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Jia J, Jin Z, Dong J, Huang J, Wang Y, Liu Y. Synergistic insights: the integrated role of CT/CTP and clinical parameters in hemorrhagic transformation prediction. Aging (Albany NY) 2024; 16:11577-11590. [PMID: 39133141 PMCID: PMC11346787 DOI: 10.18632/aging.206026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 07/09/2024] [Indexed: 08/13/2024]
Abstract
BACKGROUND Acute ischemic stroke presents significant challenges in healthcare, notably due to the risk and poor prognosis associated with hemorrhagic transformation (HT). Currently, there is a notable gap in the early clinical stage for a valid and reliable predictive model for HT. METHODS This single-center retrospective study analyzed data from 224 patients with acute ischemic stroke due to large vessel occlusion. We collected comprehensive clinical data, CT, and CTP parameters. A predictive model for HT was developed, incorporating clinical indicators alongside imaging data, and its efficacy was evaluated using decision curve analysis and calibration curves. In addition, we have also built a free browser-based online calculator based on this model for HT prediction. RESULTS The study identified atrial fibrillation and hypertension as significant risk factors for HT. Patients with HT showed more extensive initial ischemic damage and a smaller ischemic penumbra. Our novel predictive model, integrating clinical indicators with CT and CTP parameters, demonstrated superior predictive value compared to models based solely on clinical indicators. CONCLUSIONS The research highlighted the intricate interplay of clinical and imaging parameters in HT post-thrombectomy. It established a multifaceted predictive model, enhancing the understanding and management of acute ischemic stroke. Future studies should focus on validating this model in broader cohorts, further investigating the causal relationships, and exploring the nuanced effects of these parameters on patient outcomes post-stroke.
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Affiliation(s)
- Jianwen Jia
- Department of Neurosurgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zeping Jin
- Department of Neurosurgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Jing Dong
- Department of Medical Engineering, Tsinghua University Yuquan Hospital, Beijing, People’s Republic of China
| | - Jumei Huang
- Department of Neurosurgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yang Wang
- Department of Neurosurgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yunpeng Liu
- Department of Neurosurgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
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Ma J, Chervak LM, Siegler JE, Li Z, Mofatteh M, Galecio-Castillo M, Zhou S, Huang J, Lai Y, Zhang Y, Guo J, Zhang X, Cheng C, Tang J, Chen J, Chen Y. Postinterventional Petechial Hemorrhage Associated With Poor Functional Outcome After Successful Recanalization Following Endovascular Therapy. Neurosurgery 2024:00006123-990000000-01272. [PMID: 38984821 DOI: 10.1227/neu.0000000000003098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 05/25/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Endovascular therapy (EVT) has emerged as the standard for treating patients with acute ischemic stroke due to large vessel occlusion. The aim of this study was to investigate the relationship between early petechial hemorrhage and patient outcomes after successful EVT of anterior circulation. METHODS We retrospectively analyzed multicenter data from 316 patients who underwent EVT for acute occlusion of anterior circulation. Patients were divided into petechial hemorrhage group and without hemorrhage group based on post-EVT head imaging. Logistical regression analysis was performed to determine independent predictors for petechial hemorrhage, and for petechial hemorrhage as a predictor of early neurological improvement, favorable outcome at 90 days (modified Rankin Scale 0-2), and 90-day mortality, with adjustment for all factors significantly associated with these endpoints in univariate regression to P < .10. RESULTS Of 316 included patients with successful EVT, 49 (15.50%) had petechial hemorrhage. The petechial hemorrhage group showed less early neurological improvement (36.73% compared with 53.56%, P = .030), less favorable outcomes at 90 days (32.65% compared with 61.80%, P < .001, absolute risk difference 29.15%), and higher mortality at 90 days (28.57% compared with 10.49%, P = .001) then the group without hemorrhage. Petechial hemorrhage was inversely associated with favorable 90-day outcome (odds ratio = 0.415, 95% CI 0.206-0.835) and higher mortality rate at 90 days (odds ratio = 2.537, 95% CI 1.142-5.635) in multivariable regression but was not independently associated with early neurological improvement. CONCLUSION In patients with anterior large vessel occlusion who underwent successful EVT, petechial hemorrhage was associated with poor functional outcome and 90-day mortality when adjusted for complete recanalization, pre-EVT National Institute of Health Stroke Scale/Score, and Alberta Stroke Program Early Computed Tomography Score. Despite the relatively lower rate of a favorable 90-day outcome with petechial hemorrhage compared with no petechial hemorrhage, the absolute rate of a favorable outcome exceeds the natural history of medical management for this condition.
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Affiliation(s)
- Jicai Ma
- Department of Neurology, The Affiliated Yuebei People's Hospital of Shantou University Medical College, Shaoguan, China
| | - Lina M Chervak
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - James E Siegler
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Zhenzhang Li
- College of Mathematics and Systems Science, Guangdong Polytechnic Normal University, Guangzhou, China
- School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou, China
| | - Mohammad Mofatteh
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | | | - Sijie Zhou
- Department of Surgery of Cerebrovascular Diseases, First People's Hospital of Foshan, Foshan, China
| | - Jianhui Huang
- Department of Surgery of Cerebrovascular Diseases, First People's Hospital of Foshan, Foshan, China
| | - Yuzheng Lai
- Department of Neurology, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine (Nanhai District Hospital of Traditional Chinese Medicine of Foshan City), Foshan, China
| | - Youyong Zhang
- Interventional Department, The Affiliated Yuebei People's Hospital of Shantou University Medical College, Shaoguan, China
| | - Junhui Guo
- Department of Neurology, The Affiliated Yuebei People's Hospital of Shantou University Medical College, Shaoguan, China
| | - Xiuling Zhang
- Department of Neurology, The Affiliated Yuebei People's Hospital of Shantou University Medical College, Shaoguan, China
| | - Chunyun Cheng
- Department of Neurology, The Affiliated Yuebei People's Hospital of Shantou University Medical College, Shaoguan, China
| | - Jiaying Tang
- Department of Neurology, The Affiliated Yuebei People's Hospital of Shantou University Medical College, Shaoguan, China
| | - Junbin Chen
- Department of Neurology, The Affiliated Yuebei People's Hospital of Shantou University Medical College, Shaoguan, China
| | - Yimin Chen
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People's Hospital, Foshan, China
- Neuro International Collaboration (NIC), Foshan, China
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Sun J, Werdiger F, Blair C, Chen C, Yang Q, Bivard A, Lin L, Parsons M. Automatic segmentation of hemorrhagic transformation on follow-up non-contrast CT after acute ischemic stroke. Front Neuroinform 2024; 18:1382630. [PMID: 38689832 PMCID: PMC11058994 DOI: 10.3389/fninf.2024.1382630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 03/30/2024] [Indexed: 05/02/2024] Open
Abstract
Background Hemorrhagic transformation (HT) following reperfusion therapies is a serious complication for patients with acute ischemic stroke. Segmentation and quantification of hemorrhage provides critical insights into patients' condition and aids in prognosis. This study aims to automatically segment hemorrhagic regions on follow-up non-contrast head CT (NCCT) for stroke patients treated with endovascular thrombectomy (EVT). Methods Patient data were collected from 10 stroke centers across two countries. We propose a semi-automated approach with adaptive thresholding methods, eliminating the need for extensive training data and reducing computational demands. We used Dice Similarity Coefficient (DSC) and Lin's Concordance Correlation Coefficient (Lin's CCC) to evaluate the performance of the algorithm. Results A total of 51 patients were included, with 28 Type 2 hemorrhagic infarction (HI2) cases and 23 parenchymal hematoma (PH) cases. The algorithm achieved a mean DSC of 0.66 ± 0.17. Notably, performance was superior for PH cases (mean DSC of 0.73 ± 0.14) compared to HI2 cases (mean DSC of 0.61 ± 0.18). Lin's CCC was 0.88 (95% CI 0.79-0.93), indicating a strong agreement between the algorithm's results and the ground truth. In addition, the algorithm demonstrated excellent processing time, with an average of 2.7 s for each patient case. Conclusion To our knowledge, this is the first study to perform automated segmentation of post-treatment hemorrhage for acute stroke patients and evaluate the performance based on the radiological severity of HT. This rapid and effective tool has the potential to assist with predicting prognosis in stroke patients with HT after EVT.
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Affiliation(s)
- Jiacheng Sun
- Sydney Brain Centre, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Freda Werdiger
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Christopher Blair
- Sydney Brain Centre, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, NSW, Australia
| | - Chushuang Chen
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Qing Yang
- Apollo Medical Imaging Technology Pty. Ltd., Melbourne, VIC, Australia
| | - Andrew Bivard
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Longting Lin
- Sydney Brain Centre, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Mark Parsons
- Sydney Brain Centre, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, NSW, Australia
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Bui Q, Kumar A, Chen Y, Hamzehloo A, Heitsch L, Slowik A, Strbian D, Lee JM, Dhar R. CSF-Based Volumetric Imaging Biomarkers Highlight Incidence and Risk Factors for Cerebral Edema After Ischemic Stroke. Neurocrit Care 2024; 40:303-313. [PMID: 37188885 PMCID: PMC11025464 DOI: 10.1007/s12028-023-01742-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/19/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Cerebral edema has primarily been studied using midline shift or clinical deterioration as end points, which only captures the severe and delayed manifestations of a process affecting many patients with stroke. Quantitative imaging biomarkers that measure edema severity across the entire spectrum could improve its early detection, as well as identify relevant mediators of this important stroke complication. METHODS We applied an automated image analysis pipeline to measure the displacement of cerebrospinal fluid (ΔCSF) and the ratio of lesional versus contralateral hemispheric cerebrospinal fluid (CSF) volume (CSF ratio) in a cohort of 935 patients with hemispheric stroke with follow-up computed tomography scans taken a median of 26 h (interquartile range 24-31) after stroke onset. We determined diagnostic thresholds based on comparison to those without any visible edema. We modeled baseline clinical and radiographic variables against each edema biomarker and assessed how each biomarker was associated with stroke outcome (modified Rankin Scale at 90 days). RESULTS The displacement of CSF and CSF ratio were correlated with midline shift (r = 0.52 and - 0.74, p < 0.0001) but exhibited broader ranges. A ΔCSF of greater than 14% or a CSF ratio below 0.90 identified those with visible edema: more than half of the patients with stroke met these criteria, compared with only 14% who had midline shift at 24 h. Predictors of edema across all biomarkers included a higher National Institutes of Health Stroke Scale score, a lower Alberta Stroke Program Early CT score, and lower baseline CSF volume. A history of hypertension and diabetes (but not acute hyperglycemia) predicted greater ΔCSF but not midline shift. Both ΔCSF and a lower CSF ratio were associated with worse outcome, adjusting for age, National Institutes of Health Stroke Scale score, and Alberta Stroke Program Early CT score (odds ratio 1.7, 95% confidence interval 1.3-2.2 per 21% ΔCSF). CONCLUSIONS Cerebral edema can be measured in a majority of patients with stroke on follow-up computed tomography using volumetric biomarkers evaluating CSF shifts, including in many without visible midline shift. Edema formation is influenced by clinical and radiographic stroke severity but also by chronic vascular risk factors and contributes to worse stroke outcomes.
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Affiliation(s)
- Quoc Bui
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Atul Kumar
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Yasheng Chen
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Ali Hamzehloo
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Laura Heitsch
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Jin-Moo Lee
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Rajat Dhar
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA.
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Jiang YL, Zhao QS, Li A, Wu ZB, Liu LL, Lin F, Li YF. Advanced Machine Learning Models for Predicting Post-Thrombolysis Hemorrhagic Transformation in Acute Ischemic Stroke Patients: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2024; 30:10760296241279800. [PMID: 39262220 DOI: 10.1177/10760296241279800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2024] Open
Abstract
Background: Thrombolytic therapy is essential for acute ischemic stroke (AIS) management but poses a risk of hemorrhagic transformation (HT), necessitating accurate prediction to optimize patient care. Methods: A comprehensive search was conducted across PubMed, Web of Science, Scopus, Embase, and Google Scholar, covering studies from inception until July 10, 2024. Studies were included if they used machine learning (ML) or deep learning algorithms to predict HT in AIS patients treated with thrombolysis. Exclusion criteria included studies involving endovascular treatments and those not evaluating model effectiveness. Data extraction and quality assessment were performed following PRISMA guidelines and using the Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis (TRIPOD) and Prediction Model Risk of Bias Assessment Tool (PROBAST) tools. Results: Out of 1943 identified records, 12 studies were included in the final analysis, encompassing 18 007 AIS patients who received thrombolytic therapy. The ML models demonstrated high predictive performance, with pooled area under the curve (AUC) values ranging from 0.79 to 0.95. Specifically, XGBoost models achieved AUCs of up to 0.953 and Artificial Neural Network (ANN) models reached up to 0.942. Sensitivity and specificity varied significantly, with the highest sensitivity at 0.90 and specificity at 0.99. Significant predictors of HT included age, glucose levels, NIH Stroke Scale (NIHSS) score, systolic and diastolic blood pressure, and radiomic features. Despite these promising results, methodological disparities and limited external validation highlighted the need for standardized reporting and further rigorous testing. Conclusion: ML techniques, especially XGBoost and ANN, show great promise in predicting HT following thrombolysis in AIS patients, enhancing risk stratification and clinical decision-making. Future research should focus on prospective study designs, standardized reporting, and integrating ML assessments into clinical workflows to improve AIS management and patient outcomes.
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Affiliation(s)
- You-Li Jiang
- Department of Neurology, People's Hospital of Longhua, Shenzhen, China
| | - Qing-Shi Zhao
- Department of Neurology, People's Hospital of Longhua, Shenzhen, China
| | - Ao Li
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Zong-Bi Wu
- Nursing Department, Shenzhen Traditional Chinese Medicine Hospital (The Fourth Clinical Medical School of Guangzhou University of Chinese Medicine), Shenzhen, China
| | - Lin-Lin Liu
- Hengyang Medical School, School of Nursing, University of South China, Hengyang, China
| | - Fu Lin
- Department of Neurology, People's Hospital of Longhua, Shenzhen, China
| | - Yan-Feng Li
- Department of Neurology, People's Hospital of Longhua, Shenzhen, China
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Hao Y, Zhou H, Pan C, Xie G, Hu J, Zhang B, Qian S, Yan S. Prediction factors and clinical significance of different types of hemorrhagic transformation after intravenous thrombolysis. Eur J Med Res 2023; 28:509. [PMID: 37951926 PMCID: PMC10638828 DOI: 10.1186/s40001-023-01503-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 11/03/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND AND PURPOSE Hemorrhagic transformation (HT) after intravenous thrombolysis (IVT) in acute ischemic stroke seriously affects the prognosis of patients. This study aimed to investigate the risk factors of different types of HT and their correlation with prognosis after IVT. METHODS Based on the CASE II registry, we included patients with acute ischemic stroke who received IVT within 4.5 h of onset. HT was further divided into hemorrhagic infarction (HI) and parenchymal hemorrhage (PH). Poor outcome was defined as a modified Rankin Scale (mRS) score of 3-6 at 3 months. Multivariate logistic regression analysis was used to determine the independent influencing factors of HT subtypes and clinical outcome. RESULTS Among 13108 included patients, 541 (4.1%) developed HI and 440 (3.4%) developed PH. In multivariate analysis, age (OR 1.038, 95% CI 1.028 to 1.049, p < 0.001), atrial fibrillation (OR 1.446, 95% CI 1.141 to 1.943, p = 0.002), baseline diastolic pressure (OR 1.012, 95% CI 1.004 to 1.020, p = 0.005), baseline NIHSS score (OR 1.060, 95% CI 1.049 to 1.071, p < 0.001) and onset to treatment time (OR 1.002, 95% CI 1.000 to 1.004, p = 0.020) independently predicted PH after IVT. In the patients with HT, PH (OR 3.611, 95% CI 2.540 to 5.134, p < 0.001) and remote hemorrhage (OR 1.579, 95% CI 1.115 to 2.235, p = 0.010) were independently related to poor outcome. CONCLUSIONS Different types of HT after IVT had different risk factors and clinical significance. The occurrence of PH and remote hemorrhage independently increased the risk of poor outcome.
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Affiliation(s)
- Yanan Hao
- Department of Neurology, The Second Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Huan Zhou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Chengzhen Pan
- Department of Neurology, The Second Affiliated Hospital of Jiaxing University, Jiaxing, China
- Jiaxing University Master Degree Cultivation Base, Zhejiang Chinese Medical University, Hangzhou, China
| | - Guomin Xie
- Department of Neurology, Lee Hui-Lee East Hospital, Ningbo, China
| | - Jin Hu
- Department of Neurology, The First Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Bing Zhang
- Department of Neurology, Huzhou Central Hospital, Huzhou, China
| | - Shuxia Qian
- Department of Neurology, The Second Affiliated Hospital of Jiaxing University, Jiaxing, China.
| | - Shenqiang Yan
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China.
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Zubair AS, Sheth KN. Hemorrhagic Conversion of Acute Ischemic Stroke. Neurotherapeutics 2023; 20:705-711. [PMID: 37085684 PMCID: PMC10275827 DOI: 10.1007/s13311-023-01377-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 04/23/2023] Open
Abstract
Stroke is a leading cause of morbidity and mortality worldwide; a serious complication of ischemic stroke is hemorrhagic transformation. Current treatment of acute ischemic stroke includes endovascular thrombectomy and thrombolytic therapy. Both of these treatment options are linked with increased risks of hemorrhagic conversion. The diagnosis and timely management of patients with hemorrhagic conversion is critically important to patient outcomes. This review aims to discuss hemorrhagic conversion of acute ischemic stroke including discussion of the pathophysiology, review of risk factors, imaging considerations, and treatment of patients with hemorrhagic conversion.
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Affiliation(s)
- Adeel S Zubair
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
- Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT, USA
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Chen C, Ouyang M, Ong S, Zhang L, Zhang G, Delcourt C, Mair G, Liu L, Billot L, Li Q, Chen X, Parsons M, Broderick JP, Demchuk AM, Bath PM, Donnan GA, Levi C, Chalmers J, Lindley RI, Martins SO, Pontes-Neto OM, Venturelli PM, Olavarría V, Lavados P, Robinson TG, Wardlaw JM, Li G, Wang X, Song L, Anderson CS. Effects of intensive blood pressure lowering on cerebral ischaemia in thrombolysed patients: insights from the ENCHANTED trial. EClinicalMedicine 2023; 57:101849. [PMID: 36820100 PMCID: PMC9938155 DOI: 10.1016/j.eclinm.2023.101849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 02/17/2023] Open
Abstract
Background Intensive blood pressure lowering may adversely affect evolving cerebral ischaemia. We aimed to determine whether intensive blood pressure lowering altered the size of cerebral infarction in the 2196 patients who participated in the Enhanced Control of Hypertension and Thrombolysis Stroke Study, an international randomised controlled trial of intensive (systolic target 130-140 mm Hg within 1 h; maintained for 72 h) or guideline-recommended (systolic target <180 mm Hg) blood pressure management in patients with hypertension (systolic blood pressure >150 mm Hg) after thrombolysis treatment for acute ischaemic stroke between March 3, 2012 and April 30, 2018. Methods All available brain imaging were analysed centrally by expert readers. Log-linear regression was used to determine the effects of intensive blood pressure lowering on the size of cerebral infarction, with adjustment for potential confounders. The primary analysis pertained to follow-up computerised tomography (CT) scans done between 24 and 36 h. Sensitivity analysis were undertaken in patients with only a follow-up magnetic resonance imaging (MRI) and either MRI or CT at 24-36 h, and in patients with any brain imaging done at any time during follow-up. This trial is registered with ClinicalTrials.gov, number NCT01422616. Findings There were 1477 (67.3%) patients (mean age 67.7 [12.1] y; male 60%, Asian 65%) with available follow-up brain imaging for analysis, including 635 patients with a CT done at 24-36 h. Mean achieved systolic blood pressures over 1-24 h were 141 mm Hg and 149 mm Hg in the intensive group and guideline group, respectively. There was no effect of intensive blood pressure lowering on the median size (ml) of cerebral infarction on follow-up CT at 24-36 h (0.3 [IQR 0.0-16.6] in the intensive group and 0.9 [0.0-12.5] in the guideline group; log Δmean -0.17, 95% CI -0.78 to 0.43). The results were consistent in sensitivity and subgroup analyses. Interpretation Intensive blood pressure lowering treatment to a systolic target <140 mm Hg within several hours after the onset of symptoms may not increase the size of cerebral infarction in patients who receive thrombolysis treatment for acute ischaemic stroke of mild to moderate neurological severity. Funding National Health and Medical Research Council of Australia; UK Stroke Association; UK Dementia Research Institute; Ministry of Health and the National Council for Scientific and Technological Development of Brazil; Ministry for Health, Welfare, and Family Affairs of South Korea; Takeda.
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Affiliation(s)
- Chen Chen
- Neurology Department, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
| | - Menglu Ouyang
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
| | - Sheila Ong
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Luyun Zhang
- The George Institute for Global Health China, Beijing, China
- Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, Shenyang, China
| | - Guobin Zhang
- The George Institute for Global Health China, Beijing, China
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Candice Delcourt
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Grant Mair
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences and Centre in the UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Leibo Liu
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Qiang Li
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Xiaoying Chen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Mark Parsons
- Ingham Institute for Applied Medical Research, Liverpool Hospital, UNSW, Sydney, Australia
| | - Joseph P. Broderick
- Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH, USA
| | - Andrew M. Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Philip M. Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Geoffrey A. Donnan
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Christopher Levi
- Neurology Department, John Hunter Hospital, and Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Richard I. Lindley
- University of Sydney, Sydney, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Sheila O. Martins
- Stroke Division of Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Octavio M. Pontes-Neto
- Stroke Service - Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto School of Medicine, University of Sao Paulo, Ribeirão Preto, SP, Brazil
| | - Paula Muñoz Venturelli
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
- Centro de Estudios Clínicos, Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Verónica Olavarría
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
- Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Santiago, Chile
| | - Pablo Lavados
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
- Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Santiago, Chile
| | - Thompson G. Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Joanna M. Wardlaw
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences and Centre in the UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Gang Li
- Neurology Department, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xia Wang
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Lili Song
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
| | - Craig S. Anderson
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
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9
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Rana A, Yu S, Reid-Herrera S, Kamen S, Hunter K, Shaikh H, Jovin T, Thon OR, Patel P, Siegler JE, Thon JM. Eptifibatide use in ischemic stroke patients undergoing endovascular thrombectomy: A matched cohort analysis. Front Neurol 2022; 13:939215. [PMID: 36237613 PMCID: PMC9551346 DOI: 10.3389/fneur.2022.939215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Small studies have suggested that eptifibatide (EPT) may be safe in acute ischemic stroke (AIS) following intravenous thrombolysis or during endovascular therapy (EVT) for large vessel occlusion (LVO). However, studies are called upon to better delineate the safety of EPT use during EVT. Methods A comprehensive stroke center registry (09/2015-12/2020) of consecutive adults who had undergone EVT for anterior LVO was queried. Patients treated with EPT were matched with 2 control groups based on known factors associated with intracranial hemorrhage (ICH) risk - age, Alberta Stroke Program Early Computed Tomography Score (ASPECTS), and number of thrombectomy passes. Safety outcomes (intracranial hemorrhage [ICH], parenchymal hematoma [PH-2] grade hemorrhagic transformation, symptomatic ICH [sICH]) and efficacy outcomes (TICI 2B/3 recanalization, 24-h National Institutes of Health Stroke Scale [NIHSS] score), were compared between matched groups using descriptive statistics. In addition, multivariable logistic regression was used to assess for an association between EPT and PH-1/PH-2 grade hemorrhages. Results A total of 162 patients were included, 54 of whom (33%) received EPT. The rate of ICH was similar between groups (p = 0.62), while PH-2 was significantly more frequent with EPT (16.7% EPT vs. 3.7 vs. 1.9%; p = 0.009), but without significant differences in sICH (5.6% EPT vs. 7.4 vs. 3.7%; p = 0.72). Rates of TICI Score ≥ 2B were nominally higher with EPT use (83.3 vs. 77.8 vs. 77.8%, p = 0.70). Between the EPT and control groups, there were no differences in 24-h NIHSS (p = 0.09) or 90-day mortality (p = 0.58). Our adjusted multivariate analysis identified that the number of passes (p < 0.01), EPT use (p < 0.01), and tandem occlusion (p = 0.03) were independent predictors of PH1/PH2 grade hemorrhage. Additionally, every unit increase in number of passes resulted in a 1.5 times greater odds of a high-grade hemorrhagic transformation in EPT-treated patients (adjusted OR = 1.594). Conclusion In this single-center analysis, EPT use during EVT was associated with a significantly higher rate of PH1/PH2 grade hemorrhages, but not with differences in sICH, 24-h NIHSS, or 90-day mortality. Randomized prospective trials are needed to determine the safety and efficacy of EPT in this population.
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Affiliation(s)
- Ameena Rana
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Siyuan Yu
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | | | - Scott Kamen
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Krystal Hunter
- Cooper Research Institute, Cooper University Hospital, Camden, NJ, United States
| | - Hamza Shaikh
- Department of Radiology, Cooper University Hospital, Camden, NJ, United States
| | - Tudor Jovin
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | - Olga R. Thon
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | - Parth Patel
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | - Jesse M. Thon
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
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10
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Kumar A, Chen Y, Corbin A, Hamzehloo A, Abedini A, Vardar Z, Carey G, Bhatia K, Heitsch L, Derakhshan JJ, Lee JM, Dhar R. Automated Measurement of Net Water Uptake From Baseline and Follow-Up CTs in Patients With Large Vessel Occlusion Stroke. Front Neurol 2022; 13:898728. [PMID: 35832178 PMCID: PMC9271791 DOI: 10.3389/fneur.2022.898728] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
Quantifying the extent and evolution of cerebral edema developing after stroke is an important but challenging goal. Lesional net water uptake (NWU) is a promising CT-based biomarker of edema, but its measurement requires manually delineating infarcted tissue and mirrored regions in the contralateral hemisphere. We implement an imaging pipeline capable of automatically segmenting the infarct region and calculating NWU from both baseline and follow-up CTs of large-vessel occlusion (LVO) patients. Infarct core is extracted from CT perfusion images using a deconvolution algorithm while infarcts on follow-up CTs were segmented from non-contrast CT (NCCT) using a deep-learning algorithm. These infarct masks were flipped along the brain midline to generate mirrored regions in the contralateral hemisphere of NCCT; NWU was calculated as one minus the ratio of densities between regions, removing voxels segmented as CSF and with HU outside thresholds of 20-80 (normal hemisphere and baseline CT) and 0-40 (infarct region on follow-up). Automated results were compared with those obtained using manually-drawn infarcts and an ASPECTS region-of-interest based method that samples densities within the infarct and normal hemisphere, using intraclass correlation coefficient (ρ). This was tested on serial CTs from 55 patients with anterior circulation LVO (including 66 follow-up CTs). Baseline NWU using automated core was 4.3% (IQR 2.6-7.3) and correlated with manual measurement (ρ = 0.80, p < 0.0001) and ASPECTS (r = -0.60, p = 0.0001). Automatically segmented infarct volumes (median 110-ml) correlated to manually-drawn volumes (ρ = 0.96, p < 0.0001) with median Dice similarity coefficient of 0.83 (IQR 0.72-0.90). Automated NWU was 24.6% (IQR 20-27) and highly correlated to NWU from manually-drawn infarcts (ρ = 0.98) and the sampling-based method (ρ = 0.68, both p < 0.0001). We conclude that this automated imaging pipeline is able to accurately quantify region of infarction and NWU from serial CTs and could be leveraged to study the evolution and impact of edema in large cohorts of stroke patients.
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Affiliation(s)
- Atul Kumar
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Yasheng Chen
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Aaron Corbin
- Saint Louis University School of Medicine, Saint Louis, MO, United States
| | - Ali Hamzehloo
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Amin Abedini
- Department of Radiology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Zeynep Vardar
- Department of Radiology, University of Massachusetts Medical School, Worcester, MA, United States
| | - Grace Carey
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Kunal Bhatia
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Laura Heitsch
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Jamal J. Derakhshan
- Department of Radiology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Jin-Moo Lee
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Rajat Dhar
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States,*Correspondence: Rajat Dhar
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11
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Wang J, van Kranendonk KR, El-Bouri W, Majoie CBLM, Payne SJ. Mathematical modelling of haemorrhagic transformation within a multi-scale microvasculature network. Physiol Meas 2022; 43. [PMID: 35508165 DOI: 10.1088/1361-6579/ac6cc5] [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] [Accepted: 05/04/2022] [Indexed: 11/11/2022]
Abstract
Objective Haemorrhagic transformation (HT) is one of the most common complications after ischaemic stroke caused by damage to the blood-brain barrier (BBB) that could be the result of stroke progression or a complication of stroke treatment with reperfusion therapy. The aim of this study is to develop further a previous simple HT mathematical model into an enlarged multi-scale microvasculature model in order to investigate the effects of HT on the surrounding tissue and vasculature. In addition, this study investigates the relationship between tissue displacement and vascular geometry. Approach By modelling tissue displacement, capillary compression, hydraulic conductivity in tissue and vascular permeability, we establish a mathematical model to describe the change of intracranial pressure (ICP) surrounding the damaged vascular bed after HT onset applied to a 3D multi-scale microvasculature. The use of a voxel-scale model then enables us to compare our HT simulation with available clinical imaging data for perfusion and cerebral blood volume (CBV) in the multi-scale microvasculature network. Main results We showed that the haematoma diameter and the maximum tissue displacement are approximately proportional to the diameter of the breakdown vessel. Based on the voxel-scale model, we found that perfusion reduces by approximately 13-17 % and CBV reduces by around 20-25 % after HT onset due to the effect of capillary compression caused by increased interstitial pressure. The results are in good agreement with the limited experimental data. Significance This model, by enabling us to bridge the gap between the microvascular scale and clinically measurable parameters, thus provides a foundation for more detailed validation and understanding of HT in patients.
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Affiliation(s)
- Jiayu Wang
- Department of Engineering Science, Oxford University, Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, OX1 2JD, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - Katinka R van Kranendonk
- Department of Radiology and Nuclear Medicine, University of Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands, Amsterdam, Noord-Holland, 1000 GG, NETHERLANDS
| | - Wahbi El-Bouri
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Department of Cardiovascular and Metabolic Medicine, University of Liverpool, UK, Liverpool, Merseyside, L69 3BX, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, University of Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands, Amsterdam, Noord-Holland, 1000 GG, NETHERLANDS
| | - Stephen John Payne
- National Taiwan University, 106 No.1, Sec. 4, Roosevelt Rd., Da'an Dist., Taipei City 106, Taiwan (R.O.C.) Institute of Applied Mechanics, National Taiwan University, Taipei, 000123-6, TAIWAN
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12
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Hong JM, Kim DS, Kim M. Hemorrhagic Transformation After Ischemic Stroke: Mechanisms and Management. Front Neurol 2021; 12:703258. [PMID: 34917010 PMCID: PMC8669478 DOI: 10.3389/fneur.2021.703258] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 10/21/2021] [Indexed: 01/01/2023] Open
Abstract
Symptomatic hemorrhagic transformation (HT) is one of the complications most likely to lead to death in patients with acute ischemic stroke. HT after acute ischemic stroke is diagnosed when certain areas of cerebral infarction appear as cerebral hemorrhage on radiological images. Its mechanisms are usually explained by disruption of the blood-brain barrier and reperfusion injury that causes leakage of peripheral blood cells. In ischemic infarction, HT may be a natural progression of acute ischemic stroke and can be facilitated or enhanced by reperfusion therapy. Therefore, to balance risks and benefits, HT occurrence in acute stroke settings is an important factor to be considered by physicians to determine whether recanalization therapy should be performed. This review aims to illustrate the pathophysiological mechanisms of HT, outline most HT-related factors after reperfusion therapy, and describe prevention strategies for the occurrence and enlargement of HT, such as blood pressure control. Finally, we propose a promising therapeutic approach based on biological research studies that would help clinicians treat such catastrophic complications.
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Affiliation(s)
- Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
- Department of Biomedical Science, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
| | - Da Sol Kim
- Department of Biomedical Science, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
| | - Min Kim
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
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