuroradiology (V.C., P.M., K.L., I.M., J.F.V., C.R., A.B.), Montpellier, France; CHU Montpellier Neurology (I.M., D.M., C.H., C.A.), Montpellier, France; CHU Montpellier (P.F.P.), SARC, Ansesthesiology, Montpellier, France
| | - Caroline Arquizan
- From the CHU Montpellier Neuroradiology (V.C., P.M., K.L., I.M., J.F.V., C.R., A.B.), Montpellier, France; CHU Montpellier Neurology (I.M., D.M., C.H., C.A.), Montpellier, France; CHU Montpellier (P.F.P.), SARC, Ansesthesiology, Montpellier, France
| | - Alain Bonafé
- From the CHU Montpellier Neuroradiology (V.C., P.M., K.L., I.M., J.F.V., C.R., A.B.), Montpellier, France; CHU Montpellier Neurology (I.M., D.M., C.H., C.A.), Montpellier, France; CHU Montpellier (P.F.P.), SARC, Ansesthesiology, Montpellier, France
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Mortimer A, Saunders T, Cook JL. Cross-sectional imaging for diagnosis and clinical outcome prediction of acute basilar artery thrombosis. Clin Radiol 2011; 66:551-8. [DOI: 10.1016/j.crad.2010.09.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2010] [Revised: 08/18/2010] [Accepted: 09/21/2010] [Indexed: 11/28/2022]
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Abstract
Acute basilar artery thrombosis (ABT) has been largely considered a neurological catastrophe. With conventional treatment, only around 20% of patients achieve functional independence. An early presumptive diagnosis is essential to avoid treatment delay. Either multiparametric magnetic resonance imaging or computed tomography angiography source images may represent valid non-invasive tools to confirm ABT and evaluate ischemic tissue viability. The main determinant of ABT outcome is early recanalization but the most effective therapeutic option remains to be clarified. The BASICS prospective registry showed no superiority of intra-arterial over intravenous thrombolysis. Therefore, in the absence of contraindications, intravenous thrombolysis should be started as soon as possible and can be used as the main therapy when interventional procedures are not available. However, recent case series have reported high rates of functional independence (50%) after staged escalation therapy (ultra-early intravenous thrombolysis followed by on-demand endovascular mechanical thrombectomy). These results represent a hope for patients and neurologists and reinforce the need for innovation and research in this field.
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Affiliation(s)
- J F Arenillas Lara
- Unidad de Ictus, Servicio de Neurología, Hospital Clínico Universitario, Valladolid, España.
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33
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Delgado Almandoz JE, Romero JM, Pomerantz SR, Lev MH. Computed Tomography Angiography of the Carotid and Cerebral Circulation. Radiol Clin North Am 2010; 48:265-81, vii-viii. [DOI: 10.1016/j.rcl.2010.02.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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34
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Modo M. Long-term survival and serial assessment of stroke damage and recovery - practical and methodological considerations. ACTA ACUST UNITED AC 2009; 2:52-68. [PMID: 22389748 DOI: 10.6030/1939-067x-2.2.52] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Impairments caused by stroke remain the main cause for adult disability. Despite a vigorous research effort, only 1 thrombolytic treatment has been approved in acute stroke (<3h). The limitations of preclinical studies and how these can be overcome have been the subject of various guidelines. However, often these guidelines focus on the acute stroke setting and omit long-term outcome measures, such as behaviour and neuroimaging. The considerations and practicalities of including the serial assessment of these approaches and their significance to establish therapeutic efficacy are discussed here.
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Affiliation(s)
- Michel Modo
- King's College London, Institute of Psychiatry, Department of Neuroscience, London, UK
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