scholarly journals Multimodal Predictive Modeling of Endovascular Treatment Outcome for Acute Ischemic Stroke Using Machine-Learning

Stroke ◽  
2020 ◽  
Vol 51 (12) ◽  
pp. 3541-3551
Author(s):  
Gianluca Brugnara ◽  
Ulf Neuberger ◽  
Mustafa A. Mahmutoglu ◽  
Martha Foltyn ◽  
Christian Herweh ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Ct Perfusion ◽  
Predictive Performance ◽  
Receiver Operating Characteristics ◽  
Operating Characteristics ◽  
Imaging Characteristics ◽  
Receiver Operating Characteristics Curve ◽  
Receiver Operating

Background and Purpose: This study assessed the predictive performance and relative importance of clinical, multimodal imaging, and angiographic characteristics for predicting the clinical outcome of endovascular treatment for acute ischemic stroke. Methods: A consecutive series of 246 patients with acute ischemic stroke and large vessel occlusion in the anterior circulation who underwent endovascular treatment between April 2014 and January 2018 was analyzed. Clinical, conventional imaging (electronic Alberta Stroke Program Early CT Score, acute ischemic volume, site of vessel occlusion, and collateral score), and advanced imaging characteristics (CT-perfusion with quantification of ischemic penumbra and infarct core volumes) before treatment as well as angiographic (interval groin puncture-recanalization, modified Thrombolysis in Cerebral Infarction score) and postinterventional clinical (National Institutes of Health Stroke Scale score after 24 hours) and imaging characteristics (electronic Alberta Stroke Program Early CT Score, final infarction volume after 18–36 hours) were assessed. The modified Rankin Scale (mRS) score at 90 days (mRS-90) was used to measure patient outcome (favorable outcome: mRS-90 ≤2 versus unfavorable outcome: mRS-90 >2). Machine-learning with gradient boosting classifiers was used to assess the performance and relative importance of the extracted characteristics for predicting mRS-90. Results: Baseline clinical and conventional imaging characteristics predicted mRS-90 with an area under the receiver operating characteristics curve of 0.740 (95% CI, 0.733–0.747) and an accuracy of 0.711 (95% CI, 0.705–0.717). Advanced imaging with CT-perfusion did not improved the predictive performance (area under the receiver operating characteristics curve, 0.747 [95% CI, 0.740–0.755]; accuracy, 0.720 [95% CI, 0.714–0.727]; P =0.150). Further inclusion of angiographic and postinterventional characteristics significantly improved the predictive performance (area under the receiver operating characteristics curve, 0.856 [95% CI, 0.850–0.861]; accuracy, 0.804 [95% CI, 0.799–0.810]; P <0.001). The most important parameters for predicting mRS 90 were National Institutes of Health Stroke Scale score after 24 hours (importance =100%), premorbid mRS score (importance =44%) and final infarction volume on postinterventional CT after 18 to 36 hours (importance =32%). Conclusions: Integrative assessment of clinical, multimodal imaging, and angiographic characteristics with machine-learning allowed to accurately predict the clinical outcome following endovascular treatment for acute ischemic stroke. Thereby, premorbid mRS was the most important clinical predictor for mRS-90, and the final infarction volume was the most important imaging predictor, while the extent of hemodynamic impairment on CT-perfusion before treatment had limited importance.

Higher Baseline Cortical Score Predicts Good Outcome in Patients With Low Alberta Stroke Program Early Computed Tomography Score Treated with Endovascular Treatment

Neurosurgery ◽  
2020 ◽  
Author(s):  
Peng-fei Xing ◽  
Yong-wei Zhang ◽  
Lei Zhang ◽  
Zi-fu Li ◽  
Hong-jian Shen ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Endovascular Treatment ◽  
Receiver Operating Characteristics ◽  
Operating Characteristics ◽  
Good Outcome ◽  
Poor Outcome ◽  
Poor Outcome Group ◽  
Outcome Group ◽  
Receiver Operating Characteristics Curve ◽  
Receiver Operating

Abstract BACKGROUND Patients with large vessel occlusion and noncontrast computed tomography (CT) Alberta Stroke Program Early CT Score (ASPECTS) &lt;6 may benefit from endovascular treatment (EVT). There is uncertainty about who will benefit from it. OBJECTIVE To explore the predicting factors for good outcome in patients with ASPECTS &lt;6 treated with EVT. METHODS We retrospectively reviewed 60 patients with ASPECTS &lt;6 treated with EVT in our center between March 2018 and June 2019. Patients were divided into 2 groups because of the modified Rankin Score (mRS) at 90 d: good outcome group (mRS 0-2) and poor outcome group (mRS ≥3). Baseline and procedural characteristics were collected for unilateral variate and multivariate regression analyses to explore the influent variates for good outcome. RESULTS Good outcome (mRS 0-2) was achieved in 24 (40%) patients after EVT and mortality was 20% for 90 d. Compared with the poor outcome group, higher baseline cortical ASPECTS (c-ASPECTS), lower intracranial hemorrhage, and malignant brain edema after thrombectomy were noted in the good outcome group (all P &lt; .01). Multivariate logistic regression showed that only baseline c-ASPECTS (≥3) was positive factor for good outcome (odds ratio = 4.29; 95% CI, 1.21-15.20; P = .024). The receiver operating characteristics curve indicated a moderate value of c-ASPECTS for predicting good outcome, with the area under receiver operating characteristics curve 0.70 (95% CI, 0.56-0.83; P = .011). CONCLUSION Higher baseline c-ASPECTS was a predictor for good clinical outcome in patients with ASPECTS &lt;6 treated with EVT, which could be helpful to treatment decision.

scholarly journals qTICI: Quantitative assessment of brain tissue reperfusion on digital subtraction angiograms of acute ischemic stroke patients

2020 ◽  
pp. 174749302090963
Author(s):  
Haryadi Prasetya ◽  
Lucas A Ramos ◽  
Thabiso Epema ◽  
Kilian M Treurniet ◽  
Bart J Emmer ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Digital Subtraction Angiography ◽  
Quantitative Measure ◽  
Receiver Operating Characteristics ◽  
Binary Logistic Regression Analysis ◽  
Digital Subtraction ◽  
Operating Characteristics ◽  
Vessel Occlusion ◽  
Receiver Operating Characteristics Curve ◽  
Receiver Operating

Background The Thrombolysis in Cerebral Infarction (TICI) scale is an important outcome measure to evaluate the quality of endovascular stroke therapy. The TICI scale is ordinal and observer-dependent, which may result in suboptimal prediction of patient outcome and inconsistent reperfusion grading. Aims We present a semi-automated quantitative reperfusion measure (quantified TICI (qTICI)) using image processing techniques based on the TICI methodology. Methods We included patients with an intracranial proximal large vessel occlusion with complete, good quality runs of anteroposterior and lateral digital subtraction angiography from the MR CLEAN Registry. For each vessel occlusion, we identified the target downstream territory and automatically segmented the reperfused area in the target downstream territory on final digital subtraction angiography. qTICI was defined as the percentage of reperfused area in target downstream territory. The value of qTICI and extended TICI (eTICI) in predicting favorable functional outcome (modified Rankin Scale 0–2) was compared using area under receiver operating characteristics curve and binary logistic regression analysis unadjusted and adjusted for known prognostic factors. Results In total, 408 patients with M1 or internal carotid artery occlusion were included. The median qTICI was 78 (interquartile range 58–88) and 215 patients (53%) had an eTICI of 2C or higher. qTICI was comparable to eTICI in predicting favorable outcome with area under receiver operating characteristics curve of 0.63 vs. 0.62 (P = 0.8) and 0.87 vs. 0.86 (P = 0.87), for the unadjusted and adjusted analysis, respectively. In the adjusted regression analyses, both qTICI and eTICI were independently associated with functional outcome. Conclusion qTICI provides a quantitative measure of reperfusion with similar prognostic value for functional outcome to eTICI score.

scholarly journals Thrombus Imaging Characteristics and Outcomes in Acute Ischemic Stroke Patients Undergoing Endovascular Treatment

Stroke ◽  
2019 ◽  
Vol 50 (8) ◽  
pp. 2057-2064 ◽  
Author(s):  
Bruna G. Dutra ◽  
Manon L. Tolhuisen ◽  
Heitor C.B.R. Alves ◽  
Kilian M. Treurniet ◽  
Manon Kappelhof ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Odds Ratio ◽  
Internal Carotid ◽  
Common Odds Ratio ◽  
Imaging Characteristics

Background and Purpose— Thrombus imaging characteristics have been reported to be useful to predict functional outcome and reperfusion in acute ischemic stroke. However, conflicting data about this subject exist in patients undergoing endovascular treatment. Therefore, we aimed to evaluate whether thrombus imaging characteristics assessed on computed tomography are associated with outcomes in patients with acute ischemic stroke treated by endovascular treatment. Methods— The MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry is an ongoing, prospective, and observational study in all centers performing endovascular treatment in the Netherlands. We evaluated associations of thrombus imaging characteristics with the functional outcome (modified Rankin Scale at 90 days), mortality, reperfusion, duration of endovascular treatment, and symptomatic intracranial hemorrhage using univariable and multivariable regression models. Thrombus characteristics included location, clot burden score (CBS), length, relative and absolute attenuation, perviousness, and distance from the internal carotid artery terminus to the thrombus. All characteristics were assessed on thin-slice (≤2.5 mm) noncontrast computed tomography and computed tomography angiography, acquired within 30 minutes from each other. Results— In total, 408 patients were analyzed. Thrombus with distal location, higher CBS, and shorter length were associated with better functional outcome (adjusted common odds ratio, 3.3; 95% CI, 2.0–5.3 for distal M1 occlusion compared with internal carotid artery occlusion; adjusted common odds ratio, 1.15; 95% CI, 1.07–1.24 per CBS point; and adjusted common odds ratio, 0.96; 95% CI, 0.94–0.99 per mm, respectively) and reduced duration of endovascular procedure (adjusted coefficient B, −14.7; 95% CI, −24.2 to −5.1 for distal M1 occlusion compared with internal carotid artery occlusion; adjusted coefficient B, −8.5; 95% CI, −14.5 to −2.4 per CBS point; and adjusted coefficient B, 7.3; 95% CI, 2.9–11.8 per mm, respectively). Thrombus perviousness was associated with better functional outcome (adjusted common odds ratio, 1.01; 95% CI, 1.00–1.02 per Hounsfield units increase). Distal thrombi were associated with successful reperfusion (adjusted odds ratio, 2.6; 95% CI, 1.4–4.9 for proximal M1 occlusion compared with internal carotid artery occlusion). Conclusions— Distal location, higher CBS, and shorter length are associated with better functional outcome and faster endovascular procedure. Distal thrombus is strongly associated with successful reperfusion, and a pervious thrombus is associated with better functional outcome.

scholarly journals Prospective Endovascular Treatment in Acute Ischemic Stroke Evaluating Non-Contrast Head CT versus CT Perfusion (PLEASE No CTP)

2019 ◽  
Vol 8 (2-6) ◽  
pp. 116-122
Author(s):  
Ameer E. Hassan ◽  
Hafsah Shamim ◽  
Haralabos Zacharatos ◽  
Saqib A. Chaudhry ◽  
Christina Sanchez ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Symptom Onset ◽  
Ct Perfusion ◽  
Treatment Decision ◽  
Anterior Circulation ◽  
Nihss Score ◽  
Contrast Ct

Background: Studies have shown a lack of agreement of computed tomography perfusion (CTP) in the selection of acute ischemic stroke (AIS) patients for endovascular treatment. Purpose: To demonstrate whether non-contrast computed tomography (CT) within 8 h of symptom onset is comparable to CTP imaging. Methods: Prospective study of consecutive anterior circulation AIS patients with a National Institute of Health Stroke Scale (NIHSS) score > 7 presenting within 8 h of symptom onset with endovascular treatment. All patients had non-contrast CT, CT angiography, and CTP. The neuro-interventionalist was blinded to the results of the CTP and based the treatment decision using the Alberta Stroke Program Early CT score (ASPECTS). Baseline demographics, co-morbidities, and baseline NIHSS scores were collected. Outcomes were modified Rankin scale (mRS) score at discharge and in-hospital mortality. Good outcomes were defined as a mRS score of 0–2. Results: 283 AIS patients were screened for the trial, and 119 were enrolled. The remaining patients were excluded for: posterior circulation stroke, no CTP performed, could not obtain consent, and NIHSS score < 7. Mean ­NIHSS score at admission was 16.8 ± 3, and mean ASPECTS was 8.4 ± 1.4. There was no statistically significant correlation with CTP penumbra and good outcomes: 50 versus 47.8% with no penumbra present (p = 0.85). In patients without evidence of CTP penumbra, there was 22.5% mortality compared to 22.1% mortality in patients with a CTP penumbra. If ASPECTS ≥7, 64.6% had good outcome versus 13.3% if ASPECTS < 7 (p < 0.001). Patients with an ASPECTS ≥7 had 10% mortality versus 51.4% in patients with an ASPECTS < 7 (p < 0.001). Conclusions: CTP penumbra did not identify patients who would benefit from endovascular treatment when patients were selected with non-contrast CT ASPECTS ≥7. There is no correlation of CTP penumbra with good outcomes or mortality. Larger prospective trials are warranted to justify the use of CTP within 6 h of symptom onset.

scholarly journals Evaluating and comparing biomarkers with respect to the area under the receiver operating characteristics curve in two-phase case–control studies

Biostatistics ◽  
2016 ◽  
Vol 17 (3) ◽  
pp. 499-522 ◽  
Author(s):  
Ying Huang
Keyword(s):  
Case Control ◽  
Receiver Operating Characteristics ◽  
Biased Sampling ◽  
Second Phase ◽  
Operating Characteristics ◽  
Case Control Studies ◽  
Two Phase ◽  
Receiver Operating Characteristics Curve ◽  
The Impact ◽  
Receiver Operating

Abstract Two-phase sampling design, where biomarkers are subsampled from a phase-one cohort sample representative of the target population, has become the gold standard in biomarker evaluation. Many two-phase case–control studies involve biased sampling of cases and/or controls in the second phase. For example, controls are often frequency-matched to cases with respect to other covariates. Ignoring biased sampling of cases and/or controls can lead to biased inference regarding biomarkers' classification accuracy. Considering the problems of estimating and comparing the area under the receiver operating characteristics curve (AUC) for a binary disease outcome, the impact of biased sampling of cases and/or controls on inference and the strategy to efficiently account for the sampling scheme have not been well studied. In this project, we investigate the inverse-probability-weighted method to adjust for biased sampling in estimating and comparing AUC. Asymptotic properties of the estimator and its inference procedure are developed for both Bernoulli sampling and finite-population stratified sampling. In simulation studies, the weighted estimators provide valid inference for estimation and hypothesis testing, while the standard empirical estimators can generate invalid inference. We demonstrate the use of the analytical variance formula for optimizing sampling schemes in biomarker study design and the application of the proposed AUC estimators to examples in HIV vaccine research and prostate cancer research.

scholarly journals Outcome Prediction Models for Endovascular Treatment of Ischemic Stroke: Systematic Review and External Validation

Stroke ◽  
2021 ◽  
Author(s):  
Femke Kremers ◽  
Esmee Venema ◽  
Martijne Duvekot ◽  
Lonneke Yo ◽  
Reinoud Bokkers ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
The Netherlands ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Prediction Models ◽  
Predictive Performance ◽  
Data Availability ◽  
Vascular Events ◽  
Discriminative Performance

Background and Purpose: Prediction models for outcome of patients with acute ischemic stroke who will undergo endovascular treatment have been developed to improve patient management. The aim of the current study is to provide an overview of preintervention models for functional outcome after endovascular treatment and to validate these models with data from daily clinical practice. Methods: We systematically searched within Medline, Embase, Cochrane, Web of Science, to include prediction models. Models identified from the search were validated in the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) registry, which includes all patients treated with endovascular treatment within 6.5 hours after stroke onset in the Netherlands between March 2014 and November 2017. Predictive performance was evaluated according to discrimination (area under the curve) and calibration (slope and intercept of the calibration curve). Good functional outcome was defined as a score of 0–2 or 0–3 on the modified Rankin Scale depending on the model. Results: After screening 3468 publications, 19 models were included in this validation. Variables included in the models mainly addressed clinical and imaging characteristics at baseline. In the validation cohort of 3156 patients, discriminative performance ranged from 0.61 (SPAN-100 [Stroke Prognostication Using Age and NIH Stroke Scale]) to 0.80 (MR PREDICTS). Best-calibrated models were THRIVE (The Totaled Health Risks in Vascular Events; intercept −0.06 [95% CI, −0.14 to 0.02]; slope 0.84 [95% CI, 0.75–0.95]), THRIVE-c (intercept 0.08 [95% CI, −0.02 to 0.17]; slope 0.71 [95% CI, 0.65–0.77]), Stroke Checkerboard score (intercept −0.05 [95% CI, −0.13 to 0.03]; slope 0.97 [95% CI, 0.88–1.08]), and MR PREDICTS (intercept 0.43 [95% CI, 0.33–0.52]; slope 0.93 [95% CI, 0.85–1.01]). Conclusions: The THRIVE-c score and MR PREDICTS both showed a good combination of discrimination and calibration and were, therefore, superior in predicting functional outcome for patients with ischemic stroke after endovascular treatment within 6.5 hours. Since models used different predictors and several models had relatively good predictive performance, the decision on which model to use in practice may also depend on simplicity of the model, data availability, and the comparability of the population and setting.

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