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Ren H, Song H, Liu J, Cui S, Gong M, Li Y. Deep Learning Using One-stop-shop CT Scan to Predict Hemorrhagic Transformation in Stroke Patients Undergoing Reperfusion Therapy: A Multicenter Study. Acad Radiol 2025; 32:2141-2149. [PMID: 39462736 DOI: 10.1016/j.acra.2024.09.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Revised: 09/19/2024] [Accepted: 09/24/2024] [Indexed: 10/29/2024]
Abstract
RATIONALE AND OBJECTIVES Hemorrhagic transformation (HT) is one of the most serious complications in patients with acute ischemic stroke (AIS) following reperfusion therapy. The purpose of this study is to develop and validate deep learning (DL) models utilizing multiphase computed tomography angiography (CTA) and computed tomography perfusion (CTP) images for the fully automated prediction of HT. MATERIALS AND METHODS In this multicenter retrospective study, a total of 229 AIS patients who underwent reperfusion therapy from June 2019 to May 2022 were reviewed. Data set 1, comprising 183 patients from two hospitals, was utilized for training, tuning, and internal validation. Data set 2, consisting of 46 patients from a third hospital, was employed for external testing. DL models were trained to extract valuable information from multiphase CTA and CTP images. The DenseNet architecture was used to construct the DL models. We developed single-phase, single-parameter models, and combined models to predict HT. The models were evaluated using receiver operating characteristic curves. RESULTS Sixty-nine (30.1%) of 229 patients (mean age, 66.9 years ± 10.3; male, 144 [66.9%]) developed HT. Among the single-phase models, the arteriovenous phase model demonstrated the highest performance. For single-parameter models, the time-to-peak model was superior. When considering combined models, the CTA-CTP model provided the highest predictive accuracy. CONCLUSIONS DL models for predicting HT based on multiphase CTA and CTP images can be established and performed well, providing a reliable tool for clinicians to make treatment decisions.
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Affiliation(s)
- Huanhuan Ren
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Department of Radiology, Chongqing University Cancer Hospital, Chongqing 400030, China
| | - Haojie Song
- Department of Biomedical Engineering, School of Medicine, Shenzhen University, Shenzhen 518060, Guangdong, China; College of Computer and Information Science, Chongqing Normal University, Chongqing 401331, China
| | - Jiayang Liu
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Shaoguo Cui
- Department of Biomedical Engineering, School of Medicine, Shenzhen University, Shenzhen 518060, Guangdong, China
| | - Meilin Gong
- Department of Radiology, Chongqing General Hospital, Chongqing 400013, China (M.G.)
| | - Yongmei Li
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
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Yedavalli V, Salim HA, Balar A, Lakhani DA, Mei J, Lu H, Luna L, Deng F, Vagal V, Hyson NZ, Fiehler J, Stracke P, Broocks G, Heitkamp C, Albers GW, Wintermark M, Faizy TD, Heit JJ. Hypoperfusion Intensity Ratio Less Than 0.4 Is Associated with Favorable Outcomes in Unsuccessfully Reperfused Acute Ischemic Stroke with Large-Vessel Occlusion. AJNR Am J Neuroradiol 2025; 46:483-488. [PMID: 39979027 PMCID: PMC11979814 DOI: 10.3174/ajnr.a8518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 08/25/2024] [Indexed: 02/22/2025]
Abstract
BACKGROUND AND PURPOSE Endovascular thrombectomy is a standard treatment for acute ischemic stroke due to large-vessel occlusions (AIS-LVO), but a large minority of patients do not achieve successful reperfusion. This study aimed to investigate the hypoperfusion intensity ratio (HIR) as a prognostic biomarker in unsuccessfully reperfused patients with AIS-LVO. MATERIALS AND METHODS A multicenter retrospective cohort study was conducted at 2 comprehensive stroke centers, involving patients with AIS-LVO who underwent endovascular thrombectomy but did not achieve successful reperfusion, defined as a modified TICI score of 0-2a. HIR, derived from CT or MR perfusion imaging, was analyzed for its association with favorable clinical outcomes (90-day mRs score of 0-2). The optimal HIR threshold predictive of favorable outcomes was identified through receiver operating curve analysis. RESULTS Of 129 patients included, 20 (15.5%) achieved favorable outcomes. HIR of <0.4 significantly predicted favorable outcomes with a sensitivity of 66% and specificity of 80%. Patients with an HIR of <0.4 demonstrated better clinical and imaging profiles, including lower admission NIHSS scores and smaller ischemic core volumes. Multivariable logistic regression confirmed HIR, along with age and the presence of hemorrhagic transformation, as independent predictors of favorable outcomes. CONCLUSIONS In unsuccessfully reperfused patients with AIS-LVO, an HIR of <0.4 is associated with favorable outcomes, emphasizing on the importance of robust collateral circulation. This finding suggests that perfusion imaging and HIR evaluation could guide clinical decision-making and prognostication in this challenging patient subset.
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Affiliation(s)
- Vivek Yedavalli
- From the Department of Radiology, Division of Neuroradiology (V.Y., H.A.S., J.M., H.L., L.L., F.D., N.Z.H.), Johns Hopkins Medical Center, Baltimore, Maryland
| | - Hamza Adel Salim
- Department of Neuroradiology (H.A.S., M.W.), The University of Texas MD Anderson Center, Houston, Texas
| | - Aneri Balar
- Department of Radiology, Division of Neuroradiology (A.B., D.A.L.), West Virginia University, Morgantown, WV, USA
| | - Dhairya A Lakhani
- Department of Radiology, Division of Neuroradiology (A.B., D.A.L.), West Virginia University, Morgantown, WV, USA
| | - Janet Mei
- From the Department of Radiology, Division of Neuroradiology (V.Y., H.A.S., J.M., H.L., L.L., F.D., N.Z.H.), Johns Hopkins Medical Center, Baltimore, Maryland
| | - Hanzhang Lu
- From the Department of Radiology, Division of Neuroradiology (V.Y., H.A.S., J.M., H.L., L.L., F.D., N.Z.H.), Johns Hopkins Medical Center, Baltimore, Maryland
| | - Licia Luna
- From the Department of Radiology, Division of Neuroradiology (V.Y., H.A.S., J.M., H.L., L.L., F.D., N.Z.H.), Johns Hopkins Medical Center, Baltimore, Maryland
| | - Francis Deng
- From the Department of Radiology, Division of Neuroradiology (V.Y., H.A.S., J.M., H.L., L.L., F.D., N.Z.H.), Johns Hopkins Medical Center, Baltimore, Maryland
| | - Vaibhav Vagal
- Renaissance School of Medicine at Stony Brook University (V.V.), Stony Brook, New York
| | - Nathan Z Hyson
- From the Department of Radiology, Division of Neuroradiology (V.Y., H.A.S., J.M., H.L., L.L., F.D., N.Z.H.), Johns Hopkins Medical Center, Baltimore, Maryland
| | - Jens Fiehler
- Department of Radiology (J.F., G.B., C.H.), Neuroendovascular Program, University Medical Center Hamburg, Hamburg, Germany
| | - Paul Stracke
- Department of Radiology (P.S., T.D.F.), Neuroendovascular Program, University Medical Center Münster, Münster, Germany
| | - Gabriel Broocks
- Department of Radiology (J.F., G.B., C.H.), Neuroendovascular Program, University Medical Center Hamburg, Hamburg, Germany
| | - Christian Heitkamp
- Department of Radiology (J.F., G.B., C.H.), Neuroendovascular Program, University Medical Center Hamburg, Hamburg, Germany
| | - Gregory W Albers
- Department of Interventional Neuroradiology (G.W.A., J.J.H.), Stanford Medical Center, Palo Alto, California
| | - Max Wintermark
- Department of Neuroradiology (H.A.S., M.W.), The University of Texas MD Anderson Center, Houston, Texas
| | - Tobias D Faizy
- Department of Radiology (P.S., T.D.F.), Neuroendovascular Program, University Medical Center Münster, Münster, Germany
| | - Jeremy J Heit
- Department of Interventional Neuroradiology (G.W.A., J.J.H.), Stanford Medical Center, Palo Alto, California
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Issaiy M, Zarei D, Kolahi S, Liebeskind DS. Machine learning and deep learning algorithms in stroke medicine: a systematic review of hemorrhagic transformation prediction models. J Neurol 2024; 272:37. [PMID: 39666168 PMCID: PMC11638292 DOI: 10.1007/s00415-024-12810-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2024] [Accepted: 10/01/2024] [Indexed: 12/13/2024]
Abstract
BACKGROUND Acute ischemic stroke (AIS) is a major cause of morbidity and mortality, with hemorrhagic transformation (HT) further worsening outcomes. Traditional scoring systems have limited predictive accuracy for HT in AIS. Recent research has explored machine learning (ML) and deep learning (DL) algorithms for stroke management. This study evaluates and compares the effectiveness of ML and DL algorithms in predicting HT post-AIS, benchmarking them against conventional models. METHODS A systematic search was conducted across PubMed, Embase, Web of Science, Scopus, and IEEE, initially yielding 1421 studies. After screening, 24 studies met the inclusion criteria. The Prediction Model Risk of Bias Assessment Tool (PROBAST) was used to assess the quality of these studies, and a qualitative synthesis was performed due to heterogeneity in the study design. RESULTS The included studies featured diverse ML and DL algorithms, with Logistic Regression (LR), Support Vector Machine (SVM), and Random Forest (RF) being the most common. Gradient boosting (GB) showed superior performance. Median Area Under the Curve (AUC) values were 0.91 for GB, 0.83 for RF, 0.77 for LR, and 0.76 for SVM. Neural networks had a median AUC of 0.81 and convolutional neural networks (CNNs) had a median AUC of 0.91. ML techniques outperformed conventional models, particularly those integrating clinical and imaging data. CONCLUSIONS ML and DL models significantly surpass traditional scoring systems in predicting HT. These advanced models enhance clinical decision-making and improve patient outcomes. Future research should address data expansion, imaging protocol standardization, and model transparency to enhance stroke outcomes further.
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Affiliation(s)
- Mahbod Issaiy
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Sciences, Tehran, Iran
| | - Diana Zarei
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Sciences, Tehran, Iran
| | - Shahriar Kolahi
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Sciences, Tehran, Iran
| | - David S Liebeskind
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA.
- Neurovascular Imaging Research Core, University of California, Los Angeles, Los Angeles, CA, USA.
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McDonough RV, Rex NB, Ospel JM, Kashani N, Rinkel LA, Sehgal A, Fladt JC, McTaggart RA, Nogueira R, Menon B, Demchuk AM, Poppe A, Hill MD, Goyal M. Association between CT Perfusion Parameters and Hemorrhagic Transformation after Endovascular Treatment in Acute Ischemic Stroke: Results from the ESCAPE-NA1 Trial. AJNR Am J Neuroradiol 2024; 45:887-892. [PMID: 38697793 PMCID: PMC11286015 DOI: 10.3174/ajnr.a8227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/24/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND AND PURPOSE Hemorrhagic transformation can occur as a complication of endovascular treatment for acute ischemic stroke. This study aimed to determine whether ischemia depth as measured by admission CTP metrics can predict the development of hemorrhagic transformation at 24 hours. MATERIALS AND METHODS Patients with baseline CTP and 24-hour follow-up imaging from the ESCAPE-NA1 trial were included. RAPID software was used to generate CTP volume maps for relative CBF, CBV, and time-to-maximum at different thresholds. Hemorrhage on 24-hour imaging was classified according to the Heidelberg system, and volumes were calculated. Univariable and multivariable regression analyses assessed the association between CTP lesion volumes and hemorrhage/hemorrhage subtypes. RESULTS Among 408 patients with baseline CTP, 142 (35%) had hemorrhagic transformation at 24-hour follow-up, with 89 (63%) classified as hemorrhagic infarction (HI1/HI2), and 53 (37%), as parenchymal hematoma (PH1/PH2). Patients with HI or PH had larger volumes of low relative CBF and CBV at each threshold compared with those without hemorrhage. After we adjustied for baseline and treatment variables, only increased relative CBF <30% lesion volume was associated with any hemorrhage (adjusted OR, 1.14; 95% CI, 1.02-1.27 per 10 mL), as well as parenchymal hematoma (adjusted OR, 1.23; 95% CI, 1.06-1.43 per 10 mL). No significant associations were observed for hemorrhagic infarction. CONCLUSIONS Larger "core" volumes of relative CBF <30% were associated with an increased risk of PH following endovascular treatment. This particular metric, in conjunction with other clinical and imaging variables, may, therefore, help estimate the risk of post-endovascular treatment hemorrhagic complications.
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Affiliation(s)
- Rosalie V McDonough
- From the Department of Radiology (R.V.M., N.B.R., J.M.O., L.A.R., A.S., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - Nathaniel B Rex
- From the Department of Radiology (R.V.M., N.B.R., J.M.O., L.A.R., A.S., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Diagnostic Imaging (N.B.R.), Brown University, Providence, Rhode Island
| | - Johanna M Ospel
- From the Department of Radiology (R.V.M., N.B.R., J.M.O., L.A.R., A.S., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - Nima Kashani
- Department of Neurosurgery (N.K.), University of Saskatchewan, Saskatchewan, Canada
| | - Leon A Rinkel
- From the Department of Radiology (R.V.M., N.B.R., J.M.O., L.A.R., A.S., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Neurology (L.A.R.), Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Arshia Sehgal
- From the Department of Radiology (R.V.M., N.B.R., J.M.O., L.A.R., A.S., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - Joachim C Fladt
- Department of Neurology and Stroke Center (J.C.F.), University Hospital Basel, Basel, Switzerland
| | - Ryan A McTaggart
- Department of Imaging (R.A.M.), Brown University, Providence, Rhode Island
| | - Raul Nogueira
- Department of Neurology and Neurosurgery (R.N.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Bijoy Menon
- Department of Clinical Neurosciences (B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - Alexandre Poppe
- Department of Neurosciences (A.P.), Centre Hospitalier de L'Université de Montréal, Montreal, Quebec, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences (B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - Mayank Goyal
- From the Department of Radiology (R.V.M., N.B.R., J.M.O., L.A.R., A.S., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
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Safouris A, Psychogios K, Palaiodimou L, Orosz P, Magoufis G, Kargiotis O, Theodorou A, Karapanayiotides T, Spiliopoulos S, Nardai S, Sarraj A, Nguyen TN, Yaghi S, Walter S, Sacco S, Turc G, Tsivgoulis G. Update of Anticoagulation Use in Cardioembolic Stroke With a Special Reference to Endovascular Treatment. J Stroke 2024; 26:13-25. [PMID: 38326704 PMCID: PMC10850459 DOI: 10.5853/jos.2023.01578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 11/30/2023] [Accepted: 12/04/2023] [Indexed: 02/09/2024] Open
Abstract
Cardioembolic stroke is a major cause of morbidity, with a high risk of recurrence, and anticoagulation represents the mainstay of secondary stroke prevention in most patients. The implementation of endovascular treatment in routine clinical practice complicates the decision to initiate anticoagulation, especially in patients with early hemorrhagic transformation who are considered at higher risk of hematoma expansion. Late hemorrhagic transformation in the days and weeks following stroke remains a potentially serious complication for which we still do not have any established clinical or radiological prediction tools. The optimal time to initiate therapy is challenging to define since delaying effective secondary prevention treatment exposes patients to the risk of recurrent embolism. Consequently, there is clinical equipoise to define and individualize the optimal timepoint to initiate anticoagulation combining the lowest risk of hemorrhagic transformation and ischemic recurrence in cardioembolic stroke patients. In this narrative review, we will highlight and critically outline recent observational and randomized relevant evidence in different subtypes of cardioembolic stroke with a special focus on anticoagulation initiation following endovascular treatment. We will refer mainly to the commonest cause of cardioembolism, non-valvular atrial fibrillation, and examine the possible risk and benefit of anticoagulation before, during, and shortly after the acute phase of stroke. Other indications of anticoagulation after ischemic stroke will be briefly discussed. We provide a synthesis of available data to help clinicians individualize the timing of initiation of oral anticoagulation based on the presence and extent of hemorrhagic transformation as well as stroke severity.
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Affiliation(s)
- Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurointerventions, National Institute of Mental Health, Neurology and Neurosurgery, Semmelweis University, Department of Neurosurgery, Budapest, Hungary
| | | | - Lina Palaiodimou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Orosz
- Department of Neurointerventions, National Institute of Mental Health, Neurology and Neurosurgery, Semmelweis University, Department of Neurosurgery, Budapest, Hungary
| | - George Magoufis
- Interventional Neuroradiology Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Radiology, Interventional Radiology Unit, “Attikon” University Hospital, Athens, Greece
| | | | - Aikaterini Theodorou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, “Attikon” University Hospital, Athens, Greece
| | - Sándor Nardai
- Department of Neurointerventions, National Institute of Mental Health, Neurology and Neurosurgery, Semmelweis University, Department of Neurosurgery, Budapest, Hungary
| | - Amrou Sarraj
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Thanh N. Nguyen
- Department of Neurology and Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Shadi Yaghi
- Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI, USA
| | - Silke Walter
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Simona Sacco
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- INSERM U1266, Paris, France
- FHU Neurovasc, Paris, France
- Université Paris Cité, Paris, France
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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Wang M, Farouki Y, Hulscher F, Mine B, Bonnet T, Elens S, Suarez JV, Jodaitis L, Ligot N, Naeije G, Lubicz B, Guenego A. Severely Hypoperfused Brain Tissue Correlates with Final Infarct Volume Despite Recanalization in DMVO Stroke. J Belg Soc Radiol 2023; 107:90. [PMID: 38023296 PMCID: PMC10668880 DOI: 10.5334/jbsr.3269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives We sought to assess whether there were any parameter(s) on baseline computed-tomography-perfusion (CTP) strongly correlating with final-infarct-volume, and infarct volume progression after endovascular recanalization of acute ischemic stroke (AIS) with primary distal, medium vessel occlusion (DMVO). Materials and Methods We performed a retrospective analysis of consecutive AIS patients who were successfully recanalized by thrombectomy for DMVO. By comparing baseline CTP and follow-up MRI, we evaluated the correlation between baseline infarct and hypoperfusion volumes, and final infarct volume and infarct volume progression. We also examined their effect on good clinical outcome at 3 months (defined as an mRS score of 0 to 2). Results Between January 2018 and January 2021, 38 patients met the inclusion criteria (76% [29/38] female, median age 75 [66-86] years). Median final infarct volume and infarct volume progression were 8.4 mL [IQR: 5.2-44.4] and 7.2 mL [IQR: 4.3-29.1] respectively. TMax > 10 sec volume was strongly correlated with both (r = 0.831 and r = 0.771 respectively, p < 0.0001), as well as with good clinical outcome (-0.5, p = 0.001). A higher baseline TMax > 10 sec volume increased the probability of a higher final-infarct-volume (r2 = 0.690, coefficient = 0.83 [0.64-1.00], p < 0.0001), whereas it decreased the probability of good clinical outcome at 3 months (odds ratio = -0.67 [-1.17 to -0.18], p = 0.008). Conclusion TMax > 10 sec volume on baseline CTP correlates strongly with final infarct volume as well as with clinical outcome after mechanical thrombectomy for an AIS with DMVO.
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Affiliation(s)
- Maud Wang
- Department of Radiology, Leuven University Hospital, Leuven, Belgium
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Yousra Farouki
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Franny Hulscher
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Benjamin Mine
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Thomas Bonnet
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Stephanie Elens
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Juan Vazquez Suarez
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Lise Jodaitis
- Department of Neurology, Erasme University Hospital, Brussels, Belgium
| | - Noemie Ligot
- Department of Neurology, Erasme University Hospital, Brussels, Belgium
| | - Gilles Naeije
- Department of Neurology, Erasme University Hospital, Brussels, Belgium
| | - Boris Lubicz
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Adrien Guenego
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
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Grifoni E, Bini C, Signorini I, Cosentino E, Micheletti I, Dei A, Pinto G, Madonia EM, Sivieri I, Mannini M, Baldini M, Bertini E, Giannoni S, Bartolozzi ML, Guidi L, Bartalucci P, Vanni S, Segneri A, Pratesi A, Giordano A, Dainelli F, Maggi F, Romagnoli M, Cioni E, Cioffi E, Pelagalli G, Mattaliano C, Schipani E, Murgida GS, Di Martino S, Sisti E, Cozzi A, Francolini V, Masotti L. Predictive Factors for Hemorrhagic Transformation in Acute Ischemic Stroke in the REAL-World Clinical Practice. Neurologist 2023; 28:150-156. [PMID: 36044909 DOI: 10.1097/nrl.0000000000000462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Few data exists on predictive factors of hemorrhagic transformation (HT) in real-world acute ischemic stroke patients. The aims of this study were: (i) to identify predictive variables of HT (ii) to develop a score for predicting HT. METHODS We retrospectively analyzed the clinical, radiographic, and laboratory data of patients with acute ischemic stroke consecutively admitted to our Stroke Unit along two years. Patients with HT were compared with those without HT. A multivariate logistic regression analysis was performed to identify independent predictors of HT on CT scan at 24 hours to develop a practical score. RESULTS The study population consisted of 564 patients with mean age 77.5±11.8 years. Fifty-two patients (9.2%) showed HT on brain CT at 24 hours (4.9% symptomatic). NIHSS score ≥8 at Stroke Unit admission (3 points), cardioembolic etiology (2 points), acute revascularization by systemic thrombolysis and/or mechanical thrombectomy (1 point), history of previous TIA/stroke (1 point), and major vessel occlusion (1 point) were found independent risk factors of HT and were included in the score (Hemorrhagic Transformation Empoli score (HTE)). The predictive power of HTE score was good with an AUC of 0.785 (95% CI: 0.749-0.818). Compared with 5 HT predictive scores proposed in the literature (THRIVE, SPAN-100, MSS, GRASPS, SITS-SIC), the HTE score significantly better predicted HT. CONCLUSIONS NIHSS score ≥8 at Stroke Unit admission, cardioembolism, urgent revascularization, previous TIA/stroke, and major vessel occlusion were independent predictors of HT. The HTE score has a good predictive power for HT. Prospective studies are warranted.
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Elsaid N, Bigliardi G, Dell'Acqua ML, Vandelli L, Ciolli L, Picchetto L, Borzì G, Ricceri R, Pentore R, Vallone S, Meletti S, Saied A. Proposal of multimodal computed tomography-based scoring system in prediction of hemorrhagic transformation in acute ischemic stroke. Acta Neurol Belg 2023:10.1007/s13760-023-02239-5. [PMID: 37029844 DOI: 10.1007/s13760-023-02239-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/10/2023] [Indexed: 04/09/2023]
Abstract
INTRODUCTION The routinely used computed tomography (CT)-based workup in the setting of acute ischemic stroke (AIS) includes non-contrast brain CT, CT angiography (CTA), and CT perfusion. Several CT, CTA, CTP-based radiological biomarkers of hemorrhagic transformation (HT) were reported. AIM OF THE STUDY To assess the predictive value of the combined multimodal CT parameters for HT after AIS and proposal of predictive scoring scale. METHODS The source images of the NCCT, CTA and CTP of 282 AIS patients involving the anterior circulation (HT = 91, non-HT = 191) were retrospectively reviewed and the following biomarkers were recorded and analyzed: Early subtle ischemic signs, hyperdense middle cerebral artery sign (HMCAS) and Alberta Stroke Program Early CT Score (ASPECTS) < 7 in NCCT, large-vessel occlusion (LVO), clot burden score (CBS) < 6, large-vessel occlusion, poor collateral score (CS) and Tmax > 6 s ≥ 56.5 ml. A scoring system to predict HT based on these biomarkers was developed. Each biomarker counts for a single point with the total score ranging from 0 to 7. RESULTS All the aforementioned multimodal CT biomarkers and the selected cut offs were significantly associated with higher HT risk. The calculated scores were statistically significant different between the HT and the non-HT groups with AUC 0.761 (95% CI 0.703-0.819, P < 0.0000001). Rates of HT were approximately five times higher in patients with score ≥ 3. CONCLUSION Multimodal CT-based scoring system may provide highly reliable predictive model of hemorrhagic transformation in acute ischemic stroke.
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Affiliation(s)
- Nada Elsaid
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy.
- Department of Neurology, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
| | - Guido Bigliardi
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Maria Luisa Dell'Acqua
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Laura Vandelli
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Ludovico Ciolli
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Livio Picchetto
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Giuseppe Borzì
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Riccardo Ricceri
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Roberta Pentore
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Stefano Vallone
- Neuroradiology, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Stefano Meletti
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Ahmed Saied
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
- Department of Neurology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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9
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Elsaid N, Bigliardi G, Dell’Acqua ML, Vandelli L, Ciolli L, Picchetto L, Borzì G, Ricceri R, Pentore R, Vallone S, Meletti S, Saied A. The role of automated computed topography perfusion in prediction of hemorrhagic transformation after acute ischemic stroke. Neuroradiol J 2023; 36:182-188. [PMID: 35850570 PMCID: PMC10034700 DOI: 10.1177/19714009221111084] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION The role of computed tomography perfusion (CTP) in prediction of hemorrhagic transformation (HT) has been evolving. We aimed to study the role of automated perfusion post-processing software in prediction of HT using the commercially available RAPID software. METHODS Two hundred eighty-two patients with anterior circulation ischemic stroke, who underwent CTP with RAPID automated post-processing, were retrospectively enrolled and divided into HT (n = 91) and non-HT groups (n = 191). The automated RAPID-generated perfusion maps were reviewed. Mismatch volume and ratio, time to maximum (Tmax) > 4-10s volumes, hypoperfusion index, cerebral blood flow (CBF) < 20-38% volumes, cerebral blood volume (CBV) < 34%-42% volumes, and CBV index were recorded and analyzed. RESULTS The volumes of brain tissues suffering from reduction of cerebral blood flow (CBF < 20%-38%), reduction in cerebral blood volumes (CBV < 34-42%), and delayed contrast arrival times (Tmax > 4-10s) were significantly higher in the HT group. The mismatch volumes were also higher in the HT group (p = .001). Among these parameters, the Tmax > 6s volume was the most reliable and sensitive predictor of HT (p = .001, AUC = 0.667). However, the combination of the perfusion parameters can slightly improve the diagnostic efficiency (AUC = 0.703). There was no statistically significant difference between the non-HT group and either the parenchymal or the symptomatic subtypes. CONCLUSION The RAPID automated CTP parameters can provide a reliable predictor of HT overall but not the parenchymal or the symptomatic subtypes. The infarct area involving the penumbra and core represented by the Tmax > 6s threshold is the most sensitive predictor; however, the combination of the perfusion parameters can slightly improve the diagnostic efficiency.
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Affiliation(s)
- Nada Elsaid
- Stroke Unit – Neurology Clinic,
Department of Neuroscience, Ospedale Civile di
Baggiovara, AOU di Modena, Modena, Italy
- Department of Neurology, Mansoura University, Mansoura, Egypt
| | - Guido Bigliardi
- Stroke Unit – Neurology Clinic,
Department of Neuroscience, Ospedale Civile di
Baggiovara, AOU di Modena, Modena, Italy
| | - Maria Luisa Dell’Acqua
- Stroke Unit – Neurology Clinic,
Department of Neuroscience, Ospedale Civile di
Baggiovara, AOU di Modena, Modena, Italy
| | - Laura Vandelli
- Stroke Unit – Neurology Clinic,
Department of Neuroscience, Ospedale Civile di
Baggiovara, AOU di Modena, Modena, Italy
| | - Ludovico Ciolli
- Stroke Unit – Neurology Clinic,
Department of Neuroscience, Ospedale Civile di
Baggiovara, AOU di Modena, Modena, Italy
| | - Livio Picchetto
- Stroke Unit – Neurology Clinic,
Department of Neuroscience, Ospedale Civile di
Baggiovara, AOU di Modena, Modena, Italy
| | - Giuseppe Borzì
- Stroke Unit – Neurology Clinic,
Department of Neuroscience, Ospedale Civile di
Baggiovara, AOU di Modena, Modena, Italy
| | - Riccardo Ricceri
- Stroke Unit – Neurology Clinic,
Department of Neuroscience, Ospedale Civile di
Baggiovara, AOU di Modena, Modena, Italy
| | - Roberta Pentore
- Stroke Unit – Neurology Clinic,
Department of Neuroscience, Ospedale Civile di
Baggiovara, AOU di Modena, Modena, Italy
| | - Stefano Vallone
- Neuroradiology, Department of
Neuroscience, Ospedale Civile di
Baggiovara, AOU di Modena, Modena, Italy
| | - Stefano Meletti
- Stroke Unit – Neurology Clinic,
Department of Neuroscience, Ospedale Civile di
Baggiovara, AOU di Modena, Modena, Italy
| | - Ahmed Saied
- Stroke Unit – Neurology Clinic,
Department of Neuroscience, Ospedale Civile di
Baggiovara, AOU di Modena, Modena, Italy
- Department of Neurology, Mansoura University, Mansoura, Egypt
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10
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Gou LK, Li C. Qixue Shuangbu decoction and acupuncture combined with Western medicine in acute severe stroke patients. World J Clin Cases 2023; 11:556-565. [PMID: 36793635 PMCID: PMC9923850 DOI: 10.12998/wjcc.v11.i3.556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/18/2022] [Accepted: 12/21/2022] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Stroke is a common and frequently occurring disease of the nervous system and one of the three major diseases leading to human death. The incidence and mortality of stroke in China increase with age. Overall, 70 % of patients with stroke have serious disability, which results in heavy burden to their families and the society.
AIM To analyze the effects of Qixue Shuangbu decoction and acupuncture combined with Western medicine on immune indexes and digestive tract function in patients with acute severe stroke.
METHODS A total of 68 patients with acute severe stroke admitted to Lanzhou Second People’s Hospital between March 2018 and September 2021 were selected and divided into the control and observation groups according to a random number table method. The control group was administered routine Western medicine treatment, such as dehydration, lowering intracranial pressure, anticoagulation, improving cerebral blood circulation and cerebral nerve protection according to the “Guidelines for the Diagnosis and Treatment of Acute Ischemic Stroke in China.” The observation group was administered Qixue Shuangbu decoction via nasal feeding tube on the basis of the routine Western medicine treatment with simultaneous acupuncture. The two groups were compared.
RESULTS The acute physiology and chronic health evaluation II, organ dysfunction syndrome score, National Institutes of Health Stroke Scale, and traditional Chinese medicine syndrome scores of the two groups were significantly decreased compared with those measured before treatment, and the complements C3 and C4, and immunoglobulins (Ig) M and G were significantly increased compared with those observed before treatment (P < 0.05). After treatment, the scores of the observation group were lower than those of the control group, and the complement and Ig levels were higher than those of the control group (P < 0.05). The levels of diamine oxidase (DAO), D-lactic acid (D-LA), and calcitonin gene-related peptide (CGRP) in the two groups were significantly higher than those before treatment, while the levels of lipopolysaccharide, ubiquitin carboxyl-terminal hydrolase 1 (UCH-L1), tumor necrosis factor-α (TNF-α), interleukin (IL) -2, and IL-8 were significantly lower than those before treatment (P < 0.05). After treatment, DAO, D-LA, and CGRP were higher in the observation group than in the control group, while lipopolysaccharide, UCH-L1, TNF-α, IL-2, and IL-8 were lower than in the control group (P < 0.05). The hospitalization time of individuals in the observation group was shorter than that of the control group (P < 0.05).
CONCLUSION Qixue Shuangbu decoction and acupuncture combined with Western medicine for the treatment of acute severe stroke can regulate intestinal flora, reduce inflammation, improve intestinal mucosal barrier function and immune function related indicators, and promote recovery.
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Affiliation(s)
- Li-Kun Gou
- Department of Critical Care Medicine, Lanzhou Second People’s Hospital, Lanzhou 730046, Gansu Province, China
| | - Chun Li
- Department of Critical Care Medicine, Lanzhou Second People’s Hospital, Lanzhou 730046, Gansu Province, China
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11
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Wang M, Farouki Y, Hulscher F, Mine B, Bonnet T, Elens S, Vazquez Suarez J, Jodaitis L, Ligot N, Naeije G, Lubicz B, Guenego A. Early Neurological Improvement Predicts Clinical Outcome After Thrombectomy for Distal Medium Vessel Occlusions. Front Neurol 2022; 13:809066. [PMID: 35321507 PMCID: PMC8936066 DOI: 10.3389/fneur.2022.809066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/01/2022] [Indexed: 12/18/2022] Open
Abstract
Background and Purpose Good clinical outcome predictors have been established in mechanical thrombectomy (MT) for acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). An early neurological improvement (ENI), defined as a reduction of ≥8 on the National Institutes of Health Stroke Scale (NIHSS), compared with the baseline score or an NIHSS of 0 or 1 at 24 h after MT, is a strong predictor of favorable outcome. We aimed to study the impact of ENI after MT for distal medium vessel occlusions (DMVO). Methods We retrospectively analyzed the data of consecutive patients who underwent MT for a primary DMVO in one large academic center. We compared clinical outcomes between patients with DMVO stratified by ENI. Multivariate analyses were performed to determine the impact of ENI on good 90-day outcome (modified Rankin scale of 0–2) and identify factors contributing to ENI. Results Between January 2018 and January 2021, 61 patients underwent an MT for an AIS with a primary DMVO. An ENI was seen in 24 (39%) patients (ENI+). Outcomes were significantly better in ENI+ patients, with 83% achieving a good outcome at 3 months vs. 43% for patients without ENI (ENI–; p = 0.019). ENI was an independent predictive factor of good clinical outcome even after adjusting for potential confounding factors [odds ratio 12.49 (1.49–105.01), p = 0.020]. The use of intravenous tissue plasminogen activator [IVtPA; Odds-ratio 6.59 (1.82–23.89), p = 0.004] was a positive predictor of ENI. Conclusion ENI at day 1 following MT for DMVO stroke is a strong independent predictor of good to excellent 3-month clinical outcome.
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Affiliation(s)
- Maud Wang
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Yousra Farouki
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Franny Hulscher
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Benjamin Mine
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Thomas Bonnet
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Stephanie Elens
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Juan Vazquez Suarez
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Lise Jodaitis
- Department of Neurology, Erasme University Hospital, Brussels, Belgium
| | - Noémie Ligot
- Department of Neurology, Erasme University Hospital, Brussels, Belgium
| | - Gilles Naeije
- Department of Neurology, Erasme University Hospital, Brussels, Belgium
| | - Boris Lubicz
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Adrien Guenego
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
- *Correspondence: Adrien Guenego
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12
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A Review of Risk Factors and Predictors for Hemorrhagic Transformation in Patients with Acute Ischemic Stroke. Int J Vasc Med 2021; 2021:4244267. [PMID: 34912581 PMCID: PMC8668348 DOI: 10.1155/2021/4244267] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 12/26/2022] Open
Abstract
Acute ischemic strokes (AIS) and hemorrhagic strokes lead to disabling neuropsychiatric and cognitive deficits. A serious and fatal complication of AIS is the occurrence of hemorrhagic transformation (HT). HT is cerebral bleeding that occurs after an ischemic event in the infarcted areas. This review summarises how specific risk factors such as demographic factors like age, gender, and race/ethnicity, comorbidities including essential hypertension, atrial fibrillation, diabetes mellitus, congestive heart failure, and ischemic heart disease along with predictors like higher NIHSS score, larger infarction size, cardioembolic strokes, systolic blood pressure/pulse pressure variability, higher plasma glucose levels, and higher body temperature during ischemic event, lower low-density lipoprotein and total cholesterol, early ischemic changes on imaging modalities, and some rare causes make an individual more susceptible to developing HT. We also discuss few other risk factors such as the role of blood-brain barrier, increased arterial stiffness, and globulin levels in patients postreperfusion using thrombolysis and mechanical thrombectomy. In addition, we discuss the implications of dual antiplatelet therapy and the length of treatment in reference to the incidence of developing HT. Current research into inflammatory mediators and biomarkers such as Cyclooxygenase-2, matrix metalloproteinases, and soluble ST2 and their potential role as treatment options for HT is also briefly discussed. Finally, this review calls for more research into use of dual antiplatelet and the timing of antiplatelet and anticoagulant use in reference to hemorrhagic transformation.
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13
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Hong JM, Kim DS, Kim M. Hemorrhagic Transformation After Ischemic Stroke: Mechanisms and Management. Front Neurol 2021; 12:703258. [PMID: 34917010 PMCID: PMC8669478 DOI: 10.3389/fneur.2021.703258] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 10/21/2021] [Indexed: 01/01/2023] Open
Abstract
Symptomatic hemorrhagic transformation (HT) is one of the complications most likely to lead to death in patients with acute ischemic stroke. HT after acute ischemic stroke is diagnosed when certain areas of cerebral infarction appear as cerebral hemorrhage on radiological images. Its mechanisms are usually explained by disruption of the blood-brain barrier and reperfusion injury that causes leakage of peripheral blood cells. In ischemic infarction, HT may be a natural progression of acute ischemic stroke and can be facilitated or enhanced by reperfusion therapy. Therefore, to balance risks and benefits, HT occurrence in acute stroke settings is an important factor to be considered by physicians to determine whether recanalization therapy should be performed. This review aims to illustrate the pathophysiological mechanisms of HT, outline most HT-related factors after reperfusion therapy, and describe prevention strategies for the occurrence and enlargement of HT, such as blood pressure control. Finally, we propose a promising therapeutic approach based on biological research studies that would help clinicians treat such catastrophic complications.
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Affiliation(s)
- Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
- Department of Biomedical Science, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
| | - Da Sol Kim
- Department of Biomedical Science, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
| | - Min Kim
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
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14
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Zhang XX, Yao FR, Zhu JH, Chen ZG, Shen YP, Qiao YN, Shi HC, Liang JH, Wang XM, Fang Q. Nomogram to predict haemorrhagic transformation after stroke thrombolysis: a combined brain imaging and clinical study. Clin Radiol 2021; 77:e92-e98. [PMID: 34657729 DOI: 10.1016/j.crad.2021.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 09/15/2021] [Indexed: 11/26/2022]
Abstract
AIM To construct a novel nomogram by integrating computed tomography perfusion (CTP) and clinical parameters for individualised prediction of haemorrhagic transformation (HT) in intravenous thrombolysis (IVT)-treated acute ischaemic stroke (AIS) patients. METHODS Anterior circulation AIS patients who underwent IVT at a single centre from January 2018 to June 2020 were reviewed retrospectively. The CTP parameters of two regions of interest (ROI), the entire perfusion lesion areas, and the infract core areas, were assessed. HT was documented by follow-up CT 24 ± 2 h after IVT. Multivariable logistic regression was conducted by including clinical variables and CTP parameters to identify the independent predictors of HT. A nomogram was developed based on the independent predictors. The discriminative value and calibration of the nomogram were tested by concordance indexes (C-indexes) and calibration plots. Internal validation was performed using fivefold cross-validation. RESULTS The nomogram was generated using the complete data from 341 patients. Seven variables were included in the final nomogram, including: the relative cerebral blood volume (rCBV), permeability surface (PS), and relative PS (rPS) in infract core areas, the relative time to maximum (rTmax) and rPS in entire perfusion lesion areas, the National Institutes of Health Stroke Scale (NIHSS), and atrial fibrillation (AF). The C-indexes were 0.815 and 0.817 for the nomogram and internal validation. The calibration plots showed excellent agreement. CONCLUSION This is the first study establishing a nomogram based on CTP and clinical parameters to predict HT after stroke thrombolysis.
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Affiliation(s)
- X-X Zhang
- Department of Neurology, Yancheng Third People's Hospital, Yancheng, 224000, Jiangsu Province, China; Department of Neurology, The First Affiliated Hospital of Soochow University, Soochow, 215000, Jiangsu, China
| | - F-R Yao
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, 215000, Jiangsu, China
| | - J-H Zhu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Soochow, 215000, Jiangsu, China
| | - Z-G Chen
- Department of Neurology, The First Affiliated Hospital of Soochow University, Soochow, 215000, Jiangsu, China
| | - Y-P Shen
- Department of Epidemiology and Biostatistics, School of Public Health, Medical College of Soochow University, Suzhou, 215000, Jiangsu, China
| | - Y-N Qiao
- Department of Epidemiology and Biostatistics, School of Public Health, Medical College of Soochow University, Suzhou, 215000, Jiangsu, China
| | - H-C Shi
- Department of Neurology, Yancheng Third People's Hospital, Yancheng, 224000, Jiangsu Province, China
| | - J-H Liang
- Department of Imaging, Medical College of Soochow University, Suzhou, 215000, Jiangsu Province, China
| | - X-M Wang
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, 215000, Jiangsu, China.
| | - Q Fang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Soochow, 215000, Jiangsu, China.
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15
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Shen Z, Jin H, Lu Y, Sun W, Liu R, Li F, Shu J, Tai L, Li G, Chen H, Zhang G, Zhang L, Sun X, Qiu J, Wei Y, Sun W, Huang Y. Predictors and Prognosis of Symptomatic Intracranial Hemorrhage in Acute Ischemic Stroke Patients Without Thrombolysis: Analysis of Data From the Chinese Acute Ischemic Stroke Treatment Outcome Registry. Front Neurol 2021; 12:727304. [PMID: 34650508 PMCID: PMC8506002 DOI: 10.3389/fneur.2021.727304] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background and Purpose: There is limited information on symptomatic intracranial hemorrhage (sICH) in stroke patients without thrombolysis. This study aimed to evaluate the risk factors of sICH and the association between sICH and the prognosis at 3 and 12 months in acute ischemic stroke patients without thrombolysis. Methods: Data originated from the Chinese Acute Ischemic Stroke Treatment Outcome Registry. Univariate analysis and multivariate logistic regression were used to screen the risk factors of sICH. Multivariable logistic regression models were used to assess the association of sICH with poor outcome and all-cause mortality. Results: Totally, 9,484 patients were included, of which 69 (0.73%) had sICH. Atrial fibrillation (odds ratio [OR], 3.682; 95% confidence interval [CI], 1.945–6.971; p < 0.001), history of tumors (OR, 2.956; 95% CI, 1.115–7.593; p = 0.024), and the National Institutes of Health Stroke Scale (NIHSS) score on admission ([6–15: OR, 2.344; 95% CI, 1.365–4.024; p = 0.002] [>15: OR, 4.731; 95% CI, 1.648–13.583; p = 0.004]) were independently associated with sICH. After adjustment of the confounders, patients with sICH had a higher risk of poor outcome (OR, 1.983; 95% CI, 1.117–3.521; p = 0.018) at 3 months and that of all-cause mortality at 3 (OR, 6.135; 95% CI, 2.328–16.169; p < 0.001) and 12 months (OR, 3.720; 95% CI, 1.513–9.148; p = 0.004). Conclusion: sICH occurred in 0.73% of acute ischemic stroke patients without thrombolysis and was associated with a worse prognosis at 3 and 12 months. Atrial fibrillation, history of tumors, and NIHSS score at admission were independent risk factors of sICH.
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Affiliation(s)
- Zhiyuan Shen
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Haiqiang Jin
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yuxuan Lu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Wei Sun
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Ran Liu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Fan Li
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Junlong Shu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Liwen Tai
- Department of Neurology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Guozhong Li
- Department of Neurology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Huisheng Chen
- Department of Neurology, General Hospital of Shenyang Military Command, Shenyang, China
| | - Guiru Zhang
- Department of Neurology, Penglai People's Hospital, Penglai, China
| | - Lei Zhang
- Department of Neurology, Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Xuwen Sun
- Department of Neurology, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
| | - Jinhua Qiu
- Department of Neurology, Huizhou First Hospital, Huizhou, China
| | - Yan Wei
- Department of Neurology, Harrison International Peace Hospital, Hengshui, China
| | - Weiping Sun
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yining Huang
- Department of Neurology, Peking University First Hospital, Beijing, China
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16
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Jiang L, Zhou L, Yong W, Cui J, Geng W, Chen H, Zou J, Chen Y, Yin X, Chen YC. A deep learning-based model for prediction of hemorrhagic transformation after stroke. Brain Pathol 2021; 33:e13023. [PMID: 34608705 PMCID: PMC10041160 DOI: 10.1111/bpa.13023] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/26/2021] [Accepted: 09/20/2021] [Indexed: 12/29/2022] Open
Abstract
Hemorrhagic transformation (HT) is one of the most serious complications after endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) patients. The purpose of this study is to develop and validate deep-learning (DL) models based on multiparametric magnetic resonance imaging (MRI) to automatically predict HT in AIS patients. Multiparametric MRI and clinical data of AIS patients with EVT from two centers (data set 1 for training and testing: n = 338; data set 2 for validating: n = 54) were used in the DL models. The acute infarction area of diffusion-weighted imaging (DWI) and hypoperfusion of perfusion-weighted imaging (PWI) was labeled manually. Two forms of data sets (volume of interest [VOI] data sets and slice data sets) were analyzed, respectively. The models based on single parameter and multiparameter models were developed and validated to predict HT in AIS patients after EVT. Performance was evaluated by area under the receiver-operating characteristic curve (AUC), accuracy (ACC), sensitivity, specificity, negative predictive value, and positive predictive value. The results showed that the performance of single parameter model based on MTT (VOI data set: AUC = 0.933, ACC = 0.843; slice data set: AUC = 0.945, ACC = 0.833) and TTP (VOI data set: AUC = 0.916, ACC = 0.873; slice data set: AUC = 0.889, ACC = 0.818) were better than the other single parameter model. The multiparameter model based on DWI & MTT & TTP & Clinical (DMTC) had the best performance for predicting HT (VOI data set: AUC = 0.948, ACC = 0.892; slice data set: AUC = 0.932, ACC = 0.873). The DMTC model in the external validation set achieved similar performance with the testing set (VOI data set: AUC = 0.939, ACC = 0.884; slice data set: AUC = 0.927, ACC = 0.871) (p > 0.05). The proposed clinical, DWI, and PWI multiparameter DL model has great potential for assisting the periprocedural management in the early prediction HT of the AIS patients with EVT.
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Affiliation(s)
- Liang Jiang
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Leilei Zhou
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Wei Yong
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jinluan Cui
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Wen Geng
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Huiyou Chen
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jianjun Zou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yang Chen
- Laboratory of Image Science and Technology, School of Computer Science and Engineering, Southeast University, Nanjing, China
| | - Xindao Yin
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yu-Chen Chen
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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Cardio-cerebral infarction in left MCA strokes: a case series and literature review. Neurol Sci 2021; 43:2413-2422. [PMID: 34590206 PMCID: PMC8480750 DOI: 10.1007/s10072-021-05628-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/23/2021] [Indexed: 10/27/2022]
Abstract
The objective of this manuscript is to describe the challenges of Cardio-Cerebral Infarction (CCI) treatment and to highlight the variable approaches in management. CCI is a rare clinical presentation of simultaneous acute ischemic stroke (AIS) and acute myocardial infarction (AMI) and poses a therapeutic challenge for practitioners. Each disease requires timely intervention to prevent irreversible damage; however, optimal management remains unclear. We describe three cases of CCI. All three patients presented with symptomatic left MCA (M1) occlusion, with ST elevation myocardial infarction (STEMI) and left ventricular apical thrombus. Fibrinolysis and mechanical thrombectomy (MT) were discussed in all cases, but only one patient received alteplase (0.9 mg/kg) and none underwent MT. Percutaneous intervention (PCI) was done in only one case. The two patients that did not receive thrombolysis were treated with modified therapeutic heparin (no bolus), and all received antiplatelet therapy. Ultimately, all three patients passed away. CCI poses a clinical challenge for physicians including (1) optimal strategies to enable swift mechanical reperfusion to both the brain and myocardium; (2) difference in dosage of thrombolytics for AIS versus AMI; (3) risk of symptomatic intracerebral hemorrhage following administration of anticoagulation and/or antiplatelet therapy; and (4) caution with use of thrombolytics in the setting of acute STEMI due to the risk of myocardial rupture. In the absence of high quality evidence and clinical guidelines, treatment of CCI is highly individualized.
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Magoufis G, Safouris A, Raphaeli G, Kargiotis O, Psychogios K, Krogias C, Palaiodimou L, Spiliopoulos S, Polizogopoulou E, Mantatzis M, Finitsis S, Karapanayiotides T, Ellul J, Bakola E, Brountzos E, Mitsias P, Giannopoulos S, Tsivgoulis G. Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach. Ther Adv Neurol Disord 2021; 14:17562864211021182. [PMID: 34122624 PMCID: PMC8175833 DOI: 10.1177/17562864211021182] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/10/2021] [Indexed: 02/05/2023] Open
Abstract
Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.
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Affiliation(s)
- Georgios Magoufis
- Interventional Neuroradiology Unit, Metropolitan Hospital, Piraeus, Greece
| | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Guy Raphaeli
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | | | - Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Lina Palaiodimou
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Eftihia Polizogopoulou
- Emergency Medicine Clinic, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Michael Mantatzis
- Department of Radiology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Stephanos Finitsis
- Department of Interventional Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, Aristotle University of Thessaloniki, School of Medicine, Faculty of Health Sciences, AHEPA University Hospital, Thessaloniki, Greece
| | - John Ellul
- Department of Neurology, University Hospital of Patras, School of Medicine, University of Patras, Patras, Greece
| | - Eleni Bakola
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Elias Brountzos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Panayiotis Mitsias
- Department of Neurology Medical School, University of Crete, Heraklion, Crete, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian, University of Athens, School of Medicine, “Attikon” University Hospital, Iras 39, Gerakas Attikis, Athens, 15344, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
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Elands S, Casimir P, Bonnet T, Mine B, Lubicz B, Sjøgård M, Ligot N, Naeije G. Early Venous Filling Following Thrombectomy: Association With Hemorrhagic Transformation and Functional Outcome. Front Neurol 2021; 12:649079. [PMID: 33776899 PMCID: PMC7987949 DOI: 10.3389/fneur.2021.649079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 02/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Previous studies have noted the angiographic appearance of early venous filling (EVF) following recanalisation in acute ischemic stroke. However, the prognostic implications of EVF as a novel imaging biomarker remain unclear. We aimed to evaluate the correlation between EVF with (i) the risk of subsequent reperfusion hemorrhage (RPH) and (ii) the association of EVF on both the NIHSS score at 24 h and functional outcome as assessed with the Modified Rankin Scale (mRS) score at 90 days. Methods: We conducted a retrospective cohort study of patients presenting with an acute ischemic stroke due to a proximal large-vessel occlusion of the anterior circulation treated by thrombectomy. Post-reperfusion digital subtraction angiography was reviewed to look for EVF as evidenced by the contrast opacification of any cerebral vein before the late arterial phase. Results: EVF occurred in 22.4% of the 147 cases included. The presence of EVF significantly increased the risk of RPH (p = 0.0048), including the risk of symptomatic hemorrhage (p = 0.0052). The presence of EVF (p = 0.0016) and the absence of RPH (p = 0.0021) were independently associated with a better outcome as defined by the NIHSS difference at 24 h, most significantly in the EVF+RPH- group. No significant relationship was however found between either EVF or RPH and a mRS score ≤ 2 at 90 days. Conclusion: Early venous filling on angiographic imaging is a potential predictor of reperfusion hemorrhage. The absence of subsequent RPH in this sub-group is associated with better outcomes at 24 h post-thrombectomy than in those with RPH.
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Affiliation(s)
- Sophie Elands
- Department of Neurology, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Pierre Casimir
- Department of Neurology, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Thomas Bonnet
- Department of Interventional Neuroradiology, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Benjamin Mine
- Department of Interventional Neuroradiology, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Boris Lubicz
- Department of Interventional Neuroradiology, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Martin Sjøgård
- Laboratoire de Cartographie Fonctionnelle du Cerveau, Neuroscience Institute (ULB-Neuroscience Institute), Université Libre de Bruxelles, Brussels, Belgium
| | - Noémie Ligot
- Department of Neurology, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Gilles Naeije
- Department of Neurology, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Affiliation(s)
- Jeffrey L Saver
- Comprehensive Stroke Center, Department of Neurology, University of California, Los Angeles
- Associate Editor, JAMA
| | - Opeolu Adeoye
- Departments of Emergency Medicine and Neurosurgery, University of Cincinnati, Cincinnati, Ohio
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Portela de Oliveira E, Chakraborty S, Patel M, Finitsis S, Iancu D. Value of high-density sign on CT images after mechanical thrombectomy for large vessel occlusion in predicting hemorrhage and unfavorable outcome. Neuroradiol J 2020; 34:120-127. [PMID: 33283627 DOI: 10.1177/1971400920975259] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Cerebral hyperdensities can appear on head computed tomography (CT) images performed early after endovascular treatment (EVT) in patients with acute ischemic stroke and may be secondary to contrast staining or hemorrhagic transformation. The aim of this study was to determine how the high-density sign on CT affects mortality and clinical outcome and whether CT parameters predict hemorrhagic conversion or unfavorable outcome. METHODS We retrospectively reviewed a database of patients who underwent EVT with mechanical thrombectomy for acute ischemic stroke over 7 years. Included were acute stroke patients with a CT examination within 24 h post-EVT with mechanical thrombectomy, demonstrating areas of hyperdensity. We evaluated morphologic characteristics of these lesions, location, CT Hounsfield units and largest area, as well as patient demographics, EVT methods and patient outcome. RESULTS A total of 29 patients met the strict inclusion criteria. Complete recanalization was achieved in 58.6% (17/29). Seventeen (58.6%) cases of post-intervention cerebral hyperdensities were related to contrast staining and 12 (41.4%) cases to contrast staining and hemorrhage. Patient mortality was significantly higher in the hemorrhagic group (50.0% versus 5.9%, p = 0.003). The increased density on CT was associated with higher hemorrhagic risk (odds ratio 1.05, p = 0.036). CONCLUSION Patients with the high-density sign on CT images after mechanical thrombectomy for acute ischemic stroke demonstrated increased mortality and worse clinical outcome, primarily when these hyperdensities were related to hemorrhage. CT imaging parameters as higher density areas can help in the differentiation of hemorrhage from contrast staining.
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Affiliation(s)
| | - Santanu Chakraborty
- Department of Radiology, University of Ottawa; Medical Imaging Division, The Ottawa Hospital, Canada
| | - Mihilkumar Patel
- Department of Radiology, University of Ottawa; Medical Imaging Division, The Ottawa Hospital, Canada
| | - Stefanos Finitsis
- Department of Radiology, Aristotle University of Thessaloniki, Greece
| | - Daniela Iancu
- Department of Radiology, University of Montreal, Canada
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