scholarly journals Predicting Imaging Outcomes in Acute Stroke Therapy—Comparison of Magnetic Resonance Imaging and Computed Tomography

2021 ◽  
Author(s):  
Deepa Krishnaswamy ◽  
Seetharaman Cannane ◽  
Meena Nedunchelian ◽  
Shriram Varadharajan ◽  
Santhosh Poyyamoli ◽  
...  
Keyword(s):  
Infarct Size ◽  
Acute Stroke ◽  
Prospective Observational Study ◽  
Infarct Volume ◽  
Reperfusion Therapy ◽  
Final Infarct Size ◽  
Noncontrast Ct ◽  
And Diffusion ◽  
Acute Stroke Therapy

Abstract Background: Imaging of acute stroke patients in emergency settings is critical for treatment decisions. Most commonly, CT with CTA is used worldwide for acute stroke. However, MRI may be advantageous in certain settings. With advancements in endovascular clot retrieval techniques, there is a need to identify and use the best possible imaging for the diagnosis and outcome prediction of hyperacute stroke. Methods: This mixed retrospective and prospective observational study was conducted over 2 years in patients who underwent reperfusion therapies. Patients were included in this study if they had a baseline as well as follow-up noncontrast CT and diffusion-weighted imaging (DWI) MRI. We compared them for estimating final infarct size and outcomes after reperfusion therapy. Results: A total of 86 patients were included in the study. Baseline DWI found new infarcts in 33 patients compared to baseline CT. Sensitivity and specificity of CT and DWI in predicting the final infarct size was 75.3% and 76.9% and 97.2% and 92.3%, respectively. A positive correlation of 51.2% and 84.4% was noted between b-CT Alberta stroke programme early CT score (ASPECTS) and b-DWI with 72 hours DWI ASPECTS, respectively (p < 0.001). The positive predictive value of CT was 94.8% and DWI was 98.6%. None of the patients had reversible hyperintensities in the follow-up DWI. Conclusion: MRI is more sensitive and specific than noncontrast CT in predicting final infarct volume. It predicts final outcomes better and could be an alternative if available in acute stroke settings.

Abstract P327: Utilizing Iodine Contrast Extravasation Post Reperfusion and Dual Energy Ct Imaging to Predict Risk of Hemorrhagic Conversion in Acute Stroke Patients

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Tri Huynh* ◽  
Niran Vijayaraghavan* ◽  
Hannah Branstetter ◽  
Natalie Buchwald ◽  
Justin De Prey ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Infarct Volume ◽  
Reperfusion Therapy ◽  
Dual Energy ◽  
Ct Imaging ◽  
Dual Energy Ct ◽  
Stroke Patients ◽  
Post Intervention ◽  
Contrast Extravasation ◽  
Post Contrast

Introduction: Hyperintense acute reperfusion marker (HARM) has been identified on post-contrast magnetic resonance imaging (MRI) to be a marker of hemorrhagic conversion (HC) post reperfusion therapy in acute stroke patients. We have previously described a case where MRI HARM was mimicked on post contrast computed topography (CT) imaging in an acute stroke patient post reperfusion. Dual-Energy (DECT) allows for differentiation between acute blood and iodine contrast extravasation (ICE), and thus can have utility when ICE is present. Here we sought to validate whether post-intervention ICE/CT hyperdensity reperfusion maker (CT HARM), and contrast subtracted on DECT is associated with HC in acute stroke patients. Method: Data was obtained from our Institutional Review Board approved stroke admission database from January 2017 to November 2019, including ischemic stroke patients that received thrombolysis or thrombectomy, had evaluable images within 24 hours of admission, and received a DECT. Ischemic volumes of the stroke was measured on diffusion-weighted image (DWI). ICE was measured on CT head and DECT using the freehand 3D region of interest tool on the Visage Imaging PACS System. Susceptibility weighted MRI sequences were used to grade HC. Data analysis was conducted with regression modeling. Results: A total of 82 patients were included, 49% women, median age 73 (interquartile range (IQR), 61- 77), admission NIHSS 12 (IQR, 7 - 21), 24 hour change in NIHSS 4 (IQR, 0 -13), glucose 125 (IQR, 106 -158), creatinine 1.0 (IQR, 0.8 - 1.2), infarct volume 50.6 ± 7.1 mL, 48% treated with thrombectomy, 7% with PH-1 or PH-2 identified on MRI, and 56% with MCA infarcts. ICE volume was 2.6 ± 1.0 mL and DECT volume was 2.2 ± 1.1mL. ICE increased the likelihood of MRI confirmed PH-1 or PH-2 hemorrhagic conversion (odds ratio (OR) 14.34, 95% confidence interval (CI) 5.74 - 22.94) and decreased likelihood of increase in NIHSS at 24 hours (OR 0.20, 95% CI 0.01 to 0.40). There were no other significant associations with ICE or DECT volumes. Conclusion: Our results are supportive of our proposed association between CT HARM and risk of HC. More studies are needed to study whether quantitative of DECT can be predictive of stroke outcomes post reperfusion therapy.

Abstract WMP17: Early DWI Reversal Following Endovascular Reperfusion Is Typically Transient

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Manabu Inoue ◽  
Hayley M Wheeler ◽  
Michael Mlynash ◽  
Aaryani Tipirneni ◽  
Matus Straka ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Endovascular Therapy ◽  
Independent Predictor ◽  
Infarct Volume ◽  
Prognostic Significance ◽  
Reperfusion Therapy ◽  
Ischemic Lesion ◽  
Stroke Treatment ◽  
Median Volume

Background and Purpose: There are conflicting reports regarding the incidence and prognostic significance of DWI reversal following reperfusion therapy. The aim of this study was to assess the frequency and extent of early DWI reversal following endovascular therapy and to determine if early reversal is sustained or transient. Methods: This is a substudy of the DEFUSE 2. MRI with DWI and PWI was performed before (DWI 1) and within 12 hours after (DWI 2) endovascular stroke treatment and again at 5 days. Acute DWI lesions were outlined and quantified using mipav software (http://mipav.cit.nih.gov/). Ischemic lesion volumes were outlined on the Day 5 FLAIR then corrected for edema using a validated technique to determine the final infarct volume. Early DWI reversal was defined as (DWI 1 - DWI 2) >3 ml and permanent DWI reversal was defined (DWI 1 - final infarct volume) > 1 ml. Reperfusion was defined as a >50% reduction in PWI volume (Tmax >6 sec) on the MRI performed after endovascular therapy. The prognostic significance of early reversal was assessed in a regression model. Results: 104 patients had a technically adequate DWI and PWI prior to endovascular therapy (performed 4.4 [3.0-6.0] hours after symptom onset). Of these, 77 had an acute DWI lesion >3 ml and a follow-up MRI (156 min [72-342] after completion of endovascular therapy) and a 5 day MRI. Seventeen percent (13/77) of the patients had early DWI reversal representing a median (IQR) of 42.4% (25.0-57.6) of the initial DWI lesion (median volume 10.9 ml [IQR 7.3-18.2]). The incidence of early DWI reversal was 21% (11/52) following reperfusion vs. 8% (2/25) in patients who did not reperfuse (p=0.20). Of the 13 patients with early DWI reversal, permanent DWI reversal occurred in only 2 (volume of permanent DWI reversal 6.9 ml and 4.7 ml). Early DWI reversal was not an independent predictor of clinical outcome. Conclusion: Early DWI reversal occurs in about 15-20% of patients following endovascular therapy and can involve a substantial percentage of the initial DWI volume. However, early DWI reversal is usually transient and does not appear to signify tissue salvage.

scholarly journals Toward a more inclusive paradigm: thrombectomy for stroke patients with pre-existing disabilities

2020 ◽  
pp. neurintsurg-2020-016783 ◽  
Author(s):  
Robert W Regenhardt ◽  
Michael J Young ◽  
Mark R Etherton ◽  
Alvin S Das ◽  
Christopher J Stapleton ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Infarct Size ◽  
Acute Stroke ◽  
Medical History ◽  
Coronary Disease ◽  
Vulnerable Population ◽  
Modified Rankin Scale ◽  
Stroke Patients ◽  
Endovascular Thrombectomy ◽  
Final Infarct Size

BackgroundPersons with pre-existing disabilities represent over one-third of acute stroke presentations, but account for a far smaller proportion of those receiving endovascular thrombectomy (EVT) and thrombolysis. This is despite existing ethical, economic, legal, and social directives to maximize equity for this vulnerable population. We sought to determine associations between baseline modified Rankin Scale (mRS) and outcomes after EVT.MethodsIndividuals who underwent EVT were identified from a prospectively maintained database. Demographics, medical history, presentations, treatments, and outcomes were recorded. Baseline disability was defined as baseline mRS≥2. Accumulated disability was defined as the delta between baseline mRS and absolute 90-day mRS.ResultsOf 381 individuals, 49 had baseline disability (five with mRS=4, 23 mRS=3, 21 mRS=2). Those with baseline disability were older (81 vs 68 years, P<0.0001), more likely female (65% vs 49%, P=0.032), had more coronary disease (39% vs 20%, P=0.006), stroke/TIA history (35% vs 15%, P=0.002), and higher NIH Stroke Scale (19 vs 16, P=0.001). Baseline mRS was associated with absolute 90-day mRS ≤2 (OR=0.509, 95%CI=0.370–0.700). However, baseline mRS bore no association with accumulated disability by delta mRS ≤0 (ie, return to baseline, OR=1.247, 95%CI=0.943–1.648), delta mRS ≤1 (OR=1.149, 95%CI=0.906–1.458), delta mRS ≤2 (OR 1.097, 95% CI 0.869–1.386), TICI 2b–3 reperfusion (OR=0.914, 95%CI=0.712–1.173), final infarct size (P=0.853, β=−0.014), or intracerebral hemorrhage (OR=0.521, 95%CI=0.244–1.112).ConclusionsWhile baseline mRS was associated with absolute 90-day disability, there was no association with accumulated disability or other outcomes. Patients with baseline disability should not be routinely excluded from EVT based on baseline mRS alone.

Abstract 131: TICI 2A Reperfusion Increases Risk of Parenchymal Hemorrhage After Endovascular Treatment for Acute Ischemic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Erica Jones ◽  
Diogo Haussen ◽  
Raul Nogueira ◽  
Fadi Nahab ◽  
Michael Frankel ◽  
...  
Keyword(s):  
Infarct Size ◽  
Infarct Volume ◽  
Patient Characteristics ◽  
Reperfusion Therapy ◽  
Stroke Severity ◽  
Vessel Occlusion ◽  
Increased Risk ◽  
Increase Risk ◽  
Hemorrhage Risk ◽  
Post Hoc

Background: Endovascular reperfusion therapy (ERT) for acute large vessel occlusion limits infarct expansion and improves clinical outcomes but successful reperfusion may also increase risk of reperfusion injury and parenchymal hemorrhage (PH). We explored the association between levels of reperfusion and risk of PH. Methods: In a post-hoc analysis of the endovascular arm of the Interventional Management of Stroke-III randomized clinical trial, we assessed the association between levels of reperfusion (TICI0-1, 2A and 2B/3) and hemorrhage risk (PH1/2) in unadjusted and adjusted models controlling for stroke severity, final infarct volume (FIV) and level of occlusion. Results: Out of 434 participants who received ERT, 311 had documented TICI reperfusion grades (TICI 0-1: 84 [27%], TICI 2A: 108 [34.7%], TICI 2B/3: 119 [38.3%]). PH occurred in 42 (13.5%) patients. Patient characteristics are shown in Figure A. Higher reperfusion scores were associated with lower FIV (N=264, Mann-Whitney p<0.001 Figure B). Univariable predictors (p<0.10) of PH included FIV (p<0.0001), 24-hour NIHSS (p<0.0001) and TICI reperfusion grade (p=0.08). Compared to the TICI 0-1 group, TICI 2A was associated with higher odds of PH (OR=3.9, 1.26-12.1, p=0.014) while odds of PH in TICI 2B/3 reperfusion was similar to the TICI 0-1 category (OR=1.76, 0.73-4.26, p=0.2) after controlling for FIV or 24-hour NIHSS (Fig. C). Conclusions: Risk of PH appears to be highest in patients with intermediate levels of reperfusion even after adjusting for infarct size. While the reasons for this need investigating, we propose that the infarct size-mitigating effect of intermediate reperfusion may be partially offset by increased risk of PH. Our exploratory results emphasize the importance of achieving complete reperfusion during the treatment of acute LVO stroke patients.

PlA polymorphism of the glycoprotein IIIa and efficacy of reperfusion therapy in patients with acute myocardial infarction

2004 ◽  
Vol 91 (01) ◽  
pp. 141-145 ◽  
Author(s):  
Olga Gorchakova ◽  
Werner Koch ◽  
Julinda Mehilli ◽  
Nicolas von Beckerath ◽  
Markus Schwaiger ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Infarct Size ◽  
Reperfusion Therapy ◽  
Primary Treatment ◽  
Platelet Glycoprotein ◽  
Myocardial Salvage ◽  
Genotype Distribution ◽  
Final Infarct Size ◽  
Glycoprotein Iiia

SummaryThe PlA polymorphism of the platelet glycoprotein IIIa gene is associated with altered platelet function and response to antiplatelet drugs. We sought to assess whether the PlA polymorphism influences myocardial salvage achieved by reperfusion therapy in patients with acute myocardial infarction. We analyzed 292 patients enrolled in 2 randomized trials that compared stenting plus abciximab with thrombolysis (alteplase alone or alteplase plus abciximab) in acute myocardial infarction. Patients were genotyped for the PlA polymorphism using polymerase chain reaction with fluorogenic probes. Technetium-99m sestamibi was injected before and 1-2 weeks after reperfusion treatment. The scintigrams enabled the calculation of the initial perfusion defect, final infarct size, and the proportion of initial defect salvaged by reperfusion (salvage index). Clinical follow-up was done up to 18 months after primary treatment. The genotype distribution was as follows: PlA2/A2 in 3.4%, PlA1/A2 in 24.7% and PlA1/A1 in 71.9% of patients. There were no significant differences between PlA2 allele carriers and PlA1/A1 patients in salvage index (0.46±0.50 vs. 0.41±0.43, respectively, P=0.48), final infarct size (16.8±20.8% vs. 18.4±19.1% of left ventricle, respectively, P=0.46) as well as 18-month mortality (8.5% vs.7.1%, respectively, P=0.69). The lack of relationship between PlA2 allele and myocardial salvage was observed for both reperfusion strategies, stenting and thrombolysis. Thus, these findings show that the functional PlA polymorphism of platelet glycoprotein IIIa has no influence on the degree of myocardial salvage achieved by reperfusion therapies in patients with acute myocardial infarction.

High Prestroke Physical Activity Is Associated with Reduced Infarct Growth in Acute Ischemic Stroke Patients Treated with Intravenous tPA and Randomized to Remote Ischemic Perconditioning

2017 ◽  
Vol 44 (1-2) ◽  
pp. 88-95 ◽  
Author(s):  
Rolf A. Blauenfeldt ◽  
Kristina D. Hougaard ◽  
Kim Mouridsen ◽  
Grethe Andersen
Keyword(s):  
Physical Activity ◽  
Ischemic Stroke ◽  
Infarct Size ◽  
Acute Ischemic Stroke ◽  
Infarct Volume ◽  
Neuroprotective Effect ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
Remote Ischemic Perconditioning ◽  
Final Infarct Size

Background: A high prestroke physical activity (PA) level is associated with reduced stroke rate, stroke mortality, better functional outcome, and possible neuroprotective abilities. The aim of the present study was to examine the possible neuroprotective effect of prestroke PA on 24-h cerebral infarct growth in a cohort of acute ischemic stroke patients treated with intravenous tPA and randomized to remote ischemic perconditioning. Methods: In this predefined subanalysis, data from a randomized clinical trial investigating the effect of remote ischemic perconditioning (RIPerC) on AIS was used. Prestroke (7 days before admission) PA was quantified using the PA Scale for the Elderly (PASE) questionnaire at baseline. Infarct growth was evaluated using MRI (acute, 24-h, and 1-month). Results: PASE scores were obtained from 102 of 153 (67%) patients with a median (interquartile range) age of 66 (58-73) years. A high prestroke PA level correlated significantly with reduced acute infarct growth (24 h) in the linear regression model (4th quartile prestroke PA level compared with the 1st quartile), β4th quartile = -0.82 (95% CI -1.54 to -0.10). However, the effect of prestroke PA was present mainly in patients randomized to RIPerC, β4th quartile = -1.14 (95% CI -2.04 to -0.25). In patients randomized to RIPerC, prestroke PA was a predictor of final infarct size (1-month infarct volume), β4th quartile = -1.78 (95% CI -3.15 to -0.41). Conclusion: In AIS patients treated with RIPerC, as add-on to intravenous thrombolysis, the level of PA the week before the stroke was associated with decreased 24-h infarct growth and final infarct size. These results are highly encouraging and stress the need for further exploration of the potentially protective effects of both PA and remote ischemic conditioning.

Abstract 52: Results of DEFUSE 2: Imaging Endpoints

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Gregory W Albers ◽  
Matus Straka ◽  
Stephanie Kemp ◽  
Michael Mlynash ◽  
Tudor G Jovin ◽  
...  
Keyword(s):  
Clinical Response ◽  
Endovascular Therapy ◽  
Infarct Volume ◽  
Reperfusion Therapy ◽  
Early Reperfusion ◽  
Lesion Growth ◽  
Favorable Clinical Response ◽  
Multi Center Study ◽  
Automated Software

Background: The aim of DEFUSE 2 is to determine if predefined MRI profiles predict clinical and imaging outcomes following endovascular reperfusion therapy. Methods: This prospective, NIH funded, multi-center study enrolled consecutive acute stroke patients in whom an MRI scan could be obtained immediately prior to intra-arterial therapy. A follow-up MRI was performed within 12 hrs of completion of the procedure and again at 5 days. PWI and DWI lesion volumes were determined using a fully automated software program (RAPID). Lesion growth (infarct volume on 5 day FLAIR - baseline DWI volume) was compared for patients with and without the Target mismatch profile based on whether early reperfusion occurred. The Target mismatch profile was defined as PWI(Tmax>6s) / DWI >1.8, DWI <70 mL and PWI(Tmax>10s) <100 mL. Early reperfusion was defined as a >50% reduction in PWI volume following the procedure. The incidence and extent of DWI reversal was assessed and the fate of PWI lesions that were not reperfused was determined. Favorable clinical response was defined as an improvement in NIHSS ≥8 or 0-1 at 30 days. Results: This abstract represents a preliminary analysis of 71 of 101 patients who were treated with endovascular therapy (final results to be presented). Among the 54 patients with Target mismatch, early reperfusion was achieved in 70% and was associated with less infarct growth (relative median growth 210% vs. 450%, p=0.01) and a higher rate of favorable clinical response (OR=5.4; 95%CI 1.5-19.2). In patients without the Target mismatch profile (N= 13) early reperfusion was not associated with a reduction in infarct growth (relative median growth was 220% in both reperfusers and non-reperfusers; p=0.94) or an increased rate of favorable clinical response (OR=0.1; 95%CI 0.004-2.2). 96% of all voxels that were DWI positive at baseline were incorporated into the final infarct (assessed on the co-registered 5 day FLAIR); only 3 of 71 patients had FLAIR volumes that were smaller than the baseline DWI lesion (mean difference 3 mL). 80% of the voxels that had a PWI lesion (Tmax>6s) on the post-procedure scan were incorporated into the final infarct. The correlation between the union of the baseline DWI + early follow-up PWI lesion and the 5 day FLAIR volume was high (r=0.84; p< 0.0001). In 82% of the patients, the day 5 FLAIR volume was as at least as large as the union of the baseline DWI + early follow-up PWI lesion. Conclusion: Patients with the Target mismatch profile who achieve early reperfusion following intra-arterial therapy have less infarct growth and more favorable clinical outcomes. In contrast, no benefit of reperfusion was evident for non-Target mismatch patients. Baseline DWI lesions are virtually always fully incorporated into the final infarct volume, regardless of reperfusion. Tissue that remains hypoperfused (Tmax >6s) following endovascular therapy reliably progresses to infarction.

scholarly journals INCLUSION CRITERIA UPDATE OF THE INTRALUMINAL ISCHEMIC MODEL IN RAT FOR PRECLINICAL STUDIES

2017 ◽  
Author(s):  
Héctor Fernández Susavila ◽  
Ramón Iglesias Rey ◽  
Antonio Dopico López ◽  
María Pérez Mato ◽  
Tomás Sobrino Moreira ◽  
...  
Keyword(s):  
Infarct Size ◽  
Mr Angiography ◽  
Infarct Volume ◽  
Experimental Studies ◽  
Artery Occlusion ◽  
Laser Doppler ◽  
Inclusion Criteria ◽  
Diffusion Weighted Images ◽  
Summary Statement ◽  
And Diffusion

ABSTRACTA proper occlusion of the medial cerebral artery (MCA) determined by laser Doppler during cerebral ischemia in rat models is an important inclusion criteria in experimental studies. However, a successful occlusion of the artery does not always guarantee a reproducible infarct volume which is critical to validate the efficacy of new protective drugs. In this study, we have compared the variability of infarct size in ischemic animals when the artery occlusion is monitored with laser Doppler alone and in combination with MRI during artery occlusion. Infarct volume determined at 24 hours was compared between animals with laser Doppler monitoring alone and in combination with MR angiography (MRA) and diffusion weighted images (DWI). Twenty-eight animals presented a successful occlusion and reperfusion determined by Doppler monitoring with an infarct size at 24 hours of 16.71±11.58%. However, when artery occlusion and infarct damage were analyzed in these animals by MRA and DWI, 15 animals were excluded and only 13 animals were included based on Doppler and MRI inclusion criteria, with an infarct size of 21.65±6.15% at 24 hours. These results show that laser Doppler monitoring is needed but not enough to guarantee a reproducible infarct volume in rat ischemic model.Summary statementLaser Doppler monitoring in combination with DWI and MR angiography represents a reliable inclusion protocol during ischemic surgery for the analysis of protective drugs in the acute phase of stroke.

scholarly journals Improving the prediction of final infarct size in acute stroke with bolus delay-corrected perfusion MRI measures

2004 ◽  
Vol 20 (6) ◽  
pp. 941-947 ◽  
Author(s):  
Stephen E. Rose ◽  
Andrew L. Janke ◽  
Mark Griffin ◽  
Mark W. Strudwick ◽  
Simon Finnigan ◽  
...  
Keyword(s):  
Infarct Size ◽  
Acute Stroke ◽  
Perfusion Mri ◽  
Final Infarct Size
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