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Fast Automatic Detection of Large Vessel Occlusions on CT Angiography
Amukotuwa, Shalini A; Straka, Matus; Dehkharghani, Seena; Bammer, Roland
Background and Purpose- Accurate and rapid detection of anterior circulation large vessel occlusion (LVO) is of paramount importance in patients with acute stroke due to the potentially rapid infarction of at-risk tissue and the limited therapeutic window for endovascular clot retrieval. Hence, the optimal threshold of a new, fully automated software-based approach for LVO detection was determined, and its diagnostic performance evaluated in a large cohort study. Methods- For this retrospective study, data were pooled from: 2 stroke trials, DEFUSE 2 (n=62; 07/08-09/11) and DEFUSE 3 (n=213; 05/17-05/18); a cohort of endovascular clot retrieval candidates (n=82; August 2, 2014-August 30, 2015) and normals (n=111; June 6, 2017-January 28, 2019) from a single quaternary center; and code stroke patients (n=501; January 1, 2017-December 31, 2018) from a single regional hospital. All CTAs were assessed by the automated algorithm. Consensus reads by 2 neuroradiologists served as the reference standard. ROC analysis was used to assess diagnostic performance of the algorithm for detection of (1) anterior circulation LVOs involving the intracranial internal carotid artery or M1 segment middle cerebral artery (M1-MCA); (2) anterior circulation LVOs and proximal M2 segment MCA (M2-MCA) occlusions; and (3) individual segment occlusions. Results- CTAs from 926 patients (median age 70 years, interquartile range: 58-80; 422 females) were analyzed. Three hundred ninety-five patients had an anterior circulation LVO or M2-MCA occlusion (National Institutes of Health Stroke Scale 14 [median], interquartile range: 9-19). Sensitivity and specificity were 97% and 74%, respectively, for LVO detection, and 95% and 79%, respectively, when M2 occlusions were included. On analysis by occlusion site, sensitivities were 90% (M2-MCA), 97% (M1-MCA), and 97% (intracranial internal carotid artery) with corresponding area-under-the-ROC-curves of 0.874 (M2), 0.962 (M1), and 0.997 (intracranial internal carotid artery). Conclusions- Intracranial anterior circulation LVOs and proximal M2 occlusions can be rapidly and reliably detected by an automated detection tool, which may facilitate intra- and inter-instutional workflows and emergent imaging triage in the care of patients with stroke.
PMID: 31679501
ISSN: 1524-4628
CID: 4172022
Automated Detection of Intracranial Large Vessel Occlusions on Computed Tomography Angiography
Amukotuwa, Shalini A; Straka, Matus; Smith, Heather; Chandra, Ronil V; Dehkharghani, Seena; Fischbein, Nancy J; Bammer, Roland
Background and Purpose- Endovascular thrombectomy is highly effective in acute ischemic stroke patients with an anterior circulation large vessel occlusion (LVO), decreasing morbidity and mortality. Accurate and prompt identification of LVOs is imperative because these patients have large volumes of tissue that are at risk of infarction without timely reperfusion, and the treatment window is limited to 24 hours. We assessed the accuracy and speed of a commercially available fully automated LVO-detection tool in a cohort of patients presenting to a regional hospital with suspected stroke. Methods- Consecutive patients who underwent multimodal computed tomography with thin-slice computed tomography angiography between January 1, 2017 and December 31, 2018 for suspected acute ischemic stroke within 24 hours of onset were retrospectively identified. The multimodal computed tomographies were assessed by 2 neuroradiologists in consensus for the presence of an intracranial anterior circulation LVO or M2-segment middle cerebral artery occlusion (the reference standard). The patients' computed tomography angiographies were then processed using an automated LVO-detection algorithm (RAPID CTA). Receiver-operating characteristic analysis was used to determine sensitivity, specificity, and negative predictive value of the algorithm for detection of (1) an LVO and (2) either an LVO or M2-segment middle cerebral artery occlusion. Results- CTAs from 477 patients were analyzed (271 men and 206 women; median age, 71; IQR, 60-80). Median processing time was 158 seconds (IQR, 150-167 seconds). Seventy-eight patients had an anterior circulation LVO, and 28 had an isolated M2-segment middle cerebral artery occlusion. The sensitivity, negative predictive value, and specificity were 0.94, 0.98, and 0.76, respectively for detection of an intracranial LVO and 0.92, 0.97, and 0.81, respectively for detection of either an intracranial LVO or M2-segment middle cerebral artery occlusion. Conclusions- The fully automated algorithm had very high sensitivity and negative predictive value for LVO detection with fast processing times, suggesting that it can be used in the emergent setting as a screening tool to alert radiologists and expedite formal diagnosis.
PMID: 31495328
ISSN: 1524-4628
CID: 4080042
Radiological Management of Angiographically Negative, Spontaneous Intracranial Subarachnoid Hemorrhage: A Multicenter Study of Utilization and Diagnostic Yield
Sadigh, Gelareh; Menon, Ranjith K; Bhojak, Maneesh; Aladi, Abather; Mossa-Basha, Mahmud; Wu, Lei; Lehman, Vance T; Brinjikji, Waleed; Dehkharghani, Seena; Derakhshani, Ahrya; Mossa-Basha, Feras; Allen, Jason W
BACKGROUND:The optimal diagnostic evaluation for patients with angiographically negative subarachnoid hemorrhage (AN-SAH) remains controversial. OBJECTIVE:To assess the utilization rate and diagnostic yield of imaging tests routinely obtained in identifying a structural cause for AN-SAH. METHODS:In this retrospective multicenter study, consecutive adult patients admitted with nontraumatic, AN-SAH between 01/2010 and 12/2015 were included. Patients with intraparenchymal, subdural, or epidural hematomas in addition to SAH were excluded. Outcomes studied included utilization rate, diagnostic yield, and median time from admission for the following imaging tests: initial computed tomography angiography (CTA) and digital subtraction angiography (DSA), brain and cervical spine magnetic resonance imaging (MRI), and any repeat DSA or CTA performed either during initial admission or at long-term follow-up. RESULTS:A total of 752 patients were included (mean age, 53 yr; 54% male). Initial CTA and DSA were performed in 89% and 100% of patients, respectively. Brain MRI was performed in 75% of patients and was positive in 0.7% of cases. Cervical spine MRI was performed in 61% of patients and was positive in 0.2% of cases. Repeat, same-admission follow-up DSA and CTA were performed in 48% and 51% of patients and were positive in 3.3% and 1% of cases, respectively. Delayed follow-up DSA and CTA after discharge were performed in 26% and 7% of patients and were positive in 2% and 3.7% of cases, respectively, all with negative prior imaging studies. CONCLUSION/CONCLUSIONS:Cervical spine and brain MRI have extremely low diagnostic yield, both are commonly utilized in patients with AN-SAH; while repeat DSA and CTA are utilized less commonly and have slightly higher diagnostic yield.
PMID: 29850838
ISSN: 1524-4040
CID: 3166052
Cerebral MR oximetry during acetazolamide augmentation: Beyond cerebrovascular reactivity in hemodynamic failure
Leatherday, Christopher; Dehkharghani, Seena; Nahab, Fadi; Allen, Jason W; Wu, Junjie; Hu, Ranliang; Qiu, Deqiang
BACKGROUND:Oxygen extraction fraction (OEF) elevation predicts increased ischemic stroke incidence among patients with carotid steno-occlusive disease, and can be estimated from quantitative susceptibility mapping (QSM) MRI. PURPOSE/OBJECTIVE:To explore QSM oximetry during acetazolamide (ACZ) challenge, hypothesizing that detectable OEF alterations will reflect hemodynamic compromise in unilateral cerebrovascular disease (CVD) patients. STUDY TYPE/METHODS:Retrospective. SUBJECTS/METHODS:Fourteen unilateral CVD patients, and 24 healthy controls (HC). FIELD STRENGTH/SEQUENCE/UNASSIGNED:-weighted images at 3T. ASSESSMENT/RESULTS:We constructed QSM images and R2* maps from multiecho GRE images. QSM-OEF maps were generated from the susceptibility difference between venous blood and background brain tissue. Intrasubject diseased/contralateral hemisphere OEF ratios in the middle cerebral artery (MCA) territories were calculated. Intravascular susceptibility in the straight sinus (SS) and MCA was also measured. STATISTICAL TESTS/UNASSIGNED:The result significance was determined using t-tests and Pearson's correlation. RESULTS:Mean and standard deviation for the patient diseased/contralateral OEF ratios were 1.15 ± 0.14 at baseline and 1.23 ± 0.17 post-ACZ. Disease group R2* ratios were 0.95 ± 0.05 at baseline and 1.03 ± 0.08 post-ACZ. Left/right OEF and R2* ratios for the HC group were 0.98 ± 0.06 and 0.99 ± 0.038, respectively. Susceptibility (ppb) in the SS and MCA in patients was 162.63 ± 35.4 and -22.33 ± 13.70, respectively, at baseline, 124.56 ± 37.43 and -19.27 ± 23.14 post-ACZ. The HC group SS and MCA susceptibility was 146.10 ± 24.79 and -19.59 ± 12.37, respectively. Patient group OEF ratios were greater than 1.0 before and after ACZ challenge (P < 0.01 and < 0.001, respectively, one-sample t-test), and were greater than HC ratios (P < 0.001 unpaired t-test). OEF and R2* ratios increased from baseline to post-ACZ (P = 0.024, 0.004, respectively, paired t-test). Detectable blood oxygenation change was confirmed by finding SS susceptibility decreased from baseline to post-ACZ (P < 0.001, paired t-test), while MCA susceptibility did not change significantly (P = 0.67, paired t-test). DATA CONCLUSION/UNASSIGNED:These results suggest QSM is sensitive to dynamic OEF modulation during hemodynamic augmentation. LEVEL OF EVIDENCE/METHODS:3 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018.
PMID: 30390367
ISSN: 1522-2586
CID: 3455492
Age-adjusted infarct volume cut-off for favorable outcome after stroke endovascular therapy [Meeting Abstract]
Bouslama, M; Haussen, D; Rodrigues, G; Saleem, Y; Dehkharghani, S; Barreira, C; Frankel, M; Nogueira, R
Background and Aims: Optimal selection paradigms for large vessel occlusion acute stroke (LVOS) endovascular therapy (ET) are yet to be established. Previous studies have shown the benefit of adjusting infarct size to age. We sought to study the impact of age-adjusted final infarct volumes (FIV), a surrogate for pre-reperfusion infarct core, on functional outcomes and determine the ideal thresholds for good outcome discrimination (90-day mRS 0-2).
Method(s): We reviewed our prospectively collected endovascular database at a tertiary care center between 9/2010- 2/2018. All patients that underwent ET for anterior circulation LVOS and achieved full reperfusion (mTICI-3) were included and categorized into 4 age groups: (G1) <60 years, (G2) 60-69, (G3) 70-79 (G4) >=80. Baseline characteristics and outcome parameters were compared. FIV was measured on follow-up MRI or CT within 5 days of treatment. For each group, a FIV-good outcome ROC curve was constructed and Youman Index was used to identify the optimal cut-off.
Result(s): 516 patients were studied (G1:171, G2:130, G3:103, G4:112). The mean FIV was 46+/-64ml and 58% achieved good outcome. Patients with poor outcome had larger FIV in each group (p<0.01 for all). The target FIV cut-off (mL) decreased with increased age: G1:45.7(SE 56%, SP 80%); G2:30.4(SE 63%, SP 75%); G3:20.2(SE 76%, SP 65%); G4:16.9(SE 68%, SP 70%). In multivariate analysis, after adjusting for age, baseline NIHSS, glucose level and FIV, achieving a FIV less than the age-adjusted threshold was an independent predictor of good outcome (aOR:2.75 95% CI [1.43-5.29], p=0.002).
Conclusion(s): Age-adjusted infarct volume represents a strong outcome discriminator substitute and might help refine patient selection for stroke endovascular therapy
EMBASE:628559260
ISSN: 2396-9881
CID: 4001232
eTICI reperfusion: defining success in endovascular stroke therapy
Liebeskind, David S; Bracard, Serge; Guillemin, Francis; Jahan, Reza; Jovin, Tudor G; Majoie, Charles Blm; Mitchell, Peter J; van der Lugt, Aad; Menon, Bijoy K; San Román, Luis; Campbell, Bruce Cv; Muir, Keith W; Hill, Michael D; Dippel, Diederik Wj; Saver, Jeffrey L; Demchuk, Andrew M; Dávalos, Antoni; White, Philip; Brown, Scott; Goyal, Mayank; Berkhemer, O A; Fransen, P S; Beumer, D; van den Berg, L A; Lingsma, H F; Yoo, A J; Schonewille, W J; Vos, J A; Nederkoorn, P J; Wermer, M J; van Walderveen, M A; Staals, J; Hofmeijer, J; van Oostayen, J A; Lycklama À Nijeholt, G J; Boiten, J; Brouwer, P A; Emmer, B J; de Bruijn, S F; van Dijk, L C; Kappelle, J; Lo, R H; van Dijk, E J; de Vries, J; de Kort, Plm; van Rooij, Wjj; van den Berg, Jsp; van Hasselt, Baam; Aerden, Lam; Dallinga, R J; Visser, M C; Bot, Jcj; Vroomen, P C; Eshghi, O; Schreuder, Thcml; Heijboer, Rjj; Keizer, K; Tielbeek, A V; den Hertog, H M; Gerrits, D G; van den Berg-Vos, R M; Karas, G B; Steyerberg, E W; Flach, Z; Marquering, H A; Sprengers, Mes; Jenniskens, Sfm; Beenen, Lfm; van den Berg, R; Koudstaal, P J; van Zwam, W H; Roos, Ybwem; van der Lugt, A; van Oostenbrugge, R J; Majoie, Cblm; Dippel, Dwj; Brown, M M; Liebig, T; Stijnen, T; Andersson, T; Mattle, H; Wahlgren, N; van der Heijden, E; Ghannouti, N; Fleitour, N; Hooijenga, I; Puppels, C; Pellikaan, W; Geerling, A; Lindl-Velema, A; van Vemde, G; de Ridder, A; Greebe, P; de Bont-Stikkelbroeck, J; de Meris, J; Janssen, K; Struijk, W; Licher, S; Boodt, N; Ros, A; Venema, E; Slokkers, I; Ganpat, R J; Mulder, M; Saiedie, N; Heshmatollah, A; Schipperen, S; Vinken, S; van Boxtel, T; Koets, J; Boers, M; Santos, E; Borst, J; Jansen, I; Kappelhof, M; Lucas, M; Geuskens, R; Barros, R S; Dobbe, R; Csizmadia, M; Hill, M D; Goyal, M; Demchuk, A M; Menon, B K; Eesa, M; Ryckborst, K J; Wright, M R; Kamal, N R; Andersen, L; Randhawa, P A; Stewart, T; Patil, S; Minhas, P; Almekhlafi, M; Mishra, S; Clement, F; Sajobi, T; Shuaib, A; Montanera, W J; Roy, D; Silver, F L; Jovin, T G; Frei, D F; Sapkota, B; Rempel, J L; Thornton, J; Williams, D; Tampieri, D; Poppe, A Y; Dowlatshahi, D; Wong, J H; Mitha, A P; Subramaniam, S; Hull, G; Lowerison, M W; Sajobi, T; Salluzzi, M; Wright, M R; Maxwell, M; Lacusta, S; Drupals, E; Armitage, K; Barber, P A; Smith, E E; Morrish, W F; Coutts, S B; Derdeyn, C; Demaerschalk, B; Yavagal, D; Martin, R; Brant, R; Yu, Y; Willinsky, R A; Montanera, W J; Weill, A; Kenney, C; Aram, H; Stewart, T; Stys, P K; Watson, T W; Klein, G; Pearson, D; Couillard, P; Trivedi, A; Singh, D; Klourfeld, E; Imoukhuede, O; Nikneshan, D; Blayney, S; Reddy, R; Choi, P; Horton, M; Musuka, T; Dubuc, V; Field, T S; Desai, J; Adatia, S; Alseraya, A; Nambiar, V; van Dijk, R; Wong, J H; Mitha, A P; Morrish, W F; Eesa, M; Newcommon, N J; Shuaib, A; Schwindt, B; Butcher, K S; Jeerakathil, T; Buck, B; Khan, K; Naik, S S; Emery, D J; Owen, R J; Kotylak, T B; Ashforth, R A; Yeo, T A; McNally, D; Siddiqui, M; Saqqur, M; Hussain, D; Kalashyan, H; Manosalva, A; Kate, M; Gioia, L; Hasan, S; Mohammad, A; Muratoglu, M; Williams, D; Thornton, J; Cullen, A; Brennan, P; O'Hare, A; Looby, S; Hyland, D; Duff, S; McCusker, M; Hallinan, B; Lee, S; McCormack, J; Moore, A; O'Connor, M; Donegan, C; Brewer, L; Martin, A; Murphy, S; O'Rourke, K; Smyth, S; Kelly, P; Lynch, T; Daly, T; O'Brien, P; O'Driscoll, A; Martin, M; Daly, T; Collins, R; Coughlan, T; McCabe, D; Murphy, S; O'Neill, D; Mulroy, M; Lynch, O; Walsh, T; O'Donnell, M; Galvin, T; Harbison, J; McElwaine, P; Mulpeter, K; McLoughlin, C; Reardon, M; Harkin, E; Dolan, E; Watts, M; Cunningham, N; Fallon, C; Gallagher, S; Cotter, P; Crowe, M; Doyle, R; Noone, I; Lapierre, M; Coté, V A; Lanthier, S; Odier, C; Durocher, A; Raymond, J; Weill, A; Daneault, N; Deschaintre, Y; Jankowitz, B; Baxendell, L; Massaro, L; Jackson-Graves, C; Decesare, S; Porter, P; Armbruster, K; Adams, A; Billigan, J; Oakley, J; Ducruet, A; Jadhav, A; Giurgiutiu, D V; Aghaebrahim, A; Reddy, V; Hammer, M; Starr, M; Totoraitis, V; Wechsler, L; Streib, S; Rangaraju, S; Campbell, D; Rocha, M; Gulati, D; Silver, F L; Krings, T; Kalman, L; Cayley, A; Williams, J; Stewart, T; Wiegner, R; Casaubon, L K; Jaigobin, C; Del Campo, J M; Elamin, E; Schaafsma, J D; Willinsky, R A; Agid, R; Farb, R; Ter Brugge, K; Sapkoda, B L; Baxter, B W; Barton, K; Knox, A; Porter, A; Sirelkhatim, A; Devlin, T; Dellinger, C; Pitiyanuvath, N; Patterson, J; Nichols, J; Quarfordt, S; Calvert, J; Hawk, H; Fanale, C; Frei, D F; Bitner, A; Novak, A; Huddle, D; Bellon, R; Loy, D; Wagner, J; Chang, I; Lampe, E; Spencer, B; Pratt, R; Bartt, R; Shine, S; Dooley, G; Nguyen, T; Whaley, M; McCarthy, K; Teitelbaum, J; Tampieri, D; Poon, W; Campbell, N; Cortes, M; Dowlatshahi, D; Lum, C; Shamloul, R; Robert, S; Stotts, G; Shamy, M; Steffenhagen, N; Blacquiere, D; Hogan, M; AlHazzaa, M; Basir, G; Lesiuk, H; Iancu, D; Santos, M; Choe, H; Weisman, D C; Jonczak, K; Blue-Schaller, A; Shah, Q; MacKenzie, L; Klein, B; Kulandaivel, K; Kozak, O; Gzesh, D J; Harris, L J; Khoury, J S; Mandzia, J; Pelz, D; Crann, S; Fleming, L; Hesser, K; Beauchamp, B; Amato-Marzialli, B; Boulton, M; Lopez-Ojeda, P; Sharma, M; Lownie, S; Chan, R; Swartz, R; Howard, P; Golob, D; Gladstone, D; Boyle, K; Boulos, M; Hopyan, J; Yang, V; Da Costa, L; Holmstedt, C A; Turk, A S; Navarro, R; Jauch, E; Ozark, S; Turner, R; Phillips, S; Shankar, J; Jarrett, J; Gubitz, G; Maloney, W; Vandorpe, R; Schmidt, M; Heidenreich, J; Hunter, G; Kelly, M; Whelan, R; Peeling, L; Burns, P A; Hunter, A; Wiggam, I; Kerr, E; Watt, M; Fulton, A; Gordon, P; Rennie, I; Flynn, P; Smyth, G; O'Leary, S; Gentile, N; Linares, G; McNelis, P; Erkmen, K; Katz, P; Azizi, A; Weaver, M; Jungreis, C; Faro, S; Shah, P; Reimer, H; Kalugdan, V; Saposnik, G; Bharatha, A; Li, Y; Kostyrko, P; Santos, M; Marotta, T; Montanera, W; Sarma, D; Selchen, D; Spears, J; Heo, J H; Jeong, K; Kim, D J; Kim, B M; Kim, Y D; Song, D; Lee, K J; Yoo, J; Bang, O Y; Rho, S; Lee, J; Jeon, P; Kim, K H; Cha, J; Kim, S J; Ryoo, S; Lee, M J; Sohn, S I; Kim, C H; Ryu, H G; Hong, J H; Chang, H W; Lee, C Y; Rha, J; Davis, S M; Donnan, G A; Campbell, B C; Mitchell, P J; Churilov, L; Yan, B; Dowling, R; Yassi, N; Oxley, T J; Wu, T Y; Silver, G; McDonald, A; McCoy, R; Kleinig, T J; Scroop, R; Dewey, H M; Simpson, M; Brooks, M; Coulton, B; Krause, M; Harrington, T J; Steinfort, B; Faulder, K; Priglinger, M; Day, S; Phan, T; Chong, W; Holt, M; Chandra, R V; Ma, H; Young, D; Wong, K; Wijeratne, T; Tu, H; Mackay, E; Celestino, S; Bladin, C F; Loh, P S; Gilligan, A; Ross, Z; Coote, S; Frost, T; Parsons, M W; Miteff, F; Levi, C R; Ang, T; Spratt, N; Kaauwai, L; Badve, M; Rice, H; de Villiers, L; Barber, P A; McGuinness, B; Hope, A; Moriarty, M; Bennett, P; Wong, A; Coulthard, A; Lee, A; Jannes, J; Field, D; Sharma, G; Salinas, S; Cowley, E; Snow, B; Kolbe, J; Stark, R; King, J; Macdonnell, R; Attia, J; D'Este, C; Saver, J L; Goyal, M; Diener, H C; Levy, E I; Bonafé, A; Mendes Pereira, V; Jahan, R; Albers, G W; Cognard, C; Cohen, D J; Hacke, W; Jansen, O; Jovin, T G; Mattle, H P; Nogueira, R G; Siddiqui, A H; Yavagal, D R; von Kummer, R; Smith, W; Turjman, F; Hamilton, S; Chiacchierini, R; Amar, A; Sanossian, N; Loh, Y; Devlin, T; Baxter, B; Hawk, H; Sapkota, B; Quarfordt, S; Sirelkhatim, A; Dellinger, C; Barton, K; Reddy, V K; Ducruet, A; Jadhav, A; Horev, A; Giurgiutiu, D V; Totoraitis, V; Hammer, M; Jankowitz, B; Wechsler, L; Rocha, M; Gulati, D; Campbell, D; Star, M; Baxendell, L; Oakley, J; Siddiqui, A; Hopkins, L N; Snyder, K; Sawyer, R; Hall, S; Costalat, V; Riquelme, C; Machi, P; Omer, E; Arquizan, C; Mourand, I; Charif, M; Ayrignac, X; Menjot de Champfleur, N; Leboucq, N; Gascou, G; Moynier, M; du Mesnil de Rochemont, R; Singer, O; Berkefeld, J; Foerch, C; Lorenz, M; Pfeilschifer, W; Hattingen, E; Wagner, M; You, S J; Lescher, S; Braun, H; Dehkharghani, S; Belagaje, S R; Anderson, A; Lima, A; Obideen, M; Haussen, D; Dharia, R; Frankel, M; Patel, V; Owada, K; Saad, A; Amerson, L; Horn, C; Doppelheuer, S; Schindler, K; Lopes, D K; Chen, M; Moftakhar, R; Anton, C; Smreczak, M; Carpenter, J S; Boo, S; Rai, A; Roberts, T; Tarabishy, A; Gutmann, L; Brooks, C; Brick, J; Domico, J; Reimann, G; Hinrichs, K; Becker, M; Heiss, E; Selle, C; Witteler, A; Al-Boutros, S; Danch, M J; Ranft, A; Rohde, S; Burg, K; Weimar, C; Zegarac, V; Hartmann, C; Schlamann, M; Göricke, S; Ringlestein, A; Wanke, I; Mönninghoff, C; Dietzold, M; Budzik, R; Davis, T; Eubank, G; Hicks, W J; Pema, P; Vora, N; Mejilla, J; Taylor, M; Clark, W; Rontal, A; Fields, J; Peterson, B; Nesbit, G; Lutsep, H; Bozorgchami, H; Priest, R; Ologuntoye, O; Barnwell, S; Dogan, A; Herrick, K; Takahasi, C; Beadell, N; Brown, B; Jamieson, S; Hussain, M S; Russman, A; Hui, F; Wisco, D; Uchino, K; Khawaja, Z; Katzan, I; Toth, G; Cheng-Ching, E; Bain, M; Man, S; Farrag, A; George, P; John, S; Shankar, L; Drofa, A; Dahlgren, R; Bauer, A; Itreat, A; Taqui, A; Cerejo, R; Richmond, A; Ringleb, P; Bendszus, M; Möhlenbruch, M; Reiff, T; Amiri, H; Purrucker, J; Herweh, C; Pham, M; Menn, O; Ludwig, I; Acosta, I; Villar, C; Morgan, W; Sombutmai, C; Hellinger, F; Allen, E; Bellew, M; Gandhi, R; Bonwit, E; Aly, J; Ecker, R D; Seder, D; Morris, J; Skaletsky, M; Belden, J; Baker, C; Connolly, L S; Papanagiotou, P; Roth, C; Kastrup, A; Politi, M; Brunner, F; Alexandrou, M; Merdivan, H; Ramsey, C; Given Ii, C; Renfrow, S; Deshmukh, V; Sasadeusz, K; Vincent, F; Thiesing, J T; Putnam, J; Bhatt, A; Kansara, A; Caceves, D; Lowenkopf, T; Yanase, L; Zurasky, J; Dancer, S; Freeman, B; Scheibe-Mirek, T; Robison, J; Rontal, A; Roll, J; Clark, D; Rodriguez, M; Fitzsimmons, B F; Zaidat, O; Lynch, J R; Lazzaro, M; Larson, T; Padmore, L; Das, E; Farrow-Schmidt, A; Hassan, A; Tekle, W; Cate, C; Jansen, O; Cnyrim, C; Wodarg, F; Wiese, C; Binder, A; Riedel, C; Rohr, A; Lang, N; Laufs, H; Krieter, S; Remonda, L; Diepers, M; Añon, J; Nedeltchev, K; Kahles, T; Biethahn, S; Lindner, M; Chang, V; Gächter, C; Esperon, C; Guglielmetti, M; Arenillas Lara, J F; Martínez Galdámez, M; Calleja Sanz, A I; Cortijo Garcia, E; Garcia Bermejo, P; Perez, S; Mulero Carrillo, P; Crespo Vallejo, E; Ruiz Piñero, M; Lopez Mesonero, L; Reyes Muñoz, F J; Brekenfeld, C; Buhk, J H; Krützelmann, A; Thomalla, G; Cheng, B; Beck, C; Hoppe, J; Goebell, E; Holst, B; Grzyska, U; Wortmann, G; Starkman, S; Duckwiler, G; Jahan, R; Rao, N; Sheth, S; Ng, K; Noorian, A; Szeder, V; Nour, M; McManus, M; Huang, J; Tarpley, J; Tateshima, S; Gonzalez, N; Ali, L; Liebeskind, D; Hinman, J; Calderon-Arnulphi, M; Liang, C; Guzy, J; Koch, S; DeSousa, K; Gordon-Perue, G; Haussen, D; Elhammady, M; Peterson, E; Pandey, V; Dharmadhikari, S; Khandelwal, P; Malik, A; Pafford, R; Gonzalez, P; Ramdas, K; Andersen, G; Damgaard, D; Von Weitzel-Mudersbach, P; Simonsen, C; Ruiz de Morales Ayudarte, N; Poulsen, M; Sørensen, L; Karabegovich, S; Hjørringgaard, M; Hjort, N; Harbo, T; Sørensen, K; Deshaies, E; Padalino, D; Swarnkar, A; Latorre, J G; Elnour, E; El-Zammar, Z; Villwock, M; Farid, H; Balgude, A; Cross, L; Hansen, K; Holtmannspötter, M; Kondziella, D; 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BACKGROUND:Revascularization after endovascular therapy for acute ischemic stroke is measured by the Thrombolysis In Cerebral Infarction (TICI) scale, yet variability exists in scale definitions. We examined the degree of reperfusion with the expanded TICI (eTICI) scale and association with outcomes in the HERMES collaboration of recent endovascular trials. METHODS:The HERMES Imaging Core, blind to all other data, evaluated angiography after endovascular therapy in HERMES. A battery of TICI scores (mTICI, TICI, TICI2C) was used to define reperfusion of the initial target occlusion defined by non-invasive imaging and conventional angiography. RESULTS:Angiography of 801 subjects was available, including 797 defined by non-invasive imaging (154 internal carotid artery (ICA), 583 M1, 60 M2) and 748 by conventional angiography (195 ICA, 459 M1, 94 M2). Among 729 subjects in whom the reperfusion grade could be established, using eTICI (3=100%, 2C=90-99%, 2b67=67-89%, 2b50=50-66%) of the conventional angiography target occlusion, there were 63 eTICI 3 (9%), 166 eTICI 2c (23%), 218 eTICI 2b67 (30%), 103 eTICI 2b50 (14%), 100 eTICI 2a (14%), 19 eTICI 1 (3%), and 60 eTICI 0 (8%). Modified Rankin Scale shift analyses from baseline to 90 days showed that increasing TICI grades were linked with better outcomes, with significant distinctions between TICI 0/1 versus 2a (p=0.028), 2a versus 2b50 (p=0.017), and 2b50 versus 2b67 (p=0.014). CONCLUSIONS:The benefit of endovascular therapy in HERMES was strongly associated with increasing degrees of reperfusion defined by eTICI. The eTICI metric identified meaningful distinctions in clinical outcomes and may be used in future studies and routine practice.
PMID: 30194109
ISSN: 1759-8486
CID: 5121952
Penumbral imaging and functional outcome in patients with anterior circulation ischaemic stroke treated with endovascular thrombectomy versus medical therapy: a meta-analysis of individual patient-level data
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Labach, Catherine; Lautrette, Géraldine; Denier, Christian; Saliou, Guillaume; Chassin, Olivier; Dussaule, Claire; Melki, Elsa; Ozanne, Augustin; Puccinelli, Francesco; Sachet, Marina; Sarov, Mariana; Bonneville, Jean-François; Moulin, Thierry; Biondi, Alessandra; De Bustos Medeiros, Elisabeth; Vuillier, Fabrice; Courtheoux, Patrick; Viader, Fausto; Apoil-Brissard, Marion; Bataille, Mathieu; Bonnet, Anne-Laure; Cogez, Julien; Kazemi, Apolline; Touze, Emmanuel; Leclerc, Xavier; Leys, Didier; Aggour, Mohamed; Aguettaz, Pierre; Bodenant, Marie; Cordonnier, Charlotte; Deplanque, Dominique; Girot, Marie; Henon, Hilde; Kalsoum, Erwah; Lucas, Christian; Pruvo, Jean-Pierre; Zuniga, Paolo; Bonafé, Alain; Arquizan, Caroline; Costalat, Vincent; Machi, Paolo; Mourand, Isabelle; Riquelme, Carlos; Bounolleau, Pierre; Arteaga, Charles; Faivre, Anthony; Bintner, Marc; Tournebize, Patrice; Charlin, Cyril; Darcel, Françoise; Gauthier-Lasalarie, Pascale; Jeremenko, Marcia; Mouton, Servane; Zerlauth, Jean-Baptiste; Lamy, Chantal; Hervé, Deramond; Hassan, Hosseini; Gaston, André; Barral, Francis-Guy; Garnier, Pierre; Beaujeux, Rémy; Wolff, Valérie; Herbreteau, Denis; Debiais, Séverine; Murray, Alicia; Ford, Gary; Muir, Keith W; White, Philip; Clifton, Andy; Freeman, Janet; Ford, Ian; Markus, Hugh; Wardlaw, Joanna; Lees, Kennedy R; Molyneux, Andy; Robinson, Thompson; Lewis, Steff; Norrie, John; Robertson, Fergus; Perry, Richard; Dixit, Anand; Cloud, Geoffrey; Clifton, Andrew; Madigan, Jeremy; Roffe, Christine; Nayak, Sanjeev; Lobotesis, Kyriakos; Smith, Craig; Herwadkar, Amit; Kandasamy, Naga; Goddard, Tony; Bamford, John; Subramanian, Ganesh; Lenthall, Rob; Littleton, Edward; Lamin, Sal; Storey, Kelley; Ghatala, Rita; Banaras, Azra; Aeron-Thomas, John; Hazel, Bath; Maguire, Holly; Veraque, Emelda; Harrison, Louise; Keshvara, Rekha; Cunningham, James
BACKGROUND:CT perfusion (CTP) and diffusion or perfusion MRI might assist patient selection for endovascular thrombectomy. We aimed to establish whether imaging assessments of irreversibly injured ischaemic core and potentially salvageable penumbra volumes were associated with functional outcome and whether they interacted with the treatment effect of endovascular thrombectomy on functional outcome. METHODS:/s. Critically hypoperfused tissue was estimated as the volume of tissue with a CTP time to maximum longer than 6 s. Mismatch volume (ie, the estimated penumbral volume) was calculated as critically hypoperfused tissue volume minus ischaemic core volume. The association of ischaemic core and penumbral volumes with 90-day mRS score was analysed with multivariable logistic regression (functional independence, defined as mRS score 0-2) and ordinal logistic regression (functional improvement by at least one mRS category) in all patients and in a subset of those with more than 50% endovascular reperfusion, adjusted for baseline prognostic variables. The meta-analysis was prospectively designed by the HERMES executive committee, but not registered. FINDINGS:=0·94). Mismatch volume, examined only in the CTP group because of the small numbers of patients who had perfusion MRI, was not associated with either functional independence or functional improvement. In patients with CTP with more than 50% endovascular reperfusion (n=186), age, ischaemic core volume, and imaging-to-reperfusion time were independently associated with functional improvement. Risk of bias between studies was generally low. INTERPRETATION:Estimated ischaemic core volume was independently associated with functional independence and functional improvement but did not modify the treatment benefit of endovascular thrombectomy over standard medical therapy for improved functional outcome. Combining ischaemic core volume with age and expected imaging-to-reperfusion time will improve assessment of prognosis and might inform endovascular thrombectomy treatment decisions. FUNDING:Medtronic.
PMID: 30413385
ISSN: 1474-4465
CID: 5121972
A dual-tuned O-17/H-1 head array for direct brain oximetry at 3 Tesla
Lakshmanan, Karthik; Dehkharghani, Seena; Madelin, Guillaume; Brown, Ryan
ISI:000489237500001
ISSN: 0740-3194
CID: 4155922
Automated CT Perfusion Prediction of Large Vessel Acute Stroke from Intracranial Atherosclerotic Disease
Haussen, Diogo C; Bouslama, Mehdi; Dehkharghani, Seena; Grossberg, Jonathan A; Bianchi, Nicolas; Bowen, Meredith; Frankel, Michael R; Nogueira, Raul G
Background and Purpose/UNASSIGNED:We have observed that large vessel occlusion acute strokes (LVOS) due to intracranial atherosclerotic disease (ICAD) present with more benign CT perfusion (CTP) profiles, which we presume to potentially represent enhanced collateralization compared to embolic LVOS. We aim to determine if CTP profiles can predict ICAD in LVOS. Methods/UNASSIGNED:Retrospective review of a prospectively collected interventional stroke database from September 2010 to March 2015. Patients with intracranial ICA/MCA-M1/M2 occlusions and CTP were dichotomized into ICAD versus non-ICAD etiologies. Ischemic core (relative cerebral blood flow < 30%) and hypoperfusion volumes were estimated by automated CTP. Results/UNASSIGNED:= 0.01) were independently associated with ICAD. Conclusion/UNASSIGNED:An automated CTP Tmax > 4 s/Tmax > 6 s ratio ≥2 profile was found independently associated with underlying ICAD LVOS.
PMID: 30410510
ISSN: 1664-9737
CID: 3456282
Imaging features and safety and efficacy of endovascular stroke treatment: a meta-analysis of individual patient-level data
Román, Luis San; Menon, Bijoy K; Blasco, Jordi; Hernández-Pérez, María; Dávalos, Antoni; Majoie, Charles B L M; Campbell, Bruce C V; Guillemin, Francis; Lingsma, Hester; Anxionnat, René; Epstein, Jonathan; Saver, Jeffrey L; Marquering, Henk; Wong, John H; Lopes, Demetrius; Reimann, Gernot; Desal, Hubert; Dippel, Diederik W J; Coutts, Shelagh; du Mesnil de Rochemont, Richard; Yavagal, Dileep; Ferre, Jean Christophe; Roos, Yvo B W E M; Liebeskind, David S; Lenthall, Robert; Molina, Carlos; Al Ajlan, Fahad S; Reddy, Vivek; Dowlatshahi, Dar; Sourour, Nader-Antoine; Oppenheim, Catherine; Mitha, Alim P; Davis, Stephen M; Weimar, Christian; van Oostenbrugge, Robert J; Cobo, Erik; Kleinig, Timothy J; Donnan, Geoffrey A; van der Lugt, Aad; Demchuk, Andrew M; Berkhemer, Olvert A; Boers, Anna M M; Ford, Gary A; Muir, Keith W; Brown, B Scott; Jovin, Tudor; van Zwam, Wim H; Mitchell, Peter J; Hill, Michael D; White, Phil; Bracard, Serge; Goyal, Mayank; Berkhemer, Olvert A; Fransen, Puck Ss; Beumer, Debbie; van den Berg, Lucie A; Lingsma, Hester F; Yoo, Albert J; Schonewille, Wouter J; Vos, Jan Albert; Nederkoorn, Paul J; Wermer, Marieke Jh; van Walderveen, Marianne Aa; Staals, Julie; Hofmeijer, Jeannette; van Oostayen, Jacques A; Lycklama À Nijeholt, Geert J; Boiten, Jelis; Brouwer, Patrick A; Emmer, Bart J; de Bruijn, Sebastiaan F; van Dijk, Lukas C; Kappelle, Jaap; Lo, Rob H; van Dijk, Ewoud J; de Vries, Joost; de Kort, Paul L M; van Rooij, Willem Jan J; van den Berg, Jan S P; van Hasselt, Boudewijn A A M; Aerden, Leo A M; Dallinga, René J; Visser, Marieke C; Bot, Joseph C J; Vroomen, Patrick C; Eshghi, Omid; Schreuder, Tobien H C M L; Heijboer, Roel J J; Keizer, Koos; Tielbeek, Alexander V; den Hertog, Heleen M; Gerrits, Dick G; van den Berg-Vos, Renske M; Karas, Giorgos B; Steyerberg, Ewout W; Flach, Zwenneke; Marquering, Henk A; Sprengers, Marieke E S; Jenniskens, Sjoerd F M; Beenen, Ludo F M; van den Berg, René; Koudstaal, Peter J; van Zwam, Wim H; Roos, Yvo B W E M; van der Lugt, Aad; 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Zerlauth, Jean-Baptiste; Lamy, Chantal; Hervé, Deramond; Hassan, Hosseini; Gaston, André; Barral, Francis-Guy; Garnier, Pierre; Beaujeux, Rémy; Wolff, Valérie; Herbreteau, Denis; Debiais, Séverine; Murray, Alicia; Ford, Gary; Muir, Keith W; White, Philip; Brown, Martin M; Clifton, Andy; Freeman, Janet; Ford, Ian; Markus, Hugh; Wardlaw, Joanna; Lees, Kennedy R; Molyneux, Andy; Robinson, Thompson; Lewis, Steff; Norrie, John; Robertson, Fergus; Perry, Richard; Dixit, Anand; Cloud, Geoffrey; Clifton, Andrew; Madigan, Jeremy; Roffe, Christine; Nayak, Sanjeev; Lobotesis, Kyriakos; Smith, Craig; Herwadkar, Amit; Kandasamy, Naga; Goddard, Tony; Bamford, John; Subramanian, Ganesh; Lenthall, Rob; Littleton, Edward; Lamin, Sal; Storey, Kelley; Ghatala, Rita; Banaras, Azra; Aeron-Thomas, John; Hazel, Bath; Maguire, Holly; Veraque, Emelda; Harrison, Louise; Keshvara, Rekha; Cunningham, James
BACKGROUND:Evidence regarding whether imaging can be used effectively to select patients for endovascular thrombectomy (EVT) is scarce. We aimed to investigate the association between baseline imaging features and safety and efficacy of EVT in acute ischaemic stroke caused by anterior large-vessel occlusion. METHODS:In this meta-analysis of individual patient-level data, the HERMES collaboration identified in PubMed seven randomised trials in endovascular stroke that compared EVT with standard medical therapy, published between Jan 1, 2010, and Oct 31, 2017. Only trials that required vessel imaging to identify patients with proximal anterior circulation ischaemic stroke and that used predominantly stent retrievers or second-generation neurothrombectomy devices in the EVT group were included. Risk of bias was assessed with the Cochrane handbook methodology. Central investigators, masked to clinical information other than stroke side, categorised baseline imaging features of ischaemic change with the Alberta Stroke Program Early CT Score (ASPECTS) or according to involvement of more than 33% of middle cerebral artery territory, and by thrombus volume, hyperdensity, and collateral status. The primary endpoint was neurological functional disability scored on the modified Rankin Scale (mRS) score at 90 days after randomisation. Safety outcomes included symptomatic intracranial haemorrhage, parenchymal haematoma type 2 within 5 days of randomisation, and mortality within 90 days. For the primary analysis, we used mixed-methods ordinal logistic regression adjusted for age, sex, National Institutes of Health Stroke Scale score at admission, intravenous alteplase, and time from onset to randomisation, and we used interaction terms to test whether imaging categorisation at baseline modifies the association between treatment and outcome. This meta-analysis was prospectively designed by the HERMES executive committee but has not been registered. FINDINGS:=0·012). INTERPRETATION:EVT achieves better outcomes at 90 days than standard medical therapy across a broad range of baseline imaging categories, including infarcts affecting more than 33% of middle cerebral artery territory or ASPECTS less than 6, although in these patients the risk of symptomatic intracranial haemorrhage was higher in the EVT group than the control group. This analysis provides preliminary evidence for potential use of EVT in patients with large infarcts at baseline. FUNDING:Medtronic.
PMID: 30264728
ISSN: 1474-4465
CID: 5121962
