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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
Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data
Campbell, Bruce C V; van Zwam, Wim H; Goyal, Mayank; Menon, Bijoy K; Dippel, Diederik W J; Demchuk, Andrew M; Bracard, Serge; White, Philip; Dávalos, Antoni; Majoie, Charles B L M; van der Lugt, Aad; Ford, Gary A; de la Ossa, Natalia Pérez; Kelly, Michael; Bourcier, Romain; Donnan, Geoffrey A; Roos, Yvo B W E M; Bang, Oh Young; Nogueira, Raul G; Devlin, Thomas G; van den Berg, Lucie A; Clarençon, Frédéric; Burns, Paul; Carpenter, Jeffrey; Berkhemer, Olvert A; Yavagal, Dileep R; Pereira, Vitor Mendes; Ducrocq, Xavier; Dixit, Anand; Quesada, Helena; Epstein, Jonathan; Davis, Stephen M; Jansen, Olav; Rubiera, Marta; Urra, Xabier; Micard, Emilien; Lingsma, Hester F; Naggara, Olivier; Brown, Scott; Guillemin, Francis; Muir, Keith W; van Oostenbrugge, Robert J; Saver, Jeffrey L; Jovin, Tudor G; Hill, Michael D; Mitchell, Peter J; 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; van Oostenbrugge, Robert J; Majoie, Charles B L M; Dippel, Diederik W J; Brown, Martin M; Liebig, Thomas; Stijnen, Theo; 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Renou, Pauline; Fleury, Olivier; Pasco-Papon, Anne; Dubas, Frédéric; Caroff, Jildaz; Godard Ducceschi, Sophie; Hamon, Marie-Aurélie; Lecluse, Alderic; Marc, Guillaume; Giroud, Maurice; Ricolfi, Frédéric; Bejot, Yannick; Chavent, Adrien; Gentil, Arnaud; Kazemi, Apolline; Osseby, Guy-Victor; Voguet, Charlotte; Mahagne, Marie-Hélène; Sedat, Jacques; Chau, Yves; Suissa, Laurent; Lachaud, Sylvain; Houdart, Emmanuel; Stapf, Christian; Buffon Porcher, Frédérique; Chabriat, Hugues; Guedin, Pierre; Herve, Dominique; Jouvent, Eric; Mawet, Jérôme; Saint-Maurice, Jean-Pierre; Schneble, Hans-Martin; Turjman, Francis; Nighoghossian, Norbert; Berhoune, Nadia-Nawel; Bouhour, Françoise; Cho, Tae-Hee; Derex, Laurent; Felix, Sandra; Gervais-Bernard, Hélène; Gory, Benjamin; Manera, Luis; Mechtouff, Laura; Ritzenthaler, Thomas; Riva, Roberto; Salaris Silvio, Fabrizio; Tilikete, Caroline; Blanc, Raphael; Obadia, Michaël; Bartolini, Mario Bruno; Gueguen, Antoine; Piotin, Michel; Pistocchi, Silvia; Redjem, Hocine; Drouineau, Jacques; Neau, Jean-Philippe; Godeneche, Gaelle; Lamy, Matthias; Marsac, Emilia; Velasco, Stephane; Clavelou, Pierre; Chabert, Emmanuel; Bourgois, Nathalie; Cornut-Chauvinc, Catherine; Ferrier, Anna; Gabrillargues, Jean; Jean, Betty; Marques, Anna-Raquel; Vitello, Nicolas; Detante, Olivier; Barbieux, Marianne; Boubagra, Kamel; Favre Wiki, Isabelle; Garambois, Katia; Tahon, Florence; Ashok, Vasdev; Voguet, Charlotte; Coskun, Oguzhan; Guedin, Pierre; Rodesch, Georges; Lapergue, Bertrand; Bourdain, Frédéric; Evrard, Serge; Graveleau, Philippe; Decroix, Jean Pierre; Wang, Adrien; Sellal, François; Ahle, Guido; Carelli, Gabriela; Dugay, Marie-Hélène; Gaultier, Claude; Lebedinsky, Ariel Pablo; Lita, Lavinia; Musacchio, Raul Mariano; Renglewicz-Destuynder, Catherine; Tournade, Alain; Vuillemet, Françis; Montoro, Francisco Macian; Mounayer, Charbel; Faugeras, Frederic; Gimenez, Laetitia; 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; 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:General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care. METHODS:For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered. FINDINGS:Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95% CI 1·09-2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95% CI 1·75-3·10, p<0·0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1·53, 95% CI 1·14-2·04, p=0·0044). The risk of bias and variability between studies was assessed to be low. INTERPRETATION:Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons. FUNDING:Medtronic.
PMID: 29263006
ISSN: 1474-4465
CID: 5121942
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; van Oostenbrugge, Robert J; Majoie, Charles B L M; Dippel, Diederik W J; Brown, Martin M; Liebig, Thomas; Stijnen, Theo; Andersson, Tommy; Mattle, Heinrich; Wahlgren, Nils; van der Heijden, Esther; Ghannouti, Naziha; Fleitour, Nadine; Hooijenga, Imke; Puppels, Corina; Pellikaan, Wilma; Geerling, Annet; Lindl-Velema, Annemieke; van Vemde, Gina; de Ridder, Ans; Greebe, Paut; de Bont-Stikkelbroeck, José; de Meris, Joke; Janssen, Kirsten; Struijk, Willy; Licher, Silvan; Boodt, Nikki; Ros, Adriaan; Venema, Esmee; Slokkers, Ilse; Ganpat, Raymie-Jayce; Mulder, Maxim; Saiedie, Nawid; Heshmatollah, Alis; Schipperen, Stefanie; Vinken, Stefan; van Boxtel, Tiemen; Koets, Jeroen; Boers, Merel; Santos, Emilie; Borst, Jordi; Jansen, Ivo; Kappelhof, Manon; Lucas, Marit; Geuskens, Ralph; Barros, Renan Sales; Dobbe, Roeland; Csizmadia, Marloes; 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; 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Killer-Oberpfalzer, M; Mutzenbach, J; Weymayr, F; Broussalis, E; Stadler, K; Jedlitschka, A; Malek, A; Mueller-Kronast, N; Beck, P; Martin, C; Summers, D; Day, J; Bettinger, I; Holloway, W; Olds, K; Arkin, S; Akhtar, N; Boutwell, C; Crandall, S; Schwartzman, M; Weinstein, C; Brion, B; Prothmann, S; Kleine, J; Kreiser, K; Boeckh-Behrens, T; Poppert, H; Wunderlich, S; Koch, M L; Biberacher, V; Huberle, A; Gora-Stahlberg, G; Knier, B; Meindl, T; Utpadel-Fischler, D; Zech, M; Kowarik, M; Seifert, C; Schwaiger, B; Puri, A; Hou, S; Wakhloo, A; Moonis, M; Henniger, N; Goddeau, R; Massari, F; Minaeian, A; Lozano, J D; Ramzan, M; Stout, C; Patel, A; Tunguturi, A; Onteddu, S; Carandang, R; Howk, M; Ribó, M; Sanjuan, E; Rubiera, M; Pagola, J; Flores, A; Muchada, M; Meler, P; Huerga, E; Gelabert, S; Coscojuela, P; Tomasello, A; Rodriguez, D; Santamarina, E; Maisterra, O; Boned, S; Seró, L; Rovira, A; Molina, C A; Millán, M; Muñoz, L; Pérez de la Ossa, N; Gomis, M; Dorado, L; López-Cancio, E; Palomeras, E; Munuera, J; García Bermejo, P; Remollo, S; Castaño, C; García-Sort, R; Cuadras, P; Puyalto, P; Hernández-Pérez, M; Jiménez, M; Martínez-Piñeiro, A; Lucente, G; Dávalos, A; Chamorro, A; Urra, X; Obach, V; Cervera, A; Amaro, S; Llull, L; Codas, J; Balasa, M; Navarro, J; Ariño, H; Aceituno, A; Rudilosso, S; Renu, A; Macho, J M; San Roman, L; Blasco, J; López, A; MacÃas, N; Cardona, P; Quesada, H; Rubio, F; Cano, L; Lara, B; de Miquel, M A; Aja, L; Serena, J; Cobo, E; Albers, Gregory W; Lees, Kennedy R; Arenillas, J; Roberts, R; Minhas, P; Al-Ajlan, F; Salluzzi, M; Zimmel, L; Patel, S; Eesa, M; MartÃ-Fà bregas, J; Jankowitz, B; Serena, J; Salvat-Plana, M; López-Cancio, E; Bracard, S; Ducrocq, Xavier; Anxionnat, René; Baillot, Pierre-Alexandre; Barbier, Charlotte; Derelle, Anne-Laure; Lacour, Jean-Christophe; Richard, Sébastien; Samson, Yves; Sourour, Nader; Baronnet-Chauvet, Flore; Clarencon, Frédéric; Crozier, Sophie; Deltour, Sandrine; Di Maria, Federico; Le Bouc, Raphael; Leger, Anne; Mutlu, Gurkan; Rosso, Charlotte; Szatmary, Zoltan; Yger, Marion; Zavanone, Chiara; Bakchine, Serge; Pierot, Laurent; Caucheteux, Nathalie; Estrade, Laurent; Kadziolka, Krzysztof; Leautaud, Alexandre; Renkes, Céline; Serre, Isabelle; Desal, Hubert; Guillon, Benoît; Boutoleau-Bretonniere, Claire; Daumas-Duport, Benjamin; De Gaalon, Solène; Derkinderen, Pascal; Evain, Sarah; Herisson, Fanny; Laplaud, David-Axel; Lebouvier, Thibaud; Lintia-Gaultier, Alina; Pouclet-Courtemanche, Hélène; Rouaud, Tiphaine; Rouaud Jaffrenou, Violaine; Schunck, Aurélia; Sevin-Allouet, Mathieu; Toulgoat, Frederique; Wiertlewski, Sandrine; Gauvrit, Jean-Yves; Ronziere, Thomas; Cahagne, Vincent; Ferre, Jean-Christophe; Pinel, Jean-François; Raoult, Hélène; Mas, Jean-Louis; Meder, Jean-François; Al Najjar-Carpentier, Amen-Adam; Birchenall, Julia; Bodiguel, Eric; Calvet, David; Domigo, Valérie; Godon-Hardy, Sylvie; Guiraud, Vincent; Lamy, Catherine; Majhadi, Loubna; Morin, Ludovic; Naggara, Olivier; Trystram, Denis; Turc, Guillaume; Berge, Jérôme; Sibon, Igor; Menegon, Patrice; Barreau, Xavier; Rouanet, François; Debruxelles, Sabrina; Kazadi, Annabelle; Renou, Pauline; Fleury, Olivier; Pasco-Papon, Anne; Dubas, Frédéric; Caroff, Jildaz; Godard Ducceschi, Sophie; Hamon, Marie-Aurélie; Lecluse, Alderic; Marc, Guillaume; Giroud, Maurice; Ricolfi, Frédéric; Bejot, Yannick; Chavent, Adrien; Gentil, Arnaud; Kazemi, Apolline; Osseby, Guy-Victor; Voguet, Charlotte; Mahagne, Marie-Hélène; Sedat, Jacques; Chau, Yves; Suissa, Laurent; Lachaud, Sylvain; Houdart, Emmanuel; Stapf, Christian; Buffon Porcher, Frédérique; Chabriat, Hugues; Guedin, Pierre; Herve, Dominique; Jouvent, Eric; Mawet, Jérôme; Saint-Maurice, Jean-Pierre; Schneble, Hans-Martin; Turjman, Francis; Nighoghossian, Norbert; Berhoune, Nadia-Nawel; Bouhour, Françoise; Cho, Tae-Hee; Derex, Laurent; Felix, Sandra; Gervais-Bernard, Hélène; Gory, Benjamin; Manera, Luis; Mechtouff, Laura; Ritzenthaler, Thomas; Riva, Roberto; Salaris Silvio, Fabrizio; Tilikete, Caroline; Blanc, Raphael; Obadia, Michaël; Bartolini, Mario Bruno; Gueguen, Antoine; Piotin, Michel; Pistocchi, Silvia; Redjem, Hocine; Drouineau, Jacques; Neau, Jean-Philippe; Godeneche, Gaelle; Lamy, Matthias; Marsac, Emilia; Velasco, Stephane; Clavelou, Pierre; Chabert, Emmanuel; Bourgois, Nathalie; Cornut-Chauvinc, Catherine; Ferrier, Anna; Gabrillargues, Jean; Jean, Betty; Marques, Anna-Raquel; Vitello, Nicolas; Detante, Olivier; Barbieux, Marianne; Boubagra, Kamel; Favre Wiki, Isabelle; Garambois, Katia; Tahon, Florence; Ashok, Vasdev; Voguet, Charlotte; Coskun, Oguzhan; Guedin, Pierre; Rodesch, Georges; Lapergue, Bertrand; Bourdain, Frédéric; Evrard, Serge; Graveleau, Philippe; Decroix, Jean Pierre; Wang, Adrien; Sellal, François; Ahle, Guido; Carelli, Gabriela; Dugay, Marie-Hélène; Gaultier, Claude; Lebedinsky, Ariel Pablo; Lita, Lavinia; Musacchio, Raul Mariano; Renglewicz-Destuynder, Catherine; Tournade, Alain; Vuillemet, Françis; Montoro, Francisco Macian; Mounayer, Charbel; Faugeras, Frederic; Gimenez, Laetitia; 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; 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
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
Is there added value in obtaining cervical spine MRI in the assessment of nontraumatic angiographically negative subarachnoid hemorrhage? A retrospective study and meta-analysis of the literature
Sadigh, Gelareh; Holder, Chad A; Switchenko, Jeffrey M; Dehkharghani, Seena; Allen, Jason W
OBJECTIVE Diagnostic algorithms for nontraumatic angiographically negative subarachnoid hemorrhage (AN-SAH) vary, and the optimal method remains subject to debate. This study assessed the added value of cervical spine MRI in identifying a cause for nontraumatic AN-SAH. METHODS Consecutive patients 18 years of age or older who presented with nontraumatic SAH between February 1, 2009, and October 31, 2014, with negative cerebrovascular catheter angiography and subsequent cervical MRI were studied. Patients with intraparenchymal, subdural, or epidural hemorrhage; recent trauma; or known vascular malformations were excluded. All cervical MR images were reviewed by two blinded neuroradiologists. The diagnostic yield of cervical MRI was calculated. A literature review was conducted to identify studies reporting the diagnostic yield of cervical MRI in patients with AN-SAH. The weighted pooled estimate of diagnostic yield of cervical MRI was calculated. RESULTS For all 240 patients (mean age 53 years, 48% male), catheter angiography was performed within 4 days after admission (median 12 hours, interquartile range [IQR] 10 hours). Cervical MRI was performed within 19 days of admission (median 24 hours, IQR 10 hours). In a single patient, cervical MRI identified a source for SAH (cervical vascular malformation). Meta-analysis of 7 studies comprising 538 patients with AN-SAH produced a pooled estimate of 1.3% (95% confidence interval 0.5%-2.5%) for diagnostic yield of cervical MRI. No statistically significant between-study heterogeneity or publication bias was identified. CONCLUSIONS Cervical MRI following AN-SAH, in the absence of findings to suggest spinal etiology, has a very low diagnostic yield and is not routinely necessary.
PMCID:5899067
PMID: 29027857
ISSN: 1933-0693
CID: 2732092
Selection Paradigms for Large Vessel Occlusion Acute Ischemic Stroke Endovascular Therapy
Bouslama, Mehdi; Bowen, Meredith T; Haussen, Diogo C; Dehkharghani, Seena; Grossberg, Jonathan A; Rebello, LetÃcia C; Rangaraju, Srikant; Frankel, Michael R; Nogueira, Raul G
BACKGROUND:Optimal patient selection methods for thrombectomy in large vessel occlusion stroke (LVOS) are yet to be established. We sought to evaluate the ability of different selection paradigms to predict favorable outcomes. METHODS:Review of a prospectively collected database of endovascular patients with anterior circulation LVOS, adequate CT perfusion (CTP), National Institutes of Health Stroke Scale (NIHSS) ≥10 from September 2010 to March 2016. Patients were retrospectively assessed for thrombectomy eligibility by 4 mismatch criteria: Perfusion-Imaging Mismatch (PIM): between CTP-derived perfusion defect and ischemic core volumes; Clinical-Core Mismatch (CCM): between age-adjusted NIHSS and CTP core; Clinical-ASPECTS Mismatch (CAM-1): between age-adjusted NIHSS and ASPECTS; Clinical-ASPECTS Mismatch (CAM-2): between NIHSS and ASPECTS. Outcome measures were inclusion rates for each paradigm and their ability to predict good outcomes (90-day modified Rankin Scale 0-2). RESULTS:Three hundred eighty-four patients qualified. CAM-2 and CCM had higher inclusion (89.3 and 82.3%) vs. CAM-1 (67.7%) and PIM (63.3%). Proportions of selected patients were statistically different except for PIM and CAM-1 (p = 0.19), with PIM having the highest disagreement. There were no differences in good outcome rates between PIM(+)/PIM(-) (52.2 vs. 48.5%; p = 0.51) and CAM-2(+)/CAM-2(-) (52.4 vs. 38.5%; p = 0.12). CCM(+) and CAM-1(+) had higher rates compared to nonselected counterparts (53.4 vs. 38.7%, p = 0.03; 56.6 vs. 38.6%; p = 0.002). The abilities of PIM, CCM, CAM-1, and CAM-2 to predict outcomes were similar according to the c-statistic, Akaike and Bayesian information criterion. CONCLUSIONS:For patients with NIHSS ≥10, PIM appears to disqualify more patients without improving outcomes. CCM may improve selection, combining a high inclusion rate with optimal outcome discrimination across (+) and (-) patients. Future studies are warranted.
PMID: 28877524
ISSN: 1421-9786
CID: 3070962
The Brain Thermal Response as a Potential Neuroimaging Biomarker of Cerebrovascular Impairment
Fleischer, C C; Wu, J; Qiu, D; Park, S-E; Nahab, F; Dehkharghani, S
BACKGROUND AND PURPOSE: Brain temperature is critical for homeostasis, relating intimately to cerebral perfusion and metabolism. Cerebral thermometry is historically challenged by the cost and invasiveness of clinical and laboratory methodologies. We propose the use of noninvasive MR thermometry in patients with cerebrovascular disease, hypothesizing the presence of a measurable brain thermal response reflecting the tissue hemodynamic state. MATERIALS AND METHODS: Contemporaneous imaging and MR thermometry were performed in 10 patients (32-68 years of age) undergoing acetazolamide challenge for chronic, anterior circulation steno-occlusive disease. Cerebrovascular reactivity was calculated with blood oxygen level-dependent imaging and arterial spin-labeling methods. Brain temperature was calculated pre- and post-acetazolamide using previously established chemical shift thermometry. Mixed-effects models of the voxelwise relationships between the brain thermal response and cerebrovascular reactivity were computed, and the significance of model coefficients was determined with an F test (P < .05). RESULTS: We observed significant, voxelwise quadratic relationships between cerebrovascular reactivity from blood oxygen level-dependent imaging and the brain thermal response (x coefficient = 0.052, P < .001; x2coefficient = 0.0068, P < .001) and baseline brain temperatures (x coefficient = 0.59, P = .008; x2 coefficient = -0.13, P < .001). A significant linear relationship was observed for the brain thermal response with cerebrovascular reactivity from arterial spin-labeling (P = .001). CONCLUSIONS: The findings support the presence of a brain thermal response exhibiting complex but significant interactions with tissue hemodynamics, which we posit to reflect a relative balance of heat-producing versus heat-dissipating tissue states. The brain thermal response is a potential noninvasive biomarker for cerebrovascular impairment.
PMCID:5690840
PMID: 28935624
ISSN: 1936-959x
CID: 2768962
Imaging Approaches to Stroke and Neurovascular Disease
Dehkharghani, Seena; Andre, Jalal
PMID: 28525926
ISSN: 1524-4040
CID: 2604842
Computed Tomographic Perfusion Selection and Clinical Outcomes After Endovascular Therapy in Large Vessel Occlusion Stroke
Bouslama, Mehdi; Haussen, Diogo C; Grossberg, Jonathan A; Dehkharghani, Seena; Bowen, Meredith T; Rebello, Leticia C; Bianchi, Nicolas A; Frankel, Michael R; Nogueira, Raul G
BACKGROUND AND PURPOSE: Different imaging paradigms have been used to select patients for endovascular therapy in stroke. We sought to determine whether computed tomographic perfusion (CTP) selection improves endovascular therapy outcomes compared with noncontrast computed tomography alone. METHODS: Review of a prospectively collected registry of anterior circulation stroke patients undergoing stent-retriever thrombectomy at a tertiary care center between September 2010 and March 2016. Patients undergoing CTP were compared with those with noncontrast computed tomography alone. The primary outcome was the shift in the 90-day modified Rankin scale (mRS). RESULTS: A total of 602 patients were included. CTP-selected patients (n=365, 61%) were younger (P=0.02) and had fewer comorbidities. CTP selection (n=365, 61%) was associated with a favorable 90-day mRS shift (adjusted odds ratio [aOR]=1.49; 95% confidence interval [CI], 1.06-2.09; P=0.02), higher rates of good outcomes (90-day mRS score 0-2: 52.9% versus 40.4%; P=0.005), modified Thrombolysis in Cerebral Infarction-3 reperfusion (54.8% versus 40.1%; P<0.001), smaller final infarct volumes (24.7 mL [9.8-63.1 mL] versus 34.6 mL [13.1-88 mL]; P=0.017), and lower mortality (16.6% versus 26.8%; P=0.005). When matched on age, National Institutes of Health Stroke Scale (NIHSS) score, and glucose (n=424), CTP remained associated with a favorable 90-day mRS shift (P=0.016), lower mortality (P=0.02), and higher rates of reperfusion (P<0.001). CTP better predicted functional outcomes in patients presenting after 6 hours (as assessed by comparison of logistic regression models: Akaike information criterion: 199.35 versus 287.49 and Bayesian information criterion: 196.71 versus 283.27) and those with an Alberta Stroke Program Early Computed Tomography Score
PMID: 28389614
ISSN: 1524-4628
CID: 2560372
Imaging Approaches to Stroke and Neurovascular Disease
Dehkharghani, Seena; Andre, Jalal
Imaging is paramount to the diagnosis and management of ischemic stroke, offering a battery of structural and functional probes of cerebrovascular physiology. The technical underpinnings of stroke imaging continue to evolve, bringing the neuroscience community increasingly closer to high-resolution, tissue-level biomarkers of brain perfusion, metabolism, and viability. The rapid expansion of neuroimaging in this domain has met with controversies, and in many respects, a lack of generalizable conclusions regarding optimized use in cerebrovascular disease. This review aims to provide the reader with the depth and scope of both established and emerging techniques, and an overview of prevailing viewpoints regarding neuroimaging in acute ischemic stroke.
PMID: 28327964
ISSN: 1524-4040
CID: 2560362
