Side matters: differences in functional outcome and quality of life after thrombectomy in left and right hemispheric stroke

BACKGROUND

Patients with a left (LHS) or right hemispheric stroke (RHS) differ in terms of clinical symptoms due to lateralization of specific cortical functions. Studies on functional outcome after stroke and endovascular thrombectomy (EVT) comparing both hemispheres showed conflicting results so far. The impact of stroke laterality on patient-reported health-related quality of life (HRQoL) after EVT has not yet been adequately addressed and still remains unclear.

METHODS

Consecutive stroke thrombectomy patients, derived from a multi-center, prospective registry (German Stroke Registry) between June 2015 and December 2019, were included in this study. At 90 days, outcome after EVT was assessed by the modified Rankin scale (mRS) and HRQoL using the European QoL-five dimensions questionnaire utility-index (EQ-5D-I; higher values indicate better HRQoL) in patients with LHS and RHS. Adjusted regression analysis was applied to evaluate the influence of stroke laterality on outcome after EVT.

RESULTS

In total, 5683 patients were analyzed. Of these, 2953 patients (52.8%) had LHS and 2637 (47.2%) RHS. LHS patients had a higher baseline NIHSS (16 vs. 13, p < 0.001) and a higher ASPECTS (9 vs. 8, p < 0.001) compared to RHS patients. Among survivors, patients with LHS less frequently had a self-reported affected mobility (p = 0.037), suffered less often from pain (p = 0.04) and anxiety/depression (p = 0.032) three months after EVT. After adjusting for confounders (age, sex, baseline NIHSS), LHS was associated with a better HRQoL (ß coefficient 0.04, CI 95% 0.017-0.063; p = 0.001), and better functional outcome assessed by lower values on the mRS (ß coefficient - 0.109, CI 95% - 0.217-0.000; p = 0.049).

CONCLUSIONS

Ninety days after EVT, LHS patients have a better functional outcome and HRQoL. Patients with RHS should be actively assessed and treated for pain, anxiety and depression to improve their HRQoL after EVT.

Rupture risk assessment for multiple intracranial aneurysms: why there is no need for dozens of clinical, morphological and hemodynamic parameters

Introduction:

A multitude of approaches have been postulated for assessing the risk of intracranial aneurysm rupture. However, the amount of potential predictive factors is not applicable in clinical practice and they are rejected in favor of the more practical PHASES score. For the subgroup of multiple intracranial aneurysms (MIAs), the PHASES score might severely underestimate the rupture risk, as only the aneurysm with the largest diameter is considered for risk evaluation.

Methods:

In this study, we investigated 38 patients harboring a total number of 87 MIAs with respect to their morphological and hemodynamical characteristics. For the determination of the best suited parameters regarding their predictive power for aneurysm rupture, we conducted three phases of statistical evaluation. The statistical analysis aimed to identify parameters that differ significantly between ruptured and unruptured aneurysms, show smallest possible correlations among each other and have a high impact on rupture risk prediction.

Results:

Significant differences between ruptured and unruptured aneurysms were found in 16 out of 49 parameters. The lowest correlation were found for gamma, aspect ratio (AR1), aneurysm maximal relative residence time (Aneurysm_RRT_max) and aneurysm mean relative residence time. The data-driven parameter selection yielded a significant correlation of only two parameters (AR1 and the Aneurysm_RRT_max) with rupture state (area under curve = 0.75).

Conclusion:

A high number of established morphological and hemodynamical parameters seem to have no or only low effect on prediction of aneurysm rupture in patients with MIAs. For best possible rupture risk assessment of patients with MIAs, only the morphological parameter AR1 and the hemodynamical parameter Aneurysm_RRT_max need to be included in the prediction model.

MR imaging in the presurgical workup of patients with drug-resistant epilepsy

BACKGROUND AND PURPOSE

Whether an epileptic lesion is detected with MR imaging depends on the quality of the images and the expertise of the reader. We analyzed the role of 1.5-T MR imaging in the presurgical evaluation of patients with drug-resistant epilepsy at one center.

METHODS

In a 2-year prospective study, 385 patients with drug-resistant epilepsy underwent standardized MR imaging at 1.5 T. We analyzed whether lesions were detected, whether they were precisely characterized by MR imaging, and whether lesion characterization allowed us to estimate seizure outcomes.

RESULTS

Lesions were found on MR images in 318 patients (83%). Following presurgical evaluation, 209 (66%) underwent surgery, and 109 (34%) did not. Freedom from seizures was achieved in 130 (70%) of 186 patients. Nine (14%) of 66 patients without an MR imaging lesion underwent surgery; histopathologic findings were unrevealing in seven patients, and five (56%) achieved freedom from seizures. Hippocampal sclerosis was the most common lesion (52%) and correctly characterized in 101 (97%) of 104 patients. Glioneuronal tumors (20%) were sometimes imprecisely characterized: Four nonenhancing gangliogliomas were mistaken for focal cortical dysplasias. Outcomes were not different between lesion groups. However, there were trends toward a favorable outcome for focal cortical dysplasias with balloon cells and an unfavorable outcome for gyral scars.

CONCLUSION

MR imaging detection of lesions influences further presurgical workup, though lesion characterization does not allow us to predict seizure outcome. If MR imaging fails to depict a lesion and patients undergo surgery because of electrophysiologic findings, histopathologic findings are often unrevealing.

Planar Brain Surface Reformations for Localization of Cortical Brain Lesions

Cortical lesions close to the central region may be difficult to localize on orthogonal MRI slices, especially when space-occupying lesions distort the brain surface relief and obscure anatomical landmarks. The purpose of this study was to evaluate, whether localization can be improved with planar brain surface (Mercator or "pancake") reformations. Three independent MRI readers localized superficial brain lesions of 30 patients on orthogonal MRI slices and on planar brain surface views reformatted from a sagittal 3D T(1)-weighted gradient echo sequence. On orthogonal MRI slices 46% of lesions were considered easy to localize, 37% difficult and 17% could not be localized. Corresponding values for planar brain surface views were 82%, 16% and 2%, respectively. Evaluation of orthogonal MRI slices took 190 min compared to 100 min for planar brain surface views. Thus, planar brain surface reformations are a helpful and time-saving means to localize superficial brain lesions.