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McArthur MA, Tavakkol E, Bahr-Hosseini M, Jahan R, Duckwiler GR, Saver JL, Liebeskind DS, Nael K. Overestimation of ischemic core on baseline MRI in acute stroke. Interv Neuroradiol 2024:15910199231224500. [PMID: 38258456 DOI: 10.1177/15910199231224500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND AND PURPOSE In patients with acute ischemic stroke (AIS), overestimation of ischemic core on MRI-DWI has been described primarily in regions with milder reduced diffusion. We aimed to assess the possibility of ischemic core overestimation on pretreatment MRI despite using more restricted reduced diffusion (apparent diffusion coefficient (ADC) ≤620 × 10-6 mm2/s) in AIS patients with successful reperfusion. MATERIALS AND METHODS In this retrospective single institutional study, AIS patients who had pretreatment MRI underwent successful reperfusion and had follow-up MRI to determine the final infarct volume were reviewed. Pretreatment ischemic core and final infarction volumes were calculated. Ghost core was defined as overestimation of final infarct volume by baseline MRI of >10 mL. Baseline clinical, demographic, and treatment-related factors in this cohort were reviewed. RESULTS A total of 6/156 (3.8%) patients had overestimated ischemic core volume on baseline MRI, with mean overestimation of 65.6 mL. Three out of six patients had pretreatment ischemic core estimation of >70 mL, while the final infarct volume was <70 mL. All six patients had last known well-to-imaging <120 min, median (IQR): 65 (53-81) minutes. CONCLUSIONS Overestimation of ischemic core, known as ghost core, is rare using severe ADC threshold (≤620 × 10-6 mm2/s), but it does occur in nearly 1 of every 25 patients, confined to hyperacute patients imaged within 120 min of symptom onset. Awareness of this phenomenon carries implications for treatment and trial enrollment.
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Affiliation(s)
- M A McArthur
- Department of Radiological Sciences, University of California, Los Angeles, Los Angeles, USA
| | - E Tavakkol
- Department of Radiological Sciences, University of California, Los Angeles, Los Angeles, USA
| | - M Bahr-Hosseini
- Department of Neurology, University of California, Los Angeles, Los Angeles, USA
| | - R Jahan
- Department of Radiological Sciences, University of California, Los Angeles, Los Angeles, USA
| | - G R Duckwiler
- Department of Radiological Sciences, University of California, Los Angeles, Los Angeles, USA
| | - J L Saver
- Department of Neurology, University of California, Los Angeles, Los Angeles, USA
| | - D S Liebeskind
- Department of Neurology, University of California, Los Angeles, Los Angeles, USA
| | - K Nael
- Department of Radiological Sciences, University of California, Los Angeles, Los Angeles, USA
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2
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Yedavalli V, Kihira S, Shahrouki P, Hamam O, Tavakkol E, McArthur M, Qiao J, Johanna F, Doshi A, Vagal A, Khatri P, Srinivasan A, Chaudhary N, Bahr-Hosseini M, Colby GP, Nour M, Jahan R, Duckwiler G, Arnold C, Saver JL, Mocco J, Liebeskind DS, Nael K. CTP-based estimated ischemic core: A comparative multicenter study between Olea and RAPID software. J Stroke Cerebrovasc Dis 2023; 32:107297. [PMID: 37738915 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107297] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND AND PURPOSE CTP is increasingly used to assess eligibility for endovascular therapy (EVT) in patients with large vessel occlusions (LVO). There remain variability and inconsistencies between software packages for estimation of ischemic core. We aimed to use heterogenous data from four stroke centers to perform a comparative analysis for CTP-estimated ischemic core between RAPID (iSchemaView) and Olea (Olea Medical). METHODS In this retrospective multicenter study, patients with anterior circulation LVO who underwent pretreatment CTP, successful EVT (defined TICI ≥ 2b), and follow-up MRI included. Automated CTP analysis was performed using Olea platform [rCBF < 25% and differential time-to-peak (dTTP)>5s] and RAPID (rCBF < 30%). The CTP estimated core volumes were compared against the final infarct volume (FIV) on post treatment MRI-DWI. RESULTS A total of 151 patients included. The CTP-estimated ischemic core volumes (mean ± SD) were 18.7 ± 18.9 mL on Olea and 10.5 ± 17.9 mL on RAPID significantly different (p < 0.01). The correlation between CTP estimated core and MRI final infarct volume was r = 0.38, p < 0.01 for RAPID and r = 0.39, p < 0.01 for Olea. Both software platforms demonstrated a strong correlation with each other (r = 0.864, p < 0.001). Both software overestimated the ischemic core volume above 70 mL in 4 patients (2.6%). CONCLUSIONS Substantial variation between Olea and RAPID CTP-estimated core volumes exists, though rates of overcalling of large core were low and identical. Both showed comparable core volume correlation to MRI infarct volume.
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Affiliation(s)
- V Yedavalli
- Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - S Kihira
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - P Shahrouki
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - O Hamam
- Massachussetts General Hospital, Boston, MA, United States
| | - E Tavakkol
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - M McArthur
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - J Qiao
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - Fifi Johanna
- Mount Sinai School of Medicine, New York, NY, United States
| | - A Doshi
- Mount Sinai School of Medicine, New York, NY, United States
| | - A Vagal
- University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - P Khatri
- University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - A Srinivasan
- University of Michigan School of Medicine, Ann Arbor, MI, United States
| | - N Chaudhary
- University of Michigan School of Medicine, Ann Arbor, MI, United States
| | - M Bahr-Hosseini
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - G P Colby
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - M Nour
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - R Jahan
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - G Duckwiler
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - C Arnold
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - J L Saver
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - J Mocco
- Mount Sinai School of Medicine, New York, NY, United States
| | - D S Liebeskind
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - K Nael
- David Geffen School of Medicine at the University of California - Los Angeles, United States
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3
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Singh N, Ospel J, Mayank A, Marko M, Zaidat OO, Mueller-Kronast NH, Liebeskind DS, Goyal M. Nonstenotic Carotid Plaques in Ischemic Stroke: Analysis of the STRATIS Registry. AJNR Am J Neuroradiol 2021; 42:1645-1652. [PMID: 34326103 DOI: 10.3174/ajnr.a7218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/27/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Few studies assess nonstenotic carotid plaques on CTA, and the causative role of these plaques in stroke is not entirely clear. We used CTA to determine the prevalence of nonstenotic carotid plaques (<50%), plaque features, and their association with ipsilateral strokes in patients with cardioembolic and cryptogenic strokes. MATERIALS AND METHODS Data were from the Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke (STRATIS) registry, a prospective, nonrandomized registry of patients undergoing thrombectomy with the Solitaire device. The prevalence of nonstenotic carotid plaques ipsilateral and contralateral to the stroke was compared in patients with cryptogenic and cardioembolic strokes. Plaque features were further compared within both subgroups between patients with and without ipsilateral stroke. Adjusted associations among nonstenotic carotid plaque, plaque characteristics, and ipsilateral stroke in both subgroups were determined with logistic regression. RESULTS Of the 946 patients in the data base, 226 patients with cardioembolic stroke (median age, 72 years) and 141 patients with cryptogenic stroke (median age, 69 years) were included in the analysis. The prevalence of nonstenotic carotid plaque in the cardioembolic and cryptogenic subgroups was 33/226 (14.6%) and 32/141 (22.7%), respectively. Bilateral nonstenotic carotid plaques were seen in 10/226 (4.4%) patients with cardioembolic and 13/141 (9.2%) with cryptogenic strokes. Nonstenotic carotid plaques were significantly associated with ipsilateral strokes in the cardioembolic stroke (adjusted OR = 1.91; 95% CI, 1.15-3.18) and the cryptogenic stroke (adjusted OR = 1.69; 95% CI, 1.05-2.73) groups. Plaque irregularity, hypodensity, and per-millimeter increase in plaque thickness were significantly associated with ipsilateral stroke in the cryptogenic subgroup. CONCLUSIONS Nonstenotic carotid plaques were significantly associated with ipsilateral stroke in cardioembolic and cryptogenic stroke groups, and there was an association of plaque irregularity and hypodense plaque with ipsilateral stroke in the cryptogenic group, suggesting these plaques could be a potential cause of stroke in these patient subgroups.
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Affiliation(s)
- N Singh
- From the Departments of Clinical Neurosciences (N.S., A.M., M.G.)
| | - J Ospel
- Department of Radiology (J.O.), University Hospital of Basel, Basel, Switzerland
| | - A Mayank
- From the Departments of Clinical Neurosciences (N.S., A.M., M.G.)
| | - M Marko
- Department of Neurology (M.M.), Medical University of Vienna, Vienna, Austria
| | - O O Zaidat
- Neuroscience Institute (O.O.Z.), Mercy Health St. Vincent Medical Center, Toledo, Ohio
| | - N H Mueller-Kronast
- Department of Neurology (N.H.M.-K.), Delray Medical Center, Delray Beach, Florida
| | - D S Liebeskind
- UCLA Comprehensive Stroke Center (D.S.L.), Los Angeles, California
| | - M Goyal
- From the Departments of Clinical Neurosciences (N.S., A.M., M.G.) .,Diagnostic Imaging (M.G.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
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4
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Zaidi SF, Castonguay AC, Zaidat OO, Mueller-Kronast N, Liebeskind DS, Salahuddin H, Jumaa MA. Intra-Arterial Thrombolysis after Unsuccessful Mechanical Thrombectomy in the STRATIS Registry. AJNR Am J Neuroradiol 2021; 42:708-712. [PMID: 33509921 DOI: 10.3174/ajnr.a6962] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/21/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Recent data suggest that intra-arterial thrombolytics may be a safe rescue therapy for patients with acute ischemic stroke after unsuccessful mechanical thrombectomy; however, safety and efficacy remain unclear. Here, we evaluate the use of intra-arterial rtPA as a rescue therapy in the Systematic Evaluation of Patients Treated with Neurothrombectomy Devices for Acute Ischemic Stroke (STRATIS) registry. MATERIALS AND METHODS STRATIS was a prospective, multicenter, observational study of patients with acute ischemic stroke with large-vessel occlusions treated with the Solitaire stent retriever as the first-line therapy within 8 hours from symptom onset. Clinical and angiographic outcomes were compared in patients having rescue therapy treated with and without intra-arterial rtPA. Unsuccessful mechanical thrombectomy was defined as any use of rescue therapy. RESULTS A total of 212/984 (21.5%) patients received rescue therapy, of which 83 (39.2%) and 129 (60.8%) were in the no intra-arterial rtPA and intra-arterial rtPA groups, respectively. Most occlusions were M1, with 43.4% in the no intra-arterial rtPA group and 55.0% in the intra-arterial rtPA group (P = .12). The median intra-arterial rtPA dose was 4 mg (interquartile range = 2-12 mg). A trend toward higher rates of substantial reperfusion (modified TICI ≥ 2b) (84.7% versus 73.0%, P = .08), good functional outcome (59.2% versus 46.6%, P = .10), and lower rates of mortality (13.3% versus 23.3%, P = .08) was seen in the intra-arterial rtPA cohort. Rates of symptomatic intracranial hemorrhage did not differ (0% versus 1.6%, P = .54). CONCLUSIONS Use of intra-arterial rtPA as a rescue therapy after unsuccessful mechanical thrombectomy was not associated with an increased risk of symptomatic intracranial hemorrhage or mortality. Randomized clinical trials are needed to understand the safety and efficacy of intra-arterial thrombolysis as a rescue therapy after mechanical thrombectomy.
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Affiliation(s)
- S F Zaidi
- From the Department of Neurology (S.F.A., A.C.C., H.S., M.A.J.), University of Toledo, Toledo, Ohio
| | - A C Castonguay
- From the Department of Neurology (S.F.A., A.C.C., H.S., M.A.J.), University of Toledo, Toledo, Ohio
| | - O O Zaidat
- St. Vincent Mercy Hospital (O.O.Z.), Toledo, Ohio
- Department of Neurology (O.O.Z., D.S.L.), University of California Los Angeles, Los Angeles, California
| | | | - D S Liebeskind
- Department of Neurology (O.O.Z., D.S.L.), University of California Los Angeles, Los Angeles, California
| | - H Salahuddin
- From the Department of Neurology (S.F.A., A.C.C., H.S., M.A.J.), University of Toledo, Toledo, Ohio
| | - M A Jumaa
- From the Department of Neurology (S.F.A., A.C.C., H.S., M.A.J.), University of Toledo, Toledo, Ohio
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5
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Yoshie T, Yu Y, Jiang H, Honda T, Trieu H, Scalzo F, Saver JL, Liebeskind DS. Perfusion Parameter Thresholds That Discriminate Ischemic Core Vary with Time from Onset in Acute Ischemic Stroke. AJNR Am J Neuroradiol 2020; 41:1809-1815. [PMID: 32855193 DOI: 10.3174/ajnr.a6744] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 06/29/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE When mapping the ischemic core and penumbra in patients with acute ischemic stroke using perfusion imaging, the core is currently delineated by applying the same threshold value for relative CBF at all time points from onset to imaging. We investigated whether the degree of perfusion abnormality and optimal perfusion parameter thresholds for defining ischemic core vary with time from onset to imaging. MATERIALS AND METHODS In a prospectively maintained registry, consecutive patients were analyzed who had ICA or M1 occlusion, baseline perfusion and diffusion MR imaging, treatment with IV tPA and/or endovascular thrombectomy, and a witnessed, well-documented time of onset. Ten superficial and deep MCA ROIs were analyzed in ADC and perfusion-weighted images. RESULTS Among the 66 patients meeting entry criteria, onset-to-imaging time was 162 minutes (range, 94-326 minutes). Of the 660 ROIs analyzed, 164 (24.8%) showed severely or moderately reduced ADC (ADC ≤ 620, ischemic core), and 496 (75.2%), mildly reduced or normal ADC (ADC > 620). In ischemic core ADC regions, longer onset-to-imaging times were associated with more highly abnormal perfusion parameters-relative CBF: Spearman correlation, r = -0.22, P = .005; relative CBV: r = -0.41, P < .001; MTT: - r = -0.29, P < .001; and time-to-maximum: r = 0.35, P < .001. As onset-to-imaging times increased, the best cutoff values for relative CBF and relative CBV to discriminate core from noncore tissue became progressively lower and overall accuracy of the core tissue definition increased. CONCLUSIONS Perfusion abnormalities in ischemic core regions become progressively more abnormal with longer intervals from onset to imaging. Perfusion parameter value thresholds that best delineate ischemic core are more severely abnormal and have higher accuracy with longer onset-to-imaging times.
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Affiliation(s)
- T Yoshie
- From the Department of Neurology (T.Y., Y.Y., H.J., T.H., H.T., F.S., J.L.S., D.S.L.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
- Department of Neurology and Neuro Endovascular Therapy (T.Y.), St. Marianna University Toyoko Hospital, Kanagawa, Japan
| | - Y Yu
- From the Department of Neurology (T.Y., Y.Y., H.J., T.H., H.T., F.S., J.L.S., D.S.L.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - H Jiang
- From the Department of Neurology (T.Y., Y.Y., H.J., T.H., H.T., F.S., J.L.S., D.S.L.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
- Department of Neurology (H.J.), the First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - T Honda
- From the Department of Neurology (T.Y., Y.Y., H.J., T.H., H.T., F.S., J.L.S., D.S.L.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - H Trieu
- From the Department of Neurology (T.Y., Y.Y., H.J., T.H., H.T., F.S., J.L.S., D.S.L.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - F Scalzo
- From the Department of Neurology (T.Y., Y.Y., H.J., T.H., H.T., F.S., J.L.S., D.S.L.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - J L Saver
- From the Department of Neurology (T.Y., Y.Y., H.J., T.H., H.T., F.S., J.L.S., D.S.L.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - D S Liebeskind
- From the Department of Neurology (T.Y., Y.Y., H.J., T.H., H.T., F.S., J.L.S., D.S.L.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
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6
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Pu Y, Liu X, Wang Y, Meng X, Jing J, Zou X, Pan Y, Wang A, Zhao X, Johnston SC, Wang Y, Atchaneeyasakul K, Liebeskind DS, Liu L. Higher early recurrence risk and potential benefit of dual antiplatelet therapy for minor stroke with watershed infarction: subgroup analysis of CHANCE. Eur J Neurol 2020; 27:800-808. [PMID: 31997490 DOI: 10.1111/ene.14156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 01/17/2020] [Indexed: 01/05/2023]
Affiliation(s)
- Y. Pu
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
| | - X. Liu
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
| | - Y. Wang
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Center of Stroke Beijing Institute for Brain Disorders Beijing China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - X. Meng
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Center of Stroke Beijing Institute for Brain Disorders Beijing China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - J. Jing
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Center of Stroke Beijing Institute for Brain Disorders Beijing China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - X. Zou
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
| | - Y. Pan
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Center of Stroke Beijing Institute for Brain Disorders Beijing China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - A. Wang
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Center of Stroke Beijing Institute for Brain Disorders Beijing China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - X. Zhao
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Center of Stroke Beijing Institute for Brain Disorders Beijing China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - S. C. Johnston
- Dell Medical School University of Texas at Austin TX USA
| | - Y. Wang
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Center of Stroke Beijing Institute for Brain Disorders Beijing China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | | | | | - L. Liu
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Center of Stroke Beijing Institute for Brain Disorders Beijing China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
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7
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Clarençon F, Baronnet F, Shotar E, Degos V, Rolla-Bigliani C, Bartolini B, Veznedaroglu E, Budzik R, English J, Baxter B, Liebeskind DS, Krajina A, Gupta R, Miralbes S, Lüttich A, Nogueira RG, Samson Y, Alamowitch S, Sourour NA. Should posterior cerebral artery occlusions be recanalized? Insights from the Trevo Registry. Eur J Neurol 2020; 27:787-792. [PMID: 31997505 DOI: 10.1111/ene.14154] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 01/09/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to evaluate the safety and effectiveness of mechanical thrombectomy (MT) in patients with acute ischaemic stroke related to isolated and primary posterior cerebral artery (PCA) occlusions amongst the patients enrolled in the multicentre post-market Trevo Registry. METHOD Amongst the 2008 patients enrolled in the Trevo Registry with acute ischaemic stroke due to large vessel occlusion treated by MT, 22 patients (1.1%) [10 females (45.5%), mean age 66.2 ± 14.3 years (range 28-91)] had a PCA occlusion [17 P1 (77.3%) and five P2 occlusions (22.7%)]. Recanalization after the first Trevo (Stryker, Fremont, CA, USA) pass and at the end of the procedure was rated using the modified Thrombolysis in Cerebral Infarction (mTICI) score. Procedure-related complications (i.e. groin puncture complication, perforation, symptomatic haemorrhage, embolus in a new territory) were also recorded. The modified Rankin Scale at 90 days was assessed. RESULTS Median National Institutes of Health Stroke Scale at admission was 14 (interquartile range 8-16). Stroke aetiology was cardio-embolic in 68.2% of cases. Half of the patients (11/22) received intravenous tissue plasminogen activator. 54.5% of the patients were treated under general anaesthesia. Reperfusion (i.e. mTICI 2b or 3) after first pass was obtained in 65% of cases. Final mTICI 2b-3 reperfusion was obtained in all cases. Only one (4.5%) procedure-related complication was recorded (puncture site) that resolved after surgery. At 90-day follow-up, modified Rankin Scale 0-2 was obtained in 59% of the patients and 9.1% died within the first 3 months after MT. CONCLUSION Mechanical thrombectomy for PCA occlusions seems to be safe (<5% procedure-related complications) and effective. Larger repository datasets are needed.
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Affiliation(s)
- F Clarençon
- Sorbonne University, Paris, France.,Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - F Baronnet
- Department of Vascular Neurology, Pitié-Salpêtrière Hospital, Paris, France
| | - E Shotar
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - V Degos
- Sorbonne University, Paris, France.,Department of Anesthesiology, Pitié-Salpêtrière Hospital, Paris, France
| | - C Rolla-Bigliani
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - B Bartolini
- Department of Radiology, Interventional Neuroradiology Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - E Veznedaroglu
- Endovascular Neurosurgery, Drexel Neurosciences Institute, Philadelphia, PA, USA
| | - R Budzik
- Interventional Neuroradiology, Riverside Methodist Hospital/Ohio Health Research Institute, Columbus, OH, USA
| | - J English
- Interventional Neurology, California Pacific Medical Center, San Francisco, CA, USA
| | - B Baxter
- Interventional Neuroradiology, Erlanger, Chattanooga, TN, USA
| | - D S Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - A Krajina
- Department of Radiology, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - R Gupta
- Interventional Neurology, Wellstar Health System, Atlanta, GA, USA
| | - S Miralbes
- Hospital Universitario Son Espases, Mallorca, España
| | - A Lüttich
- Hospital de Donostia, San Sebastian, España
| | - R G Nogueira
- Department of Neurology, Marcus Stroke and Neuroscience Center/Grady Memorial Hospital/Emory University, Atlanta, GA, USA
| | - Y Samson
- Sorbonne University, Paris, France.,Department of Vascular Neurology, Pitié-Salpêtrière Hospital, Paris, France
| | - S Alamowitch
- Sorbonne University, Paris, France.,Department of Vascular Neurology, Saint Antoine University Hospital, Paris, France
| | - N-A Sourour
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
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8
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Staessens S, Fitzgerald S, Andersson T, Clarençon F, Denorme F, Gounis MJ, Hacke W, Liebeskind DS, Szikora I, van Es ACGM, Brinjikji W, Doyle KM, De Meyer SF. Histological stroke clot analysis after thrombectomy: Technical aspects and recommendations. Int J Stroke 2019; 15:467-476. [DOI: 10.1177/1747493019884527] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The recent advent of endovascular procedures has created the unique opportunity to collect and analyze thrombi removed from cerebral arteries, instigating a novel subfield in stroke research. Insights into thrombus characteristics and composition could play an important role in ongoing efforts to improve acute ischemic stroke therapy. An increasing number of centers are collecting stroke thrombi. This paper aims at providing guiding information on thrombus handling, procedures, and analysis in order to facilitate and standardize this emerging research field.
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Affiliation(s)
- S Staessens
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - S Fitzgerald
- CÚRAM-Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - T Andersson
- Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
- Department of Neuroradiology, Karolinska University Hospital and Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - F Clarençon
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, APHP, Paris, France
| | - F Denorme
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - MJ Gounis
- Division of Neuroimaging and Intervention and New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - W Hacke
- Department of Neurology, University Hospital Heidelberg, Ruprecht-Karls University, Heidelberg, Germany
| | - DS Liebeskind
- Neurovascular Imaging Research Core and UCLA Stroke Center, University of California, Los Angeles, CA, USA
| | - I Szikora
- Department of Neuroradiology, National Institute of Neurosciences, Budapest, Hungary
| | - ACGM van Es
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center (EMC), Rotterdam, The Netherlands
| | - W Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - KM Doyle
- CÚRAM-Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - SF De Meyer
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
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9
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Yu YN, Liu MW, Villablanca JP, Li ML, Xu YY, Gao S, Feng F, Liebeskind DS, Scalzo F, Xu WH. Middle Cerebral Artery Plaque Hyperintensity on T2-Weighted Vessel Wall Imaging Is Associated with Ischemic Stroke. AJNR Am J Neuroradiol 2019; 40:1886-1892. [PMID: 31624115 DOI: 10.3174/ajnr.a6260] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 08/27/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND PURPOSE Vessel wall imaging can identify intracranial atherosclerotic plaque and give clues about its components. We aimed to investigate whether the plaque hyperintensity in the middle cerebral artery on T2-weighted vessel wall imaging is associated with ischemic stroke. MATERIALS AND METHODS We retrospectively reviewed our institutional vessel wall MR imaging data base. Patients with an acute ischemic stroke within 7-day onset in the MCA territory were enrolled. Patients with stroke and stenotic MCA plaque (stenosis degree, ≥50%) were included for analysis. Ipsilateral MCA plaque was defined as symptomatic, and contralateral plaque, as asymptomatic. Plaque was manually delineated on T2-weighted vessel wall imaging. The plaque signal was normalized to the ipsilateral muscle signal. The thresholds and volume of normalized plaque signal were investigated using logistic regression and receiver operating characteristic analysis to determine the association between normalized plaque signal and stroke. RESULTS One hundred eight stenotic MCAs were analyzed (from 88 patients, 66 men; mean age, 58 ± 15 years), including 72 symptomatic and 36 asymptomatic MCA plaques. Symptomatic MCA plaque showed larger plaque hyperintensity volume compared with asymptomatic MCA plaque. The logistic regression model incorporating stenosis degree, remodeling ratio, and normalized plaque signal 1.3-1.4 (OR, 6.25; 95% CI, 1.90-20.57) had a higher area under curve in differentiating symptomatic/asymptomatic MCA plaque, compared with a model with only stenosis degree and remodeling ratio (area under curve, 0.884 versus 0.806; P =.008). CONCLUSIONS The MCA plaque hyperintensity on T2-weighted vessel wall imaging is independently associated with ischemic stroke and adds value to symptomatic MCA plaque classification. Measuring the normalized signal intensity may serve as a practical and integrative approach to the analysis of intracranial atherosclerotic plaque.
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Affiliation(s)
- Y-N Yu
- From the Departments of Neurology (Y.-N.Y., Y.-Y.X., S.G., W.-H.X.)
| | - M-W Liu
- Neurovascular Imaging Research Core and UCLA Stroke Center (M.-W.L., D.S.L., F.S.), Los Angeles, California
| | | | - M-L Li
- Radiology (M.-L.L., F.F.), Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Y-Y Xu
- From the Departments of Neurology (Y.-N.Y., Y.-Y.X., S.G., W.-H.X.)
| | - S Gao
- From the Departments of Neurology (Y.-N.Y., Y.-Y.X., S.G., W.-H.X.)
| | - F Feng
- Radiology (M.-L.L., F.F.), Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - D S Liebeskind
- Neurovascular Imaging Research Core and UCLA Stroke Center (M.-W.L., D.S.L., F.S.), Los Angeles, California
| | - F Scalzo
- Neurovascular Imaging Research Core and UCLA Stroke Center (M.-W.L., D.S.L., F.S.), Los Angeles, California
| | - W-H Xu
- From the Departments of Neurology (Y.-N.Y., Y.-Y.X., S.G., W.-H.X.)
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10
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Leung TWH, Fan SY, Ip HL, Lau AYL, Siu DYW, Dai EYL, Wong LKS, Liebeskind DS. Effects of collateral circulation on haemodynamic flow status in intracranial artery stenosis depicted by computational fluid dynamics. Hong Kong Med J 2019; 25 Suppl 5:18-21. [PMID: 31416981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Affiliation(s)
- T W H Leung
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - S Y Fan
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - H L Ip
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - A Y L Lau
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - D Y W Siu
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - E Y L Dai
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - L K S Wong
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - D S Liebeskind
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong
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11
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Behme D, Gera RG, Tsogkas I, Colla R, Liman J, Maier IL, Liebeskind DS, Psychogios MN. Impact of Time on Thrombolysis in Cerebral Infarction Score Results. Clin Neuroradiol 2019; 30:345-353. [PMID: 31069414 DOI: 10.1007/s00062-019-00786-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/19/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE Extended thrombolysis in cerebral infarction (eTICI) score results of 2b or higher are known to be predictors for favorable outcome after acute stroke. Additionally, time is a major factor influencing outcome after ischemic stroke. Until today only little is known about the impact of time on angiographic results regarding the outcome after mechanical thrombectomy; however, this impact might be of interest if an initially unfavorable angiographic result has to be improved. METHODS Retrospective study of 164 patients with large vessel occlusion of the anterior circulation treated by mechanical thrombectomy. Multiple logistic regression analysis of relevant periprocedural and procedural times in respect to the probability of achieving functional independence at 90 days in respect to different eTICI results was performed to build a time and TICI score-dependent model for outcome prediction in which the influence of time was assumed to be steady among the TICI grades. RESULTS The probability of achieving a favorable outcome is significantly different between eTICI2b-50, 67, TICI2c and TICI3 results (p < 0.001). The odds for achieving a favorable outcome decrease over time and differ for each TICI category and time point. The individual odds for each patient, time point and TICI grade can be calculated based on this model. CONCLUSION The impact of periprocedural and procedural times and eTICI reperfusion results adds a new dimension to the decision-making process in patients with primary unfavorable angiographic results.
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Affiliation(s)
- D Behme
- Department of Neuroradiology, University Medical Center Göttingen, Robert Koch Str. 40, 37099, Göttingen, Germany.
| | - R G Gera
- Department of Medical Statistics, University Medical Center Göttingen, 37075, Göttingen, Germany
| | - I Tsogkas
- Department of Neuroradiology, University Medical Center Göttingen, Robert Koch Str. 40, 37099, Göttingen, Germany
| | - R Colla
- Department of Neuroradiology, University Medical Center Göttingen, Robert Koch Str. 40, 37099, Göttingen, Germany
| | - J Liman
- Department of Neurology, University Medical Center Göttingen, 37075, Göttingen, Germany
| | - I L Maier
- Department of Neurology, University Medical Center Göttingen, 37075, Göttingen, Germany
| | - D S Liebeskind
- Neurovascular Imaging Research Core and Stroke Center, Department of Neurology, UCLA, Los Angeles, CA, USA
| | - M N Psychogios
- Department of Neuroradiology, University Medical Center Göttingen, Robert Koch Str. 40, 37099, Göttingen, Germany
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12
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Buschmann EE, Hillmeister P, Bondke Persson A, Liebeskind DS, Schlich L, Kamenzky R, Busjahn A, Buschmann IR, Bramlage P, Hetzel A, Reinhard M. Short-term external counterpulsation augments cerebral blood flow and tissue oxygenation in chronic cerebrovascular occlusive disease. Eur J Neurol 2018; 25:1326-1332. [PMID: 29924461 PMCID: PMC6221180 DOI: 10.1111/ene.13725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 06/19/2018] [Indexed: 11/30/2022]
Abstract
Background and purpose External counterpulsation improves cerebral perfusion velocity in acute stroke and may stimulate collateral artery growth. However, whether (non‐acute) at‐risk patients with high‐grade carotid artery disease may benefit from counterpulsation needs to be validated. Methods Twenty‐eight patients (71 ± 6.5 years, five women) with asymptomatic unilateral chronic severe internal carotid artery stenosis (>70%) or occlusion were randomized to receive 20 min active counterpulsation followed by sham treatment or vice versa. Cerebral blood flow velocity (CBFV) (measured bilaterally by transcranial middle cerebral artery Doppler), tissue oxygenation index (TOI) (measured over the bilateral prefrontal cortex by near‐infrared spectroscopy) and cerebral hemodynamic parameters, such as relative pulse slope index (RPSI), were monitored. Results Ipsilateral mean CBFV (ΔVmean +3.5 ± 1.2 cm/s) and tissue oxygenation (ΔTOI +2.86 ± 0.8) increased significantly during active counterpulsation compared to baseline, whilst the sham had little effect (ΔVmean +1.13 ± 1.1 cm/s; ΔTOI +1.25 ± 0.65). On contralateral sides, neither counterpulsation nor sham control had any effect on either parameter. During counterpulsation, early dynamic changes in ΔRPSI of the ipsilateral CBFV signal predicted improved tissue oxygenation during counterpulsation (odds ratio 1.179, 95% confidence interval 1.01–1.51), whilst baseline cerebrovascular reactivity to hypercapnia failed to show an association. Conclusions In patients with high‐grade carotid disease, ipsilateral cerebral oxygenation and blood flow velocity are increased by counterpulsation. This is a necessary condition for the stimulation of regenerative collateral artery growth and thus a therapeutic concept for the prevention of cerebral ischaemia. This study provides a rationale for further clinical investigations on the long‐term effects of counterpulsation on cerebral hemodynamics and collateral growth.
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Affiliation(s)
- E E Buschmann
- Department for Cardiology, Center of Internal Medicine, Medical University Graz, Graz, Austria.,Brandenburg School of Medicine, Center for Internal Medicine I, Department for Angiology, Brandenburg an der Havel, Germany.,Department of Cardiology, Charité Universitaetsmedizin Berlin, Campus Virchow, Berlin, Germany
| | - P Hillmeister
- Brandenburg School of Medicine, Center for Internal Medicine I, Department for Angiology, Brandenburg an der Havel, Germany.,Department of Cardiology, Charité Universitaetsmedizin Berlin, Campus Virchow, Berlin, Germany
| | - A Bondke Persson
- Institute of Vegetative Physiology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - D S Liebeskind
- Neurovascular Imaging Research Core and UCLA Stroke Center, Los Angeles, CA, USA
| | - L Schlich
- Department of Neurology, University of Freiburg, Freiburg, Germany
| | - R Kamenzky
- Department of Cardiology, Charité Universitaetsmedizin Berlin, Campus Virchow, Berlin, Germany
| | | | - I R Buschmann
- Brandenburg School of Medicine, Center for Internal Medicine I, Department for Angiology, Brandenburg an der Havel, Germany.,Department of Cardiology, Charité Universitaetsmedizin Berlin, Campus Virchow, Berlin, Germany
| | - P Bramlage
- Brandenburg School of Medicine, Center for Internal Medicine I, Department for Angiology, Brandenburg an der Havel, Germany.,Institute für Pharmakologie und Präventive Medizin, Cloppenburg, Germany
| | - A Hetzel
- Schwarzwaldklinik Neurologie, Bad Krozingen, Germany
| | - M Reinhard
- Department of Neurology, University of Freiburg, Freiburg, Germany.,Department of Neurology and Clinical Neurophysiology, Medical Center Esslingen, Academic Teaching Hospital of the University of Tübingen, Tübingen, Germany
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13
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Leng X, Lan L, Ip HL, Fan F, Ma SH, Ma K, Liu H, Yan Z, Liu J, Abrigo J, Soo YOY, Liebeskind DS, Wong KS, Leung TW. Translesional pressure gradient and leptomeningeal collateral status in symptomatic middle cerebral artery stenosis. Eur J Neurol 2017; 25:404-410. [PMID: 29171118 DOI: 10.1111/ene.13521] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 11/20/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE Leptomeningeal collateral (LMC) status governs the prognosis of large artery occlusive stroke, although factors determining LMC status are not fully elucidated. The aim was to investigate metrics affecting LMC status in such patients by using computational fluid dynamics (CFD) models based on computed tomography angiography (CTA). METHODS In this cross-sectional study, patients with recent ischaemic stroke or transient ischaemic attack attributed to atherosclerotic M1 middle cerebral artery (MCA) stenosis (50%-99%) were recruited. Demographic, clinical and imaging data of these patients were collected. Ipsilesional LMC status was graded as good or poor by assessing the laterality of anterior and posterior cerebral arteries in CTA. A CFD model based on CTA was constructed to reflect focal hemodynamics in the distal internal carotid artery, M1 MCA and A1 anterior cerebral artery. Pressure gradients were calculated across culprit MCA stenotic lesions in CFD models. Predictors for good LMC status were sought in univariate and multivariate analyses. RESULTS Amongst the 85 patients enrolled (mean age 61.5 ± 10.9 years), 38 (44.7%) had good ipsilesional LMC status. The mean pressure gradient across MCA lesions was 14.8 ± 18.1 mmHg. Advanced age (P = 0.030) and a larger translesional pressure gradient (P = 0.029) independently predicted good LMCs. A lower fasting blood glucose level also showed a trend for good LMCs (P = 0.058). CONCLUSIONS Our study suggested a correlation between translesional pressure gradient and maturation of LMCs in intracranial atherosclerotic disease. Further studies with more exquisite and dynamic monitoring of cerebral hemodynamics and LMC evolution are needed to verify the current findings.
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Affiliation(s)
- X Leng
- Division of Neurology, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.,Shenzhen Research Institute, Chinese University of Hong Kong, Shenzhen, China
| | - L Lan
- Division of Neurology, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - H L Ip
- Division of Neurology, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - F Fan
- Division of Neurology, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - S H Ma
- Division of Neurology, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - K Ma
- Division of Neurology, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - H Liu
- Division of Neurology, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.,Department of Imaging and Interventional Radiology, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Z Yan
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - J Liu
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - J Abrigo
- Department of Imaging and Interventional Radiology, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Y O Y Soo
- Division of Neurology, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - D S Liebeskind
- Neurovascular Imaging Research Core, Department of Neurology, University of California, Los Angeles, CA, USA
| | - K S Wong
- Division of Neurology, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - T W Leung
- Division of Neurology, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
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14
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Zhang X, Zhang M, Ding W, Yan S, Liebeskind DS, Lou M. Distinct predictive role of collateral status on clinical outcome in variant stroke subtypes of acute large arterial occlusion. Eur J Neurol 2017; 25:293-300. [PMID: 29053905 DOI: 10.1111/ene.13493] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/16/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Clinical trials have shown that robust collateral flow has a relationship with good clinical outcome; however, different stroke subtypes were lumped together. This study explored the relationship between baseline collaterals and the onset-to-imaging time (OIT) and the correlation between pre-treatment collateral status and clinical outcome amongst different subtypes. METHOD Prospectively collected data from consecutive acute ischaemic stroke patients with acute middle cerebral artery occlusion who received reperfusion therapy were reviewed. The regional leptomeningeal score (20 points) was based on the scoring extent of contrast opacification in the six Alberta Stroke Program Early CT Score (ASPECTS) cortical regions (M1-6), parasagittal anterior cerebral artery territory and the basal ganglia by perfusion-derived dynamic four-dimensional computed tomography angiography (4D CTA). Stroke subtype was determined by the TOAST classification criteria. A 3-months modified Rankin Scale score of 0-2 was defined as a good outcome. RESULTS The analysis included 158 patients: 30 (19.0%) patients had large artery atherosclerotic stroke (LAA), 87 (55.1%) cardioembolic stroke (CE) and 41 (25.9%) stroke of undetermined etiology. Baseline collateral was negatively correlated with OIT (P = 0.0205) in the CE group after adjusting for female sex, smoking, hyperlipidemia, baseline National Institutes of Health Stroke Scale (NIHSS) and baseline mismatch ratio, but not in the LAA group. Baseline collateral showed a strong relationship with good clinical outcome after adjusting for recanalization, baseline NIHSS, age and female sex (odds ratio 1.120, confidence interval 1.013-1.238, P = 0.027) in all patients and in the CE group (odds ratio 3.223, confidence interval 1.212-8.570, P = 0.019), but not in the LAA patients. CONCLUSIONS Based on 4D CTA, sustained good leptomeningeal collaterals may predict good outcome in CE but not in LAA patients. Moreover, the extent of collaterals was associated with OIT in the CE patients, which indicates prompt reperfusion therapy in this group of patients.
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Affiliation(s)
- X Zhang
- Department of Neurology, School of Medicine, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - M Zhang
- Department of Neurology, School of Medicine, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - W Ding
- Department of Radiology, School of Medicine, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - S Yan
- Department of Neurology, School of Medicine, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - D S Liebeskind
- UCLA Stroke Center, University of California Los Angeles, Los Angeles, CA, USA
| | - M Lou
- Department of Neurology, School of Medicine, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
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15
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Chen Y, Yan S, Xu M, Zhong G, Liebeskind DS, Lou M. More extensive white matter hyperintensity is linked with higher risk of remote intracerebral hemorrhage after intravenous thrombolysis. Eur J Neurol 2017; 25:380-e15. [PMID: 29115734 DOI: 10.1111/ene.13517] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 11/02/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Y. Chen
- Department of Neurology The Second Affiliated Hospital of Zhejiang University School of Medicine Hangzhou China
| | - S. Yan
- Department of Neurology The Second Affiliated Hospital of Zhejiang University School of Medicine Hangzhou China
| | - M. Xu
- Department of Neurology The Second Affiliated Hospital of Zhejiang University School of Medicine Hangzhou China
| | - G. Zhong
- Department of Neurology The Second Affiliated Hospital of Zhejiang University School of Medicine Hangzhou China
| | | | - M. Lou
- Department of Neurology The Second Affiliated Hospital of Zhejiang University School of Medicine Hangzhou China
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16
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Tomsick TA, Liebeskind DS, Hill MD, von Kummer R, Goyal M, Broderick JP. Reply. AJNR Am J Neuroradiol 2017; 38:E44-E45. [PMID: 28473347 DOI: 10.3174/ajnr.a5200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- T A Tomsick
- Department of Radiology University of Cincinnati Academic Health Center University Hospital Cincinnati, Ohio
| | - D S Liebeskind
- University of California, Los Angeles Stroke Center Los Angeles, California
| | - M D Hill
- Calgary Stroke Program Department of Clinical Neurosciences, Medicine Community Health Sciences, Hotchkiss Brain Institute University of Calgary, Foothills Hospital Calgary, Alberta, Canada
| | - R von Kummer
- Department of Neuroradiology Dresden University Stroke Center Universitätsklinikum Carl Gustav Carusan de Technischen Universität Dresden Dresden, Germany
| | - M Goyal
- Department of Radiology and Clinical Neurosciences University of Calgary Calgary, Alberta, Canada
| | - J P Broderick
- Department of Neurology University of Cincinnati Academic Health Center Cincinnati, Ohio
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17
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Tomsick TA, Carrozzella J, Foster L, Hill MD, von Kummer R, Goyal M, Demchuk AM, Khatri P, Palesch Y, Broderick JP, Yeatts SD, Liebeskind DS. Endovascular Therapy of M2 Occlusion in IMS III: Role of M2 Segment Definition and Location on Clinical and Revascularization Outcomes. AJNR Am J Neuroradiol 2016; 38:84-89. [PMID: 27765740 DOI: 10.3174/ajnr.a4979] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/01/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Uncertainty persists regarding the safety and efficacy of endovascular therapy of M2 occlusions following IV tPA. We reviewed the impact of revascularization on clinical outcomes in 83 patients with M2 occlusions in the Interventional Management of Stroke III trial according to specific M1-M2 segment anatomic features. MATERIALS AND METHODS Perfusion of any M2 branch distinguished M2-versus-M1 occlusion. Prespecified modified TICI and arterial occlusive lesion revascularization and clinical mRS 0-2 end points at 90 days for endovascular therapy-treated M2 occlusions were analyzed. Post hoc analyses of the relationship of outcomes to multiple baseline angiographic M2 and M1 subgroup characteristics were performed. RESULTS Of 83 participants with M2 occlusion who underwent endovascular therapy, 41.0% achieved mRS 0-2 at 90 days, including 46.6% with modified TICI 2-3 reperfusion compared with 26.1% with modified TICI 0-1 reperfusion (risk difference, 20.6%; 95% CI, -1.4%-42.5%). mRS 0-2 outcome was associated with reperfusion for M2 trunk (n = 9) or M2 division (n = 42) occlusions, but not for M2 branch occlusions (n = 28). Of participants with trunk and division occlusions, 63.2% with modified TICI 2a and 42.9% with modified TICI 2b reperfusion achieved mRS 0-2 outcomes; mRS 0-2 outcomes for M2 trunk occlusions (33%) did not differ from distal (38.2%) and proximal (26.9%) M1 occlusions. CONCLUSIONS mRS 0-2 at 90 days was dependent on reperfusion for M2 trunk but not for M2 branch occlusions. For M2 division occlusions, good outcome with modified TICI 2b reperfusion did not differ from that in modified TICI 2a. M2 segment definition and occlusion location may contribute to differences in revascularization and good outcome between Interventional Management of Stroke III and other endovascular therapy studies.
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Affiliation(s)
- T A Tomsick
- From the Department of Radiology (T.A.T., J.C.), University of Cincinnati Academic Health Center, University Hospital, Cincinnati, Ohio
| | - J Carrozzella
- From the Department of Radiology (T.A.T., J.C.), University of Cincinnati Academic Health Center, University Hospital, Cincinnati, Ohio
| | - L Foster
- Department of Biostatistics, Bioinformatics, and Epidemiology (L.F., Y.P., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
| | - M D Hill
- Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Medicine, Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada
| | - R von Kummer
- Department of Neuroradiology (R.v.K.), Dresden University Stroke Center, Universitätsklinikum Carl Gustav Carusan deTechnischen Universität Dresden, Dresden, Germany
| | - M Goyal
- Department of Radiology and Clinical Neurosciences (M.G.), University of Calgary, Calgary, Alberta, Canada
| | - A M Demchuk
- Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Medicine, Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada
| | - P Khatri
- Department of Neurology (P.K., J.P.B.), University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - Y Palesch
- Department of Biostatistics, Bioinformatics, and Epidemiology (L.F., Y.P., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
| | - J P Broderick
- Department of Neurology (P.K., J.P.B.), University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - S D Yeatts
- Department of Biostatistics, Bioinformatics, and Epidemiology (L.F., Y.P., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
| | - D S Liebeskind
- University of California Los Angeles Stroke Center (D.S.L.), Los Angeles, California
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18
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Yan S, Chen Q, Zhang X, Xu M, Han Q, Shao A, Liebeskind DS, Lou M. Extensive blooming artifact predicts no recanalization after intravenous thrombolysis. Eur J Neurol 2015; 23:737-43. [PMID: 26706832 DOI: 10.1111/ene.12930] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Accepted: 11/04/2015] [Indexed: 11/29/2022]
Affiliation(s)
- S. Yan
- Department of Neurology; School of Medicine; Second Affiliated Hospital of Zhejiang University; Hangzhou China
| | - Q. Chen
- Department of Neurology; School of Medicine; Second Affiliated Hospital of Zhejiang University; Hangzhou China
| | - X. Zhang
- Department of Neurology; School of Medicine; Second Affiliated Hospital of Zhejiang University; Hangzhou China
| | - M. Xu
- Department of Neurology; School of Medicine; Second Affiliated Hospital of Zhejiang University; Hangzhou China
| | - Q. Han
- Department of Neurology; School of Medicine; Second Affiliated Hospital of Zhejiang University; Hangzhou China
| | - A. Shao
- Department of Neurosurgery; School of Medicine; Second Affiliated Hospital of Zhejiang University; Hangzhou China
| | - D. S. Liebeskind
- University of California − Los Angeles Stroke Center; Los Angeles CA USA
| | - M. Lou
- Department of Neurology; School of Medicine; Second Affiliated Hospital of Zhejiang University; Hangzhou China
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Coutinho JM, Liebeskind DS, Slater LA, Nogueira RG, Baxter BW, Levy EI, Siddiqui AH, Goyal M, Zaidat OO, Davalos A, Bonafé A, Jahan R, Gralla J, Saver JL, Pereira VM. Mechanical Thrombectomy for Isolated M2 Occlusions: A Post Hoc Analysis of the STAR, SWIFT, and SWIFT PRIME Studies. AJNR Am J Neuroradiol 2015; 37:667-72. [PMID: 26564442 DOI: 10.3174/ajnr.a4591] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 08/11/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy is beneficial for patients with acute ischemic stroke and a proximal anterior occlusion, but it is unclear if these results can be extrapolated to patients with an M2 occlusion. The purpose of this study was to examine the technical aspects, safety, and outcomes of mechanical thrombectomy with a stent retriever in patients with an isolated M2 occlusion who were included in 3 large multicenter prospective studies. MATERIALS AND METHODS We included patients from the Solitaire Flow Restoration Thrombectomy for Acute Revascularization (STAR), Solitaire With the Intention For Thrombectomy (SWIFT), and Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT PRIME) studies, 3 large multicenter prospective studies on thrombectomy for ischemic stroke. We compared outcomes and technical details of patients with an M2 with those with an M1 occlusion. All patients were treated with a stent retriever. Imaging data and outcomes were scored by an independent core laboratory. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction score of 2b/3. RESULTS We included 50 patients with an M2 and 249 patients with an M1 occlusion. Patients with an M2 occlusion were older (mean age, 71 versus 67 years; P = .04) and had a lower NIHSS score (median, 13 versus 17; P < .001) compared with those with an M1 occlusion. Procedural time was nonsignificantly shorter in patients with an M2 occlusion (median, 29 versus 35 minutes; P = .41). The average number of passes with a stent retriever was also nonsignificantly lower in patients with an M2 occlusion (mean, 1.4 versus 1.7; P = .07). There were no significant differences in successful reperfusion (85% versus 82%, P = .82), symptomatic intracerebral hemorrhages (2% versus 2%, P = 1.0), device-related serious adverse events (6% versus 4%, P = .46), or modified Rankin Scale score 0-2 at follow-up (60% versus 56%, P = .64). CONCLUSIONS Endovascular reperfusion therapy appears to be feasible in selected patients with ischemic stroke and an M2 occlusion.
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Affiliation(s)
- J M Coutinho
- From the Divisions of Neuroradiology (J.M.C., L.-A.S., V.M.P.)
| | - D S Liebeskind
- Neurovascular Imaging Research Core and the University of California, Los Angeles Stroke Center (D.S.L.), Los Angeles, California
| | - L-A Slater
- From the Divisions of Neuroradiology (J.M.C., L.-A.S., V.M.P.)
| | - R G Nogueira
- Marcus Stroke and Neuroscience Center (R.G.N.), Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - B W Baxter
- Department of Radiology (B.W.B.), Erlanger Hospital at University of Tennessee, Chattanooga, Tennessee
| | - E I Levy
- Department of Neurosurgery (E.I.L., A.H.S.)
| | - A H Siddiqui
- Department of Neurosurgery (E.I.L., A.H.S.) Toshiba Stroke and Vascular Research Center (A.H.S.), State University of New York at Buffalo, Buffalo, New York
| | - M Goyal
- Departments of Radiology and Clinical Neurosciences (M.G.), University of Calgary, Calgary, Alberta, Canada
| | - O O Zaidat
- Department of Neurology (O.O.Z.), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - A Davalos
- Department of Neurosciences (A.D.), Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| | - A Bonafé
- Department of Neuroradiology (A.B.), Hôpital Gui-de-Chauliac, Montpellier, France
| | - R Jahan
- Division of Interventional Neuroradiology (R.J.)
| | - J Gralla
- Departments of Diagnostic and Interventional Neuroradiology (J.G.), Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - J L Saver
- Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - V M Pereira
- From the Divisions of Neuroradiology (J.M.C., L.-A.S., V.M.P.) Neurosurgery (V.M.P.), Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
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Tomsick TA, Foster LD, Liebeskind DS, Hill MD, Carrozella J, Goyal M, von Kummer R, Demchuk AM, Dzialowski I, Puetz V, Jovin T, Morales H, Palesch YY, Broderick J, Khatri P, Yeatts SD. Outcome Differences between Intra-Arterial Iso- and Low-Osmolality Iodinated Radiographic Contrast Media in the Interventional Management of Stroke III Trial. AJNR Am J Neuroradiol 2015; 36:2074-81. [PMID: 26228892 DOI: 10.3174/ajnr.a4421] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 03/03/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Intracarotid arterial infusion of nonionic, low-osmolal iohexol contrast medium has been associated with increased intracranial hemorrhage in a rat middle cerebral artery occlusion model compared with saline infusion. Iso-osmolal iodixanol (290 mOsm/kg H2O) infusion demonstrated smaller infarcts and less intracranial hemorrhage compared with low-osmolal iopamidol and saline. No studies comparing iodinated radiographic contrast media in human stroke have been performed, to our knowledge. We hypothesized that low-osmolal contrast media may be associated with worse outcomes compared with iodixanol in the Interventional Management of Stroke III Trial (IMS III). MATERIALS AND METHODS We reviewed prospective iodinated radiographic contrast media data for 133 M1 occlusions treated with endovascular therapy. We compared 5 prespecified efficacy and safety end points (mRS 0-2 outcome, modified TICI 2b-3 reperfusion, asymptomatic and symptomatic intracranial hemorrhage, and mortality) between those receiving iodixanol (n = 31) or low-osmolal contrast media (n = 102). Variables imbalanced between iodinated radiographic contrast media types or associated with outcome were considered potential covariates for the adjusted models. In addition to the iodinated radiographic contrast media type, final covariates were those selected by using the stepwise method in a logistic regression model. Adjusted relative risks were then estimated by using a log-link regression model. RESULTS Of baseline or endovascular therapy variables potentially linked to outcome, prior antiplatelet agent use was more common and microcatheter iodinated radiographic contrast media injections were fewer with iodixanol. Relative risk point estimates are in favor of iodixanol for the 5 prespecified end points with M1 occlusion. The percentage of risk differences are numerically greater for microcatheter injections with iodixanol. CONCLUSIONS While data favoring the use of iso-osmolal iodixanol for reperfusion of M1 occlusion following IV rtPA are inconclusive, potential pathophysiologic mechanisms suggesting clinical benefit warrant further investigation.
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Affiliation(s)
- T A Tomsick
- From the Department of Radiology (T.A.T., J.C., H.M.), University of Cincinnati Academic Health Center, University Hospital, Cincinnati, Ohio
| | - L D Foster
- Department of Public Health Sciences (L.D.F., Y.Y.P., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
| | - D S Liebeskind
- University of California, Los Angeles Stroke Center (D.S.L.), Los Angeles, California
| | - M D Hill
- Department of Radiology and Clinical Neurosciences (M.D.H., M.G.)
| | - J Carrozella
- From the Department of Radiology (T.A.T., J.C., H.M.), University of Cincinnati Academic Health Center, University Hospital, Cincinnati, Ohio
| | - M Goyal
- Department of Radiology and Clinical Neurosciences (M.D.H., M.G.)
| | | | - A M Demchuk
- Calgary Stroke Program (A.M.D.), Department of Clinical Neurosciences/Medicine/Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - I Dzialowski
- Department of Neurology (I.D.), Elblandklinikum Meissen, Academic Teaching Hospital of Universitätsklinikum, Carl Gustav Carus Technische Universität Dresden, Meißen, Germany
| | - V Puetz
- Neurology (V.P.), Dresden University Stroke Center, Universitätsklinikum Carl Gustav Carus Technischen Universität Dresden, Dresden, Germany
| | - T Jovin
- The Stroke Institute (T.J.), University of Pittsburgh Medical Center, Pittsburgh. Pennsylvania
| | - H Morales
- From the Department of Radiology (T.A.T., J.C., H.M.), University of Cincinnati Academic Health Center, University Hospital, Cincinnati, Ohio
| | - Y Y Palesch
- Department of Public Health Sciences (L.D.F., Y.Y.P., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
| | - J Broderick
- Department of Neurology (J.B., P.K.), University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - P Khatri
- Department of Neurology (J.B., P.K.), University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - S D Yeatts
- Department of Public Health Sciences (L.D.F., Y.Y.P., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
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Affiliation(s)
- D S Liebeskind
- Neurovascular Imaging Research Core and the UCLA Stroke Center, Los Angeles, CA, USA.
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Dorhout Mees SM, Algra A, Wong GKC, Poon WS, Bradford CM, Saver JL, Starkman S, Rinkel GJE, van den Bergh WM, van Kooten F, Dirven CM, van Gijn J, Vermeulen M, Rinkel GJE, Boet R, Chan MTV, Gin T, Ng SCP, Zee BCY, Al-Shahi Salman R, Boiten J, Kuijsten H, Lavados PM, van Oostenbrugge RJ, Vandertop WP, Finfer S, O'Connor A, Yarad E, Firth R, McCallister R, Harrington T, Steinfort B, Faulder K, Assaad N, Morgan M, Starkman S, Eckstein M, Stratton SJ, Pratt FD, Hamilton S, Conwit R, Liebeskind DS, Sung G, Kramer I, Moreau G, Goldweber R, Sanossian N. Early Magnesium Treatment After Aneurysmal Subarachnoid Hemorrhage: Individual Patient Data Meta-Analysis. Stroke 2015; 46:3190-3. [PMID: 26463689 DOI: 10.1161/strokeaha.115.010575] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 09/08/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Delayed cerebral ischemia (DCI) is an important cause of poor outcome after aneurysmal subarachnoid hemorrhage (SAH). Trials of magnesium treatment starting <4 days after symptom onset found no effect on poor outcome or DCI in SAH. Earlier installment of treatment might be more effective, but individual trials had not enough power for such a subanalysis. We performed an individual patient data meta-analysis to study whether magnesium is effective when given within different time frames within 24 hours after the SAH. METHODS Patients were divided into categories according to the delay between symptom onset and start of the study medication: <6, 6 to 12, 12 to 24, and >24 hours. We calculated adjusted risk ratios with corresponding 95% confidence intervals for magnesium versus placebo treatment for poor outcome and DCI. RESULTS We included 5 trials totaling 1981 patients; 83 patients started treatment<6 hours. For poor outcome, the adjusted risk ratios of magnesium treatment for start <6 hours were 1.44 (95% confidence interval, 0.83-2.51); for 6 to 12 hours 1.03 (0.65-1.63), for 12 to 24 hours 0.84 (0.65-1.09), and for >24 hours 1.06 (0.87-1.31), and for DCI, <6 hours 1.76 (0.68-4.58), for 6 to 12 hours 2.09 (0.99-4.39), for 12 to 24 hours 0.80 (0.56-1.16), and for >24 hours 1.08 (0.88-1.32). CONCLUSIONS This meta-analysis suggests no beneficial effect of magnesium treatment on poor outcome or DCI when started early after SAH onset. Although the number of patients was small and a beneficial effect cannot be definitively excluded, we found no justification for a new trial with early magnesium treatment after SAH.
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Affiliation(s)
- Sanne M Dorhout Mees
- From the Department of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience (S.M.D.M., A.A., G.J.E.R.) and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, Utrecht, The Netherlands; Division of Neurosurgery, Department of Critical Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China (G.K.C.W., W.S.P.); Department of Critical Care, Royal North Shore Hospital, Sydney, Australia (C.M.B.); Department of Neurology (J.L.S.) and Departments of Emergency Medicine and Neurology (S.S.), Comprehensive Stroke Center, David Geffen School of Medicine at the University of California, Los Angeles; and Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands (W.M.v.d.B.)
| | - Ale Algra
- From the Department of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience (S.M.D.M., A.A., G.J.E.R.) and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, Utrecht, The Netherlands; Division of Neurosurgery, Department of Critical Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China (G.K.C.W., W.S.P.); Department of Critical Care, Royal North Shore Hospital, Sydney, Australia (C.M.B.); Department of Neurology (J.L.S.) and Departments of Emergency Medicine and Neurology (S.S.), Comprehensive Stroke Center, David Geffen School of Medicine at the University of California, Los Angeles; and Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands (W.M.v.d.B.)
| | - George K C Wong
- From the Department of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience (S.M.D.M., A.A., G.J.E.R.) and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, Utrecht, The Netherlands; Division of Neurosurgery, Department of Critical Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China (G.K.C.W., W.S.P.); Department of Critical Care, Royal North Shore Hospital, Sydney, Australia (C.M.B.); Department of Neurology (J.L.S.) and Departments of Emergency Medicine and Neurology (S.S.), Comprehensive Stroke Center, David Geffen School of Medicine at the University of California, Los Angeles; and Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands (W.M.v.d.B.)
| | - Wai S Poon
- From the Department of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience (S.M.D.M., A.A., G.J.E.R.) and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, Utrecht, The Netherlands; Division of Neurosurgery, Department of Critical Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China (G.K.C.W., W.S.P.); Department of Critical Care, Royal North Shore Hospital, Sydney, Australia (C.M.B.); Department of Neurology (J.L.S.) and Departments of Emergency Medicine and Neurology (S.S.), Comprehensive Stroke Center, David Geffen School of Medicine at the University of California, Los Angeles; and Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands (W.M.v.d.B.)
| | - Celia M Bradford
- From the Department of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience (S.M.D.M., A.A., G.J.E.R.) and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, Utrecht, The Netherlands; Division of Neurosurgery, Department of Critical Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China (G.K.C.W., W.S.P.); Department of Critical Care, Royal North Shore Hospital, Sydney, Australia (C.M.B.); Department of Neurology (J.L.S.) and Departments of Emergency Medicine and Neurology (S.S.), Comprehensive Stroke Center, David Geffen School of Medicine at the University of California, Los Angeles; and Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands (W.M.v.d.B.)
| | - Jeffrey L Saver
- From the Department of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience (S.M.D.M., A.A., G.J.E.R.) and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, Utrecht, The Netherlands; Division of Neurosurgery, Department of Critical Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China (G.K.C.W., W.S.P.); Department of Critical Care, Royal North Shore Hospital, Sydney, Australia (C.M.B.); Department of Neurology (J.L.S.) and Departments of Emergency Medicine and Neurology (S.S.), Comprehensive Stroke Center, David Geffen School of Medicine at the University of California, Los Angeles; and Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands (W.M.v.d.B.)
| | - Sidney Starkman
- From the Department of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience (S.M.D.M., A.A., G.J.E.R.) and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, Utrecht, The Netherlands; Division of Neurosurgery, Department of Critical Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China (G.K.C.W., W.S.P.); Department of Critical Care, Royal North Shore Hospital, Sydney, Australia (C.M.B.); Department of Neurology (J.L.S.) and Departments of Emergency Medicine and Neurology (S.S.), Comprehensive Stroke Center, David Geffen School of Medicine at the University of California, Los Angeles; and Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands (W.M.v.d.B.)
| | - Gabriel J E Rinkel
- From the Department of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience (S.M.D.M., A.A., G.J.E.R.) and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, Utrecht, The Netherlands; Division of Neurosurgery, Department of Critical Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China (G.K.C.W., W.S.P.); Department of Critical Care, Royal North Shore Hospital, Sydney, Australia (C.M.B.); Department of Neurology (J.L.S.) and Departments of Emergency Medicine and Neurology (S.S.), Comprehensive Stroke Center, David Geffen School of Medicine at the University of California, Los Angeles; and Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands (W.M.v.d.B.)
| | - Walter M van den Bergh
- From the Department of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience (S.M.D.M., A.A., G.J.E.R.) and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, Utrecht, The Netherlands; Division of Neurosurgery, Department of Critical Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China (G.K.C.W., W.S.P.); Department of Critical Care, Royal North Shore Hospital, Sydney, Australia (C.M.B.); Department of Neurology (J.L.S.) and Departments of Emergency Medicine and Neurology (S.S.), Comprehensive Stroke Center, David Geffen School of Medicine at the University of California, Los Angeles; and Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands (W.M.v.d.B.).
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Hwang YH, Kang DH, Kim YW, Kim YS, Park SP, Liebeskind DS. Impact of time-to-reperfusion on outcome in patients with poor collaterals. AJNR Am J Neuroradiol 2015; 36:495-500. [PMID: 25376808 DOI: 10.3174/ajnr.a4151] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The relationship between reperfusion and clinical outcome is time-dependent, and the effect of reperfusion on outcome can vary on the basis of the extent of collateral flow. We aimed to identify the impact of time-to-reperfusion on outcome relative to baseline angiographic collateral grade in patients successfully treated with endovascular revascularization for acute large-vessel anterior circulation stroke. MATERIALS AND METHODS Two hundred seven patients were selected for analysis from our prospectively maintained registry. Inclusion criteria were M1 MCA ± ICA occlusions, onset-to-puncture time within 8 hours, and successful endovascular reperfusion. Baseline angiographic collateral grades were independently evaluated and dichotomized into poor (0-1) versus good (2-4). Multivariable analyses were performed to identify the effect of collateral-flow adequacy on favorable outcome on the basis of onset-to-reperfusion time and puncture-to-reperfusion time. RESULTS In the poor collateral group, the odds of favorable outcome significantly dropped for patients with onset-to-reperfusion time of >300 minutes or puncture-to-reperfusion time of >60 minutes (onset-to-puncture time: ≤300, 59% versus >300, 32%; OR, 0.24; P = .011; puncture-to-reperfusion time: ≤60, 73% versus >60, 32%; OR, 0.21, P = .011), whereas the probability of favorable outcome in the good collateral group was not significantly influenced by onset-to-reperfusion time or puncture-to-reperfusion time. In the subgroup lesion-volume growth analysis by using DWI, the effect of puncture-to-reperfusion time of >60 minutes was significantly greater compared with the effect of puncture-to-reperfusion time of <60 minutes in the poor collateral group (β = 41.6 cm(3), P = .001). CONCLUSIONS Time-to-reperfusion including onset-to-reperfusion time and puncture-to-reperfusion time in patients with poor collaterals is an important limiting factor for favorable outcome in a time-dependent fashion. Future trials may benefit from a noninvasive imaging technique to detect poor collaterals along with a strategy for rapid reperfusion.
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Affiliation(s)
- Y-H Hwang
- From the Departments of Neurology (Y.-H.H., Y.-W.K., S.-P.P.) Cerebrovascular Center (Y.-H.H., D.-H.K., Y.-W.K., Y.-S.K.), Kyungpook National University Hospital, Daegu, Korea School of Medicine (Y.-H.H., D.-H.K., Y.-W.K., Y.-S.K., S.-P.P.), Kyungpook National University, Daegu, Korea
| | - D-H Kang
- Neurosurgery (D.-H.K.) Radiology (D.-H.K., Y.-W.K., Y.-S.K.) Cerebrovascular Center (Y.-H.H., D.-H.K., Y.-W.K., Y.-S.K.), Kyungpook National University Hospital, Daegu, Korea School of Medicine (Y.-H.H., D.-H.K., Y.-W.K., Y.-S.K., S.-P.P.), Kyungpook National University, Daegu, Korea
| | - Y-W Kim
- From the Departments of Neurology (Y.-H.H., Y.-W.K., S.-P.P.) Radiology (D.-H.K., Y.-W.K., Y.-S.K.) Cerebrovascular Center (Y.-H.H., D.-H.K., Y.-W.K., Y.-S.K.), Kyungpook National University Hospital, Daegu, Korea School of Medicine (Y.-H.H., D.-H.K., Y.-W.K., Y.-S.K., S.-P.P.), Kyungpook National University, Daegu, Korea
| | - Y-S Kim
- Radiology (D.-H.K., Y.-W.K., Y.-S.K.) Cerebrovascular Center (Y.-H.H., D.-H.K., Y.-W.K., Y.-S.K.), Kyungpook National University Hospital, Daegu, Korea School of Medicine (Y.-H.H., D.-H.K., Y.-W.K., Y.-S.K., S.-P.P.), Kyungpook National University, Daegu, Korea
| | - S-P Park
- From the Departments of Neurology (Y.-H.H., Y.-W.K., S.-P.P.) School of Medicine (Y.-H.H., D.-H.K., Y.-W.K., Y.-S.K., S.-P.P.), Kyungpook National University, Daegu, Korea
| | - D S Liebeskind
- UCLA Stroke Center (D.S.L.), University of California, Los Angeles, Los Angeles, California
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Nael K, Meshksar A, Ellingson B, Pirastehfar M, Salamon N, Finn P, Liebeskind DS, Villablanca JP. Combined low-dose contrast-enhanced MR angiography and perfusion for acute ischemic stroke at 3T: A more efficient stroke protocol. AJNR Am J Neuroradiol 2014; 35:1078-84. [PMID: 24503557 DOI: 10.3174/ajnr.a3848] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE There is need to improve image acquisition speed for MR imaging in evaluation of patients with acute ischemic stroke. The purpose of this study was to evaluate the feasibility of a 3T MR stroke protocol that combines low-dose contrast-enhanced MRA and dynamic susceptibility contrast perfusion, without additional contrast. METHODS Thirty patients with acute stroke who underwent 3T MR imaging followed by DSA were retrospectively enrolled. TOF-MRA of the neck and brain and 3D contrast-enhanced MRA of the craniocervical arteries were obtained. A total of 0.1 mmol/kg of gadolinium was used for both contrast-enhanced MRA (0.05 mmol/kg) and dynamic susceptibility contrast perfusion (0.05 mmol/kg) (referred to as half-dose). An age-matched control stroke population underwent TOF-MRA and full-dose (0.1 mmol/kg) dynamic susceptibility contrast perfusion. The cervicocranial arteries were divided into 25 segments. Degree of arterial stenosis on contrast-enhanced MRA and TOF-MRA was compared with DSA. Time-to-maximum maps (>6 seconds) were evaluated for image quality and hypoperfusion. Quantitative analysis of arterial input function curves, SNR, and maximum T2* effects were compared between half- and full-dose groups. RESULTS The intermodality agreements (k) for arterial stenosis were 0.89 for DSA/contrast-enhanced MRA and 0.63 for DSA/TOF-MRA. Detection specificity of >50% arterial stenosis was lower for TOF-MRA (89%) versus contrast-enhanced MRA (97%) as the result of overestimation of 10% (39/410) of segments by TOF-MRA. The DWI-perfusion mismatch was identified in both groups with high interobserver agreement (r = 1). There was no significant difference between full width at half maximum of the arterial input function curves (P = .14) or the SNR values (0.6) between the half-dose and full-dose groups. CONCLUSIONS In patients with acute stroke, combined low-dose contrast-enhanced MRA and dynamic susceptibility contrast perfusion at 3T is feasible and results in significant scan time and contrast dose reductions.
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Affiliation(s)
- K Nael
- From the Department of Medical Imaging (K.N., A.M.), University of Arizona, Tucson, Arizona
| | - A Meshksar
- From the Department of Medical Imaging (K.N., A.M.), University of Arizona, Tucson, Arizona
| | - B Ellingson
- Department of Radiological Sciences (B.E., M.P., N.S., P.F., J.P.V.)
| | - M Pirastehfar
- Department of Radiological Sciences (B.E., M.P., N.S., P.F., J.P.V.)
| | - N Salamon
- Department of Radiological Sciences (B.E., M.P., N.S., P.F., J.P.V.)
| | - P Finn
- Department of Radiological Sciences (B.E., M.P., N.S., P.F., J.P.V.)
| | - D S Liebeskind
- Department of Neurology, Stroke Center (D.S.L.), University of California, Los Angeles, Los Angeles, California
| | - J P Villablanca
- Department of Radiological Sciences (B.E., M.P., N.S., P.F., J.P.V.)
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Schellinger PD, Shuaib A, Köhrmann M, Liebeskind DS, Jovin T, Hammer MD, Sen S, Huang DY, Solander S, Gupta R, Leker RR, Saver JL. Reduced mortality and severe disability rates in the SENTIS trial. AJNR Am J Neuroradiol 2013; 34:2312-6. [PMID: 23828106 DOI: 10.3174/ajnr.a3613] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial showed a trend for reduced all-cause mortality and positive secondary safety end point outcomes. We present further analyses of the mortality and severe disability data from the Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial. MATERIALS AND METHODS The Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial was a multicenter, randomized, controlled trial that evaluated the safety and effectiveness of the NeuroFlo catheter in patients with stroke. The current analysis was performed on the as-treated population. All-cause and stroke-related mortality rates at 90 days were compared between groups, and logistic regression models were fit to obtain ORs and 95% CIs for the treated versus not-treated groups. We categorized death-associated serious adverse events as neurologic versus non-neurologic events and performed multiple logistic regression analyses. We analyzed severe disability and mortality by outcomes of the mRS. Patient allocation was gathered by use of a poststudy survey. RESULTS All-cause mortality trended in favor of treated patients (11.5% versus 16.1%; P = .079) and stroke-related mortality was significantly reduced in treated patients (7.5% versus 14.2%; P = .009). Logistic regression analysis for freedom from stroke-related mortality favored treatment (OR, 2.41; 95% CI, 1.22, 4.77; P = .012). Treated patients had numerically fewer neurologic causes of stroke-related deaths (52.9% versus 73.0%; P = .214). Among the 90-day survivors, nominally fewer treated patients were severely disabled (mRS 5) (5.6% versus 7.5%; OR, 1.72; 95% CI, 0.72, 4.14; P = .223). Differences in allocation of care did not account for the reduced mortality rates. CONCLUSIONS There were consistent reductions in all-cause and stroke-related mortality in the NeuroFlo-treated patients. This reduction in mortality did not result in an increase in severe disability.
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Wintermark M, Sanelli PC, Albers GW, Bello J, Derdeyn C, Hetts SW, Johnson MH, Kidwell C, Lev MH, Liebeskind DS, Rowley H, Schaefer PW, Sunshine JL, Zaharchuk G, Meltzer CC. Imaging recommendations for acute stroke and transient ischemic attack patients: A joint statement by the American Society of Neuroradiology, the American College of Radiology, and the Society of NeuroInterventional Surgery. AJNR Am J Neuroradiol 2013; 34:E117-27. [PMID: 23907247 DOI: 10.3174/ajnr.a3690] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
SUMMARY Stroke is a leading cause of death and disability worldwide. Imaging plays a critical role in evaluating patients suspected of acute stroke and transient ischemic attack, especially before initiating treatment. Over the past few decades, major advances have occurred in stroke imaging and treatment, including Food and Drug Administration approval of recanalization therapies for the treatment of acute ischemic stroke. A wide variety of imaging techniques has become available to assess vascular lesions and brain tissue status in acute stroke patients. However, the practical challenge for physicians is to understand the multiple facets of these imaging techniques, including which imaging techniques to implement and how to optimally use them, given available resources at their local institution. Important considerations include constraints of time, cost, access to imaging modalities, preferences of treating physicians, availability of expertise, and availability of endovascular therapy. The choice of which imaging techniques to employ is impacted by both the time urgency for evaluation of patients and the complexity of the literature on acute stroke imaging. Ideally, imaging algorithms should incorporate techniques that provide optimal benefit for improved patient outcomes without delaying treatment.
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Affiliation(s)
- M Wintermark
- Departments of Radiology, Neurology, Neurosurgery, and Biomedical Engineering, University of Virginia, Charlottesville, Virginia
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Liebeskind DS, Marcinkevicius E, Pranevicius M, Pranevicius O, Ragauskas A, Matijosaitis V, Zakelis R, Petrikonis K, Rastenyte D, Piper I, Daubaris G, Miller MM, Chang T, Keating R, Sable C, Ragauskas A, Matijosaitis V, Zakelis R, Petrikonis K, Rastenyte D, Piper I, Daubaris G. Clinical Assessment of Noninvasive Intracranial Pressure Absolute Value Measurement Method. Neurology 2013; 80:507. [DOI: 10.1212/wnl.0b013e318281bfa4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Zaidat OO, Lazzaro MA, Liebeskind DS, Janjua N, Wechsler L, Nogueira RG, Edgell RC, Kalia JS, Badruddin A, English J, Yavagal D, Kirmani JF, Alexandrov AV, Khatri P. Revascularization grading in endovascular acute ischemic stroke therapy. Neurology 2012; 79:S110-6. [PMID: 23008384 DOI: 10.1212/wnl.0b013e3182695916] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Recanalization and angiographic reperfusion are key elements to successful endovascular and interventional acute ischemic stroke (AIS) therapy. Intravenous recombinant tissue plasminogen activator (rt-PA), the only established revascularization therapy approved by the US Food & Drug Administration for AIS, may be less effective for large artery occlusion. Thus, there is enthusiasm for endovascular revascularization therapies, which likely provide higher recanalization rates, and trials are ongoing to determine clinical efficacy and compare various methods. It is anticipated that clinical efficacy will be well correlated with revascularization of viable tissue in a timely manner. METHOD Reporting, interpretation, and comparison of the various revascularization grading methods require agreement on measurement criteria, reproducibility, ease of use, and correlation with clinical outcome. These parameters were reviewed by performing a Medline literature search from 1965 to 2011. This review critically evaluates current revascularization grading systems. RESULTS AND CONCLUSION The most commonly used revascularization grading methods in AIS interventional therapy trials are the thrombolysis in cerebral ischemia (TICI, pronounced "tissy") and thrombolysis in myocardial ischemia (TIMI) scores. Until further technical and imaging advances can incorporate real-time reliable perfusion studies in the angio-suite to delineate regional perfusion more accurately, the TICI grading system is the best defined and most widely used scheme. Other grading systems may be used for research and correlation purposes. A new scale that combines primary site occlusion, lesion location, and perfusion should be explored in the future.
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Affiliation(s)
- O O Zaidat
- Department of Neurology, Medical College of Wisconsin/Froedtert Hospital, Milwaukee, WI, USA.
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Abstract
BACKGROUND AND PURPOSE The importance of LMF in the outcome after acute ischemic stroke is increasingly recognized, but imaging presents a wide range of options for identification of collaterals and there is no single system for grading collateral flow. The aim of this study was to systematically review the literature on the available methods for measuring LMF adequacy. MATERIALS AND METHODS We performed a systematic review of Ovid, MEDLINE, and Embase databases for studies in which flow in the leptomeningeal collateral vessels was evaluated. Imaging technique, grading scale, and reliability assessment for collateral flow measurement were recorded. RESULTS We found 81 publications describing 63 methods for grading collateral flow on the basis of conventional angiography (n = 41), CT (n = 7), MR imaging (n = 9), and transcranial Doppler (n = 6). Inter- and/or intraobserver agreement was assessed in only 8 publications. CONCLUSIONS There is inconsistency in how LMF is graded, with a variety of grading scales and imaging modalities being used. Consistency in evaluating collateral flow at baseline is required for the impact of collateral flow to be fully appreciated.
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Affiliation(s)
- F McVerry
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
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Hammer MD, Schwamm L, Starkman S, Schellinger PD, Jovin T, Nogueira R, Burgin WS, Sen S, Diener HC, Watson T, Michel P, Shuaib A, Dillon W, Liebeskind DS. Safety and feasibility of NeuroFlo use in eight- to 24-hour ischemic stroke patients. Int J Stroke 2012; 7:655-61. [PMID: 22264202 DOI: 10.1111/j.1747-4949.2011.00719.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acute treatment of ischemic stroke patients presenting more than eight-hours after symptom onset remains limited and largely unproven. Partial aortic occlusion using the NeuroFlo catheter can augment cerebral perfusion in animals. We investigated the safety and feasibility of employing this novel catheter to treat ischemic stroke patients eight-hours to 24 h following symptom onset. METHODS A multicenter, single-arm trial enrolled ischemic stroke patients at nine international academic medical centers. Eligibility included age 18-85 years old, National Institutes of Health stroke scale (NIHSS) score between four and 20, within eight-hours to 24 h after symptom onset, and perfusion-diffusion mismatch confirmed by magnetic resonance imaging. The primary outcome was all adverse events occurring from baseline to 30 days posttreatment. Secondary outcomes included stroke severity on neurological indices through 90 days. This study is registered with ClinicalTrials.gov, number NCT00436592. RESULTS A total of 26 patients were enrolled. Of these, 25 received treatment (one excluded due to aortic morphology); five (20%) died. Favorable neurological outcome at 90 days (modified Rankin score 0-2 vs. 3-6) was associated with lower baseline NIHSS (P < 0·001) and with longer duration from symptom discovery to treatment. There were no symptomatic intracranial hemorrhages or parenchymal hematomas. Asymptomatic intracranial hemorrhage was visible on computed tomography in 32% and only on microbleed in another 20%. CONCLUSIONS Partial aortic occlusion using the NeuroFlo catheter, a novel collateral therapeutic strategy, appears safe and feasible in stroke patients eight-hours to 24 h after symptom onset.
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Affiliation(s)
- M D Hammer
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Azizyan A, Sanossian N, Mogensen MA, Liebeskind DS. Fluid-attenuated inversion recovery vascular hyperintensities: an important imaging marker for cerebrovascular disease. AJNR Am J Neuroradiol 2010; 32:1771-5. [PMID: 21051516 DOI: 10.3174/ajnr.a2265] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Vascular hyperintensities have been noted on FLAIR sequences obtained in the setting of acute stroke and intracranial steno-occlusive disease. The presence of FVHs likely represents disordered blood flow, often from collaterals distal to arterial occlusion or stenosis. As opposed to other vessel signs seen in arterial insufficiency, FVH is unique in that it does not represent thrombus, but rather sluggish or disordered blood flow through vessels. This review will discuss the diagnostic and prognostic value of FVH and its impact on clinical decision-making.
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Affiliation(s)
- A Azizyan
- Keck School of Medicine, University of Southern California, Los Angeles, USA
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Loh Y, Liebeskind DS, Shi ZS, Jahan R, Gonzalez NR, Tateshima S, Vespa PM, Starkman S, Saver JL, Viñuela F, Duckwiler GR. Partial recanalization of concomitant internal carotid-middle cerebral arterial occlusions promotes distal recanalization of residual thrombus within 24 h. J Neurointerv Surg 2010; 3:38-42. [PMID: 21990786 DOI: 10.1136/jnis.2009.002097] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Acute, simultaneous, concomitant internal carotid artery (ICA) and middle cerebral arteries (MCA) occlusions almost invariably lead to significant neurological disability if left untreated. Endovascular therapy is frequently the method of treatment in such situations but there remains a chance of incomplete recanalization. Successful recanalization of the proximal aspect of the occlusion may allow for endogenous thrombolysis and facilitate further endogenous recanalization of any residual MCA occlusion. METHODS Consecutive patients with acute ischemic stroke undergoing endovascular therapy for tandem extracranial ICA-MCA or contiguous intracranial ICA-MCA occlusions were retrospectively analyzed. Rates of facilitated endogenous recanalization at 24 h (FER(24)) were compared by imaging within the immediate post-intervention 5-24 h period in those with proximal recanalization and in those without. RESULTS 17 patients were included in the analysis. 12 patients had good initial proximal recanalization but a residual partial or total occlusion of the MCA while five patients failed any recanalization. Seven patients (58.3%) in the first group and none in the second had FER(24) on interval imaging after intervention (p=0.04). The probability of death and disability at discharge was less in patients with FER(24) than those without (p=0.05). CONCLUSIONS More than half of all patients who present with both ICA and MCA occlusions who are only partially recanalized will undergo facilitated endogenous recanalization within the subsequent 24 h following intervention.
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Affiliation(s)
- Y Loh
- Division of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
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Loh Y, McArthur DL, Vespa P, Shi ZS, Liebeskind DS, Jahan R, Gonzalez NR, Starkman S, Saver JL, Tateshima S, Duckwiler GR, Viñuela F. The risk of acute radiocontrast-mediated kidney injury following endovascular therapy for acute ischemic stroke is low. AJNR Am J Neuroradiol 2010; 31:1584-7. [PMID: 20522566 DOI: 10.3174/ajnr.a2136] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular therapy is an alternative for the treatment of AIS resulting from large intracranial arterial occlusions that depends on the use of iodinated RCM. The risk of RCM-mediated AKI following endovascular therapy for AIS may be different from that following coronary interventions because patients may not have identical risk factors. MATERIALS AND METHODS All consecutive patients with large-vessel AIS undergoing endovascular therapy were prospectively recorded. We recorded the baseline kidney function, and RCM-AKI was assessed according to the AKIN criteria at 48 hours after RCM administration. We compared the rate of RCM-AKI 48 hours after the procedure and sought to determine whether any preexisting factors increased the risk of RCM-AKI. RESULTS We identified 99 patients meeting inclusion criteria. The average volume of contrast was 189 ± 71 mL, and the average creatinine change was -4.6% at 48 hours postangiography. There were 3 patients with RCM-AKI. Although all 3 patients died as a result of their strokes, return to baseline creatinine levels occurred before death. There was a trend toward higher rates of premorbid diabetes mellitus, chronic renal insufficiency, preadmission statin and NSAID use, and a higher serum creatinine level on admission for the RCM-AKI group. The volume of procedural contrast was similar between groups (those with and those without RCM-AKI) (P = .5). CONCLUSIONS In this small study, the rate of RCM-AKI following endovascular intervention for AIS was very low. A much larger study is required to determine its true incidence.
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Affiliation(s)
- Y Loh
- Division of Neurosurgery, David Geffen School of Medicine at the University of California at Los Angeles, CA, USA.
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Loh Y, Kim D, Shi ZS, Tateshima S, Vespa PM, Gonzalez NR, Starkman S, Saver JL, Jahan R, Liebeskind DS, Duckwiler GR, Viñuela F. Higher rates of mortality but not morbidity follow intracranial mechanical thrombectomy in the elderly. AJNR Am J Neuroradiol 2010; 31:1181-5. [PMID: 20395387 DOI: 10.3174/ajnr.a2079] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy is a promising means of recanalizing acute cerebrovascular occlusions in certain situations. We sought to determine if increasing age adversely affects prognosis. MATERIALS AND METHODS We reviewed all Merci thrombectomy cases and compared patients younger than 80 years of age with older individuals. We compared these 2 age groups with respect to recanalization rates, hospital LOS, hemorrhagic transformation, and death and disability on discharge. RESULTS Elderly patients were more likely to die from their stroke than those younger than 80 years of age, regardless of recanalization success (48% versus 15%; OR, 5.5; 95% CI, 2.1-14.1). Among survivors, there was no difference in the probability of having a good functional outcome (mRS, <or=2) by discharge (38% versus 40%; OR, 0.9; 95% CI, 0.3-2.8). Hemorrhagic transformation did not vary between age groups. CONCLUSIONS Among patients undergoing mechanical thrombectomy for acute cerebrovascular occlusions, increased age conveys a higher rate of stroke-related death, but disability at discharge in this group is similar to that of younger survivors.
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Affiliation(s)
- Yince Loh
- Division of Neurosurgery, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA.
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Liebeskind DS. ICAS 2009: Intracranial Atherosclerosis from a to V. Int J Stroke 2010; 5:135. [DOI: 10.1111/j.1747-4949.2010.00418.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Loh Y, Jahan R, McArthur DL, Shi ZS, Gonzalez NR, Duckwiler GR, Vespa PM, Starkman S, Saver JL, Tateshima S, Liebeskind DS, Viñuela F. Recanalization rates decrease with increasing thrombectomy attempts. AJNR Am J Neuroradiol 2010; 31:935-9. [PMID: 20075091 DOI: 10.3174/ajnr.a1958] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Use of the Merci retriever is increasing as a means to reopen large intracranial arterial occlusions. We sought to determine whether there is an optimum number of retrieval attempts that yields the highest recanalization rates and after which the probability of success decreases. MATERIALS AND METHODS All consecutive patients undergoing Merci retrieval for large cerebral artery occlusions were prospectively tracked at a comprehensive stroke center. We analyzed ICA, M1 segment of the MCA, and vertebrobasilar occlusions. We compared the revascularization of the primary AOL with the number of documented retrieval attempts used to achieve that AOL score. For tandem lesions, each target lesion was compared separately on the basis of where the device was deployed. RESULTS We identified a total of 97 patients with 115 arterial occlusions. The median number of attempts per target vessel was 3, while the median final AOL score was 2. Up to 3 retrieval attempts correlated with good revascularization (AOL 2 or 3). When >or=4 attempts were performed, the end result was more often failed revascularization (AOL 0 or 1) and procedural complications (P = .006). CONCLUSIONS In our experience, 3 may be the optimum number of Merci retrieval attempts per target vessel occlusion. Four or more attempts may not improve the chances of recanalization, while increasing the risk of complications.
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Affiliation(s)
- Y Loh
- Division of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
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Liebeskind DS, Kidwell CS. Back to the future: Reconsidering the hemodynamics of cerebral ischemia. Neurology 2009; 72:1118-9. [DOI: 10.1212/01.wnl.0000345370.80832.c4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Singer OC, Berkefeld J, Lorenz MW, Fiehler J, Albers GW, Lansberg MG, Kastrup A, Rovira A, Liebeskind DS, Gass A, Rosso C, Derex L, Kim JS, Neumann-Haefelin T. Risk of symptomatic intracerebral hemorrhage in patients treated with intra-arterial thrombolysis. Cerebrovasc Dis 2009; 27:368-74. [PMID: 19218803 DOI: 10.1159/000202427] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Accepted: 11/25/2008] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In intra-arterial (IA) thrombolysis trials, higher rates of symptomatic intracerebral haemorrhage (sICH) were found than in trials with intravenous (IV) recombinant tissue plasminogen activator (tPA); this observation could have been due to the inclusion of more severely affected patients in IA thrombolysis trials. In the present study, we investigated the rate of sICH in IA and combined IV + IA thrombolysis versus IV thrombolysis after adjusting for differences in clinical and MRI parameters. METHODS In this multicenter study, we systematically analyzed data from 645 patients with anterior-circulation strokes treated with either IV or IA thrombolysis within 6 h following symptom onset. Thrombolytic regimens included (1) IV tPA treatment (n = 536) and (2) IA treatment with either tPA or urokinase (n = 74) or (3) combined IV + IA treatment with either tPA or urokinase (n = 35). RESULTS 44 (6.8%) patients developed sICH. sICH patients had significantly higher scores on the National Institutes of Health Stroke Scale (NIHSS) at admission and pretreatment DWI lesions. The sICH risk was 5.2% (n = 28) in IV thrombolysis, which is significantly lower than in IA (12.5%, n = 9) or IV + IA thrombolysis (20%, n = 7). In a binary logistic regression analysis including age, NIHSS score, time to thrombolysis, initial diffusion weighted imaging lesion size, mode of thrombolytic treatment and thrombolytic agent, the mode of thrombolytic treatment remained an independent predictor for sICH. The odds ratio for IA or IV + IA versus IV treatment was 3.466 (1.19-10.01, 95% CI, p < 0.05). CONCLUSION In this series, IA and IV + IA thrombolysis is associated with an increased sICH risk as compared to IV thrombolysis, and this risk is independent of differences in baseline parameters such as age, initial NIHSS score or pretreatment lesion size.
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Affiliation(s)
- O C Singer
- Klinik für Neurologie, Goethe-Universität, Frankfurt, Germany.
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Bang OY, Saver JL, Alger JR, Starkman S, Ovbiagele B, Liebeskind DS. Determinants of the distribution and severity of hypoperfusion in patients with ischemic stroke. Neurology 2008; 71:1804-11. [PMID: 19029520 DOI: 10.1212/01.wnl.0000335929.06390.d3] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND In acute cerebral ischemia, two variables characterize the extent of hypoperfusion: the volume of hypoperfused tissue and the intensity of hypoperfusion within these regions. We evaluated the determinants of the intensity of hypoperfusion within oligemic regions among patients who were eligible for recanalization therapy for acute ischemic stroke. METHODS We analyzed data, including pretreatment diffusion-weighted imaging (DWI) and perfusion-weighted imaging, on 119 patients with acute middle cerebral artery infarctions. The intensity of hypoperfusion within oligemic regions was characterized by the hypoperfusion intensity ratio (HIR), defined as the volume of tissue with severe hypoperfusion (Tmax > or = 8 seconds) divided by the volume of tissue with any hypoperfusion (Tmax > or = 2 seconds). Based on the DWI data, we divided the patients into four stroke phenotypes: large cortical, small (< 1 cm diameter) cortical, border-zone, and deep pattern. RESULTS The mean (SD) volume of severe hypoperfusion was 54.6 (52.5) mL, and that of any hypoperfusion was 140.8 (81.3) mL. The HIR ranged widely, from 0.002 to 0.974, with a median of 0.35 (interquartile range 0.13-0.60). The volume of any hypoperfusion did not predict the intensity of hypoperfusion within the affected region (r = 0.10, p = 0.284). Angiographic collateral flow grade was associated with HIRs (p value for trend = 0.019) and differed among DWI lesion patterns. In multivariate analysis, diastolic pressure on admission (odds ratio 0.959, 95% CI 0.922-0.998) and DWI pattern of deep infarcts (odds ratio 18.004 compared with large cortical pattern, 95% CI 1.855-173.807) were independently associated with a low HIR. CONCLUSIONS The intensity of hypoperfusion within an oligemic field is largely independent of the size of the oligemia region. Predictors of lesser intensity of hypoperfusion are lower diastolic blood pressure and presence of a deep diffusion-weighted imaging lesion pattern.
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Affiliation(s)
- O Y Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University, 50 Irwon-dong, Gangnam-gu, Seoul, 135-710, South Korea.
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Sanossian N, Saver JL, Alger JR, Kim D, Duckwiler GR, Jahan R, Vinuela F, Ovbiagele B, Liebeskind DS. Angiography reveals that fluid-attenuated inversion recovery vascular hyperintensities are due to slow flow, not thrombus. AJNR Am J Neuroradiol 2008; 30:564-8. [PMID: 19022866 DOI: 10.3174/ajnr.a1388] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Fluid-attenuated inversion recovery (FLAIR) vascular hyperintensities (FVH) are commonly encountered on MR imaging studies performed shortly after the onset of acute ischemic stroke. Prior reports have speculated regarding the pathogenesis of this finding, yet definitive correlative angiographic studies have not been performed. We studied the pathophysiologic and hemodynamic correlates of FVH on conventional angiography and concurrent MR imaging sequences. MATERIALS AND METHODS Retrospective review of FLAIR and gradient-refocused echo MR imaging sequences acquired immediately before conventional angiography for acute stroke was conducted in a blinded fashion. The presence, location, and morphology of FVH were noted and correlated with markers of thrombotic occlusion and collateral flow on angiography. Angiographic collaterals were graded on a 5-point scale incorporating extent and hemodynamic aspects. RESULTS A prospective ischemic stroke registry of 632 patients was searched to identify 74 patients (mean age, 63.4 +/- 20 years; 48% women) having undergone FLAIR sequences immediately before angiography. Median time from FLAIR to angiography was 2.9 hours (interquartile range, 1.1-4.7 hours). FVH were present in 53/74 (72%) of all acute stroke cases with subsequent angiography. FVH distal to an arterial occlusion were associated with a high grade of leptomeningeal collateral blood flow. CONCLUSIONS FVH are observed in areas of blood flow proximal and distal to stenosis or occlusion and are noted with more extensive collateral circulation.
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Affiliation(s)
- N Sanossian
- Stroke Center and Department of Neurology, University of Southern California, Los Angeles, CA 90033, USA.
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Bang OY, Saver JL, Buck BH, Alger JR, Starkman S, Ovbiagele B, Kim D, Jahan R, Duckwiler GR, Yoon SR, Viñuela F, Liebeskind DS. Impact of collateral flow on tissue fate in acute ischaemic stroke. J Neurol Neurosurg Psychiatry 2008; 79:625-9. [PMID: 18077482 PMCID: PMC2702489 DOI: 10.1136/jnnp.2007.132100] [Citation(s) in RCA: 290] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Collaterals may sustain penumbra prior to recanalisation yet the influence of baseline collateral flow on infarct growth following endovascular therapy remains unknown. METHODS Consecutive patients underwent serial diffusion and perfusion MRI before and after endovascular therapy for acute cerebral ischaemia. We assessed the relationship between MRI diffusion and perfusion lesion indices, angiographic collateral grade and infarct growth. Tmax perfusion lesion maps were generated and diffusion-perfusion mismatch regions were divided into Tmax >or=4 s (severe delay) and Tmax >or=2 but <4 s (mild delay). RESULTS Among 44 patients, collateral grade was poor in 7 (15.9%), intermediate in 20 (45.5%) and good in 17 (38.6%) patients. Although diffusion-perfusion mismatch volume was not different depending on the collateral grade, patients with good collaterals had larger areas of milder perfusion delay than those with poor collaterals (p = 0.005). Among 32 patients who underwent day 3-5 post-treatment MRIs, the degree of pretreatment collateral circulation (r = -0.476, p = 0.006) and volume of diffusion-perfusion mismatch (r = 0.371, p = 0.037) were correlated with infarct growth. Greatest infarct growth occurred in patients with both non-recanalisation and poor collaterals. Multiple regression analysis revealed that pretreatment collateral grade was independently associated with infarct growth. CONCLUSION Our data suggest that angiographic collateral grade and penumbral volume interactively shape tissue fate in patients undergoing endovascular recanalisation therapy. These angiographic and MRI parameters provide complementary information about residual blood flow that may help guide treatment decision making in acute cerebral ischaemia.
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Affiliation(s)
- O Y Bang
- Department of Neurology, Samsung Medical Centre, Sungkyunkwan University, Seoul, South Korea
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Bang OY, Saver JL, Liebeskind DS, Pineda S, Ovbiagele B. Association of serum lipid indices with large artery atherosclerotic stroke. Neurology 2007; 70:841-7. [DOI: 10.1212/01.wnl.0000294323.48661.a9] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
Papillary fibroelastoma (PFE) is a rare primary benign cardiac tumor with significant embolic potential. Diagnosis and requisite surgical treatment may be neglected unless transesophageal echocardiography (TEE) is performed. A 72-year-old man with hypertension and diabetes had a right middle cerebral artery stroke of unclear cause after standard work-up. Subsequent TEE indicated an aortic valve PFE. The TEE may be the only diagnostic modality to identify embolic lesions such as PFE and must be strongly considered in cryptogenic large vessel stroke.
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Affiliation(s)
- D S Liebeskind
- University of California Los Angeles Medical Center, Los Angeles, CA, USA
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Ovbiagele B, Saver JL, Starkman S, Kim D, Ali LK, Jahan R, Duckwiler GR, Viñuela F, Pineda S, Liebeskind DS. Statin enhancement of collateralization in acute stroke. Neurology 2007; 68:2129-31. [PMID: 17562834 DOI: 10.1212/01.wnl.0000264931.34941.f0] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Collateral circulation influences cerebral infarction occurrence and size. Statins may improve ischemic stroke outcomes. We evaluated the relationship between prestroke statin use and pretreatment angiographic collateral grade among acute ischemic stroke patients presenting with occlusion of a major cerebral artery. After adjusting for covariates, the statin-treated group had significantly higher collateral scores than non-statin users, suggesting an association between statin use and better collateralization during acute stroke.
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Affiliation(s)
- B Ovbiagele
- Department of Neurology, UCLA Medical Center, Los Angeles, CA 90095, USA.
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Ramchandren S, Cross BJ, Liebeskind DS. Emergent headaches during pregnancy: correlation between neurologic examination and neuroimaging. AJNR Am J Neuroradiol 2007; 28:1085-7. [PMID: 17569963 PMCID: PMC8134146 DOI: 10.3174/ajnr.a0506] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2006] [Accepted: 11/02/2006] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Emergent evaluation of the pregnant headache patient requires rational selection of acute neuroimaging studies, yet guidelines do not exist. We investigated the demographic and clinical features that are predictive of intracranial pathologic lesions on neuroimaging studies in pregnant women with emergent headaches. MATERIALS AND METHODS We conducted a retrospective review of demographic factors, clinical features, and radiologic findings in a consecutive case series of 63 pregnant women emergently evaluated with a chief complaint of headache, including those with previous headache histories. Clinical data were abstracted from emergency department records, hospital course, and discharge summaries. Multivariate logistic regression analysis examined predictors of intracranial pathologic lesions on emergent neuroimaging studies. RESULTS Multiparous African American women constituted 63% of the case subjects. Headaches were frequently accompanied by photophobia (59%), nausea (52%), vomiting (37%), and occasionally with fever (11%), meningismus (9%), or seizures (7%). A total of 43% of case subjects had abnormal neurologic examination findings. Emergent neuroimaging, including noncontrast head CT and MR imaging, revealed an underlying headache etiology in 27%, including cerebral venous thrombosis, reversible posterior leukoencephalopathy, pseudotumor, and intracranial hemorrhage. The odds of having intracranial pathologic lesions on neuroimaging were 2.7 times higher in patients with abnormal results on neurologic examination (P=.085). CONCLUSIONS Emergent neuroimaging studies may reveal an underlying headache etiology in 27% of pregnant women. Further research with a larger sample size is needed to determine what clinical factors are predictive of a pathologic condition on neuroimaging studies.
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Affiliation(s)
- S Ramchandren
- Department of Neurology, University of Michigan Health System, Ann Arbor, MI 48109, USA.
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Humpich MC, Kurre W, Singer OC, Liebeskind DS, Kastrup A, Thomalla G, Berkefeld J, Neumann-Haefelin T. Risikostratifizierung Thrombolyse-assoziierter symptomatischer Hirnblutungen mittels DWI-ASPECTS. Akt Neurol 2007. [DOI: 10.1055/s-2007-987494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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48
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Bang OY, Saver JL, Liebeskind DS, Starkman S, Villablanca P, Salamon N, Buck B, Ali L, Restrepo L, Vinuela F, Duckwiler G, Jahan R, Razinia T, Ovbiagele B. Cholesterol level and symptomatic hemorrhagic transformation after ischemic stroke thrombolysis. Neurology 2006; 68:737-42. [PMID: 17182976 DOI: 10.1212/01.wnl.0000252799.64165.d5] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Prestroke statin use may improve ischemic stroke outcomes, yet there is also evidence that statins and extremely low cholesterol levels may increase the risk of intracranial hemorrhage. We evaluated the independent effect of statin use and admission cholesterol level on risk of symptomatic hemorrhagic transformation (sHT) after recanalization therapy for acute ischemic stroke. METHODS We analyzed ischemic stroke patients recorded in a prospectively maintained registry that received recanalization therapies (IV or intra-arterial fibrinolysis or endovascular embolectomy) at a university medical center from September 2002 to May 2006. The independent effect of premorbid statin use on sHT post intervention was evaluated by logistic regression, adjusting for prognostic and treatment variables known to predict increased HT risk after ischemic stroke. RESULTS Among 104 patients, mean age was 70 years, and 49% were men. Male sex, hypertension, statin use, low total cholesterol and low-density lipoprotein (LDL) cholesterol, current smoking, elevated glucose levels, and higher admission NIH Stroke Scale (NIHSS) score were all associated with a greater risk of sHT in univariate analysis. After adjusting for covariates, low LDL cholesterol (odds ratio [OR], 0.968 per 1-mg/dL increase; 95% CI, 0.941 to 0.995), current smoking (OR, 14.568; 95% CI, 1.590 to 133.493), and higher NIHSS score (OR, 1.265 per 1-point increase; 95% CI, 1.047 to 1.529) were independently associated with sHT risk. CONCLUSIONS Lower admission low-density lipoprotein cholesterol level with or without statin use, current smoking, and greater stroke severity are associated with greater risk for symptomatic hemorrhagic transformation after recanalization therapy for ischemic stroke.
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Affiliation(s)
- O Y Bang
- Department of Neurology, School of Medicine, Sungkyunkwan University, Samsung Medical Center, Seoul, Korea
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Ovbiagele B, Liebeskind DS, Starkman S, Sanossian N, Kim D, Razinia T, Saver JL. Are elevated admission calcium levels associated with better outcomes after ischemic stroke? Neurology 2006; 67:170-3. [PMID: 16832104 DOI: 10.1212/01.wnl.0000223629.07811.ae] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Calcium (Ca(2+)) and magnesium (Mg(2+)) influence the molecular pathways of ischemic neuronal death. The authors evaluated the impact of admission serum Ca(2+) and Mg(2+) levels, on incident stroke severity and discharge functional outcome. After adjusting for covariates, higher admission Ca(2+) was significantly associated with lesser stroke severity and better discharge functional outcome. Admission Mg(2+) was not an independent clinical outcome prognosticator.
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Affiliation(s)
- B Ovbiagele
- Stroke Center and Department of Neurology, UCLA Medical Center, USA.
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50
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Shah SH, Liebeskind DS, Saver JL, Starkman S, Vinuela F, Duckwiler G, Jahan R, Kim D, Sanossian N, Vespa P, Ovbiagele B. Influence of gender on outcomes after intra-arterial thrombolysis for acute ischemic stroke. Neurology 2006; 66:1745-6. [PMID: 16769954 DOI: 10.1212/01.wnl.0000218208.31305.84] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Recent data suggest that women obtain greater benefit than men from IV fibrinolysis for acute ischemic stroke. It is unknown whether this gender-thrombolysis advantage extends to those treated with intra-arterial (IA) thrombolysis. The authors evaluated the independent effect of gender among ischemic stroke patients treated with IA fibrinolysis and found no differences in short-term clinical and angiographic outcomes between men and women who received IA thrombolysis for acute ischemic stroke.
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Affiliation(s)
- S H Shah
- Department of Neurology, UCLA Medical Center, USA.
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