Selecting the Appropriate First-Line Strategy Based on Hyperdense Vessel Sign in Acute Ischemic Stroke Increases First Pass Recanalization: A Tertiary Center Experience

Background: The data pertaining to selecting an optimal first-line strategy (stent retriever [SR] vs. contact aspiration [CA]) based on noncontrast computed tomography (NCCT) in cases of acute ischemic stroke consequent to large vessel occlusion (LVO) is lacking. Aims: This article studies the influence of hyperdense vessel sign (HVS) in selecting optimal first-line strategy, with intention of increasing first-pass recanalization (FPR). Methods: Upfront approach at our center is SR technique with rescue therapy (CA) adoption consequent to three failed SR attempts to achieve successful recanalization. Data of patients with acute LVO who underwent mechanical thrombectomy from June 2017 to May 2020 was retrospectively analyzed. Patients were classified into HVS (+) and HVS (–) cohort. Rate of successful recanalization (first pass, early, and final) and efficacy of rescue therapy was assessed between the two cohorts. Results: Of 52 patients included, 28 and 24 were assigned to the HVS (+) and HVS (–) cohort, respectively. FPR was observed in 50% of HVS (+) and 20.9% of HVS (–) (p = 0.029). Early recanalization was documented in 64.2% of HVS (+) and 37.5% of HVS (–) (p = 0.054). Rescue therapy need was higher in patients not demonstrating HVS (p = 0.062). Successful recanalization was achieved with rescue therapy in 50% of HVS (–) group. Conclusion: A higher FPR is achievable following individualized first-pass strategy (based on NCCT appearance of clot), instead of a generalized SR first-pass approach. This CT imaging-based strategy is a step closer to achieving primary angiographic goal of FPR.

Factors Contributing to Attenuation of Cerebral Venous Sinus in Brain Noncontrast Computed Tomography Scan

Background/Aim In noncontrast computed tomography (NCCT), an apparently hyper-attenuated cerebral venous sinus (CVS) may lead to suspicion of CVS thrombosis. Understanding the factors affecting attenuation of CVS can guide us toward true diagnosis. Hence, the aim of the study was to determine the effect of different factors such as hematocrit, hemoglobin, age, blood urea nitrogen (BUN), creatinine, leukocyte and platelet count, and sex on the attenuation of CVS on brain NCCT. Material and Methods Total 1,680 patients were included in this study, and their demographic and laboratory data and brain NCCT were reviewed. In their brain NCCT, the average attenuation of superior sagittal sinus and both right and left sigmoid sinuses was measured. Data analysis was conducted using the Statistical Package for the Social Sciences version 21.0 software by Kolmogorov-Smirnov, Spearman's correlation coefficient, and multiple linear regression tests. The significance level was considered less than 0.05. Results Hematocrit (B = 0.251, p < 0.001), hemoglobin (B = 0.533, p < 0.001), and creatinine (B = − 0.270, p = 0.048) were determined as predictors of attenuation of superior sagittal sinus. For both sigmoid sinuses, hematocrit (p < 0.001) and hemoglobin (p < 0.001) were determined as positive predictors, and creatinine (p < 0.001) and BUN (p < 0.002) were determined as negative and positive predictors, respectively. Conclusion Hemoglobin, hematocrit, creatinine, and BUN are the main factors that should be considered in the assessment of CVS density on brain NCCT. As with increasing hematocrit and hemoglobin of the subject, the CVS density in NCCT increases, and with increasing creatinine and in some instance decreasing BUN of the subject, the CVS density in NCCT decreases.

Noncontrast Computed Tomography Markers of Cerebral Hemorrhage Expansion: Diagnostic Accuracy Meta-Analysis

Background and purpose Assess the diagnostic accuracy of noncontrast computed tomography (NCCT) markers of hematoma expansion in patients with primary intracerebral hemorrhage. Methods We performed a meta-analysis of observational studies and randomized controlled trials with available data for calculation of sensitivity and specificity of NCCT markers for hematoma expansion (absolute growth >6 or 12.5 mL and/or relative growth >33%). The following NCCT markers were analyzed: irregular shape, island sign (shape-related features); hypodensity, heterogeneous density, blend sign, black hole sign, and swirl sign (density-related features). Pooled accuracy values for each marker were derived from hierarchical logistic regression models. Results A total of 10,363 subjects from 23 eligible studies were included. Significant risk of bias of included studies was noted. Hematoma expansion frequency ranged from 7% to 40%, mean intracerebral hemorrhage volume from 9 to 27.8 ml, presence of NCCT markers from 9% (island sign) to 82% (irregular shape). Among shape features, sensitivity ranged from 0.32 (95%CI = 0.20–0.47) for island sign to 0.68 (95%CI = 0.57–0.77) for irregular shape, specificity ranged from 0.47 (95%CI = 0.36–0.59) for irregular shape to 0.92 (95%CI = 0.85–0.96) for island sign; among density features sensitivity ranged from 0.28 (95%CI = 0.21–0.35) for black hole sign to 0.63 (95%CI = 0.44–0.78) for hypodensity, specificity ranged from 0.65 (95%CI = 0.56–0.73) for heterogeneous density to 0.89 (95%CI = 0.85–0.92) for blend sign. Conclusion Diagnostic accuracy of NCCT markers remains suboptimal for implementation in clinical trials although density features performed better than shape-related features. This analysis may help in better tailoring patients’ selection for hematoma expansion targeted trials.

Location-Specific Radiomics Score: Novel Imaging Marker for Predicting Poor Outcome of Deep and Lobar Spontaneous Intracerebral Hemorrhage

Objective: To derive and validate a location-specific radiomics score (Rad-score) based on noncontrast computed tomography for predicting poor deep and lobar spontaneous intracerebral hemorrhage (SICH) outcome.Methods: In total, 494 SICH patients from multiple centers were retrospectively reviewed. Poor outcome was considered mRS 3–6 at 6 months. The Rad-score was derived using optimal radiomics features. The optimal location-specific Rad-score cut-offs for poor deep and lobar SICH outcomes were identified using receiver operating characteristic curve analysis. Univariable and multivariable analyses were used to determine independent poor outcome predictors. The combined models for deep and lobar SICH were constructed using independent predictors of poor outcomes, including dichotomized Rad-score in the derivation cohort, which was validated in the validation cohort.Results: Of 494 SICH patients, 392 (79%) had deep SICH, and 373 (76%) had poor outcomes. The Glasgow Coma Scale score, haematoma enlargement, haematoma location, haematoma volume and Rad-score were independent predictors of poor outcomes (all P &lt; 0.05). Cut-offs of Rad-score, 82.90 (AUC = 0.794) in deep SICH and 80.77 (AUC = 0.823) in lobar SICH, were identified for predicting poor outcomes. For deep SICH, the AUCs of the combined model were 0.856 and 0.831 in the derivation and validation cohorts, respectively. For lobar SICH, the combined model AUCs were 0.866 and 0.843 in the derivation and validation cohorts, respectively.Conclusion: Location-specific Rad-scores and combined models can identify subjects at high risk of poor deep and lobar SICH outcomes, which could improve clinical trial design by screening target patients.

Morphological Subtypes of Intracranial Internal Carotid Artery Arteriosclerosis and the Risk of Stroke

Background and Purpose: Accumulating evidence highlights the existence of distinct morphological subtypes of intracranial carotid arteriosclerosis. So far, little is known on the prevalence of these subtypes and subsequent stroke risk in the general population. We determined the prevalence of morphological subtypes of intracranial arteriosclerosis and assessed the risk of stroke associated with these subtypes. Methods: Between 2003 and 2006, 2391 stroke-free participants (mean age 69.6, 51.7% women) from the population-based Rotterdam Study underwent noncontrast computed tomography to visualize calcification in the intracranial carotid arteries as a proxy for intracranial arteriosclerosis. Calcification morphology was evaluated according to a validated grading scale and categorized into intimal, internal elastic lamina (IEL), or mixed subtype. Follow-up for stroke was complete until January 1, 2016. We used multivariable Cox regression to assess associations of each subtype with incident stroke. Results: The prevalence of calcification was 82% of which 39% had the intimal subtype, 48% IEL subtype, and 13% a mixed subtype. During a median follow-up of 10.4 years, 155 participants had a stroke. All 3 subtypes were associated with a higher risk of stroke (adjusted hazard ratio [95% CI] for intimal: 2.11 [1.07–4.13], IEL: 2.66 [1.39–5.11], and mixed subtype 2.57 [1.18–5.61]). The association of the IEL subtype with stroke was strongest among older participants. The association of the intimal subtype with stroke was noticeably stronger in women than in men. Conclusions: Calcification of the IEL was the most prevalent subtype of intracranial arteriosclerosis. All 3 subtypes were associated with an increased risk of stroke, with noticeable age and sex-specific differences.

Effect of routine preoperative screening for aortic calcifications using noncontrast computed tomography on stroke rate in cardiac surgery: the randomized controlled CRICKET study

Objectives To evaluate if routine screening for aortic calcification using unenhanced CT lowers the risk of stroke and alters the surgical approach in patients undergoing general cardiac surgery compared with standard of care (SoC). Methods In this prospective, multicenter, randomized controlled trial, adult patients scheduled for cardiac surgery from September 2014 to October 2019 were randomized 1:1 into two groups: SoC alone, including chest radiography, vs. SoC plus preoperative noncontrast CT. The primary endpoint was in-hospital perioperative stroke. Secondary endpoints were preoperative change of the surgical approach, in-hospital mortality, and postoperative delirium. The trial was halted halfway for expected futility, as the conditional power analysis showed a chance < 1% of finding the hypothesized effect. Results A total of 862 patients were evaluated (SoC-group: 433 patients (66 ± 11 years; 74.1% male) vs. SoC + CT-group: 429 patients (66 ± 10 years; 69.9% male)). The perioperative stroke rate (SoC + CT: 2.1%, 9/429 vs. SoC: 1.2%, 5/433, p = 0.27) and rate of changed surgical approach (SoC + CT: 4.0% (17/429) vs. SoC: 2.8% (12/433, p = 0.35) did not differ between groups. In-hospital mortality and postoperative delirium were comparable between groups. In the SoC + CT group, aortic calcification was observed on CT in the ascending aorta in 28% (108/380) and in the aortic arch in 70% (265/379). Conclusions Preoperative noncontrast CT in cardiac surgery candidates did not influence the surgical approach nor the incidence of perioperative stroke compared with standard of care. Aortic calcification is a frequent finding on the CT scan in these patients but results in major surgical alterations to prevent stroke in only few patients. Key Points • Aortic calcification is a frequent finding on noncontrast computed tomography prior to cardiac surgery. • Routine use of noncontrast computed tomography does not often lead to a change of the surgical approach, when compared to standard of care. • No effect was observed on perioperative stroke after cardiac surgery when using routine noncontrast computed tomography screening on top of standard of care.

Accelerated coronary calcium burden in breast cancer patients after radiotherapy: a comparison with age and race matched healthy women

Background Radiotherapy (RT) might lead to atherosclerotic plaque buildup and coronary artery stenosis of breast cancer (BC) survivors, and coronary artery calcium (CAC) might be a sign of preclinical atherosclerosis. This study explores possible determinants affecting the acceleration of CAC burden in BC patients after adjuvant RT. Methods Female BC patients receiving adjuvant RT from 2002 to 2010 were included. All patients received noncontrast computed tomography (NCCT) of thorax before and after adjuvant RT. Their CAC burden was compared with healthy controls from the Multi-Ethnic Study of Atherosclerosis (MESA) cohort. The progression of the CAC burden was manifested by the increment of CAC percentiles (%CACinc). Results Ninety-four patients, including both left- and right-side BC, were enrolled in this study. From undergoing the first to second NCCT, the %CACinc in BC patients significantly increased rather than non-BC women. In addition, the %CACinc was significantly higher in left-side than right-side BC patients (p < 0.05), and significant differences in most heart outcomes were found between the two groups. Besides, the lower the mean right coronary artery (RCA) dose, the lower the risks of CAC percentiles increase ≥ 50% after adjusting the disease's laterality. Conclusions A significantly higher accelerated CAC burden in BC patients than non-BC women represents that BC could affect accelerated CAC. A higher risk of accelerated CAC burden was found in left-side than right-side BC patients after adjuvant RT. A decrease of the mean RCA dose could reduce more than 50% of the risk of accelerated CAC burden in BC patients.

White Matter Lesions and Outcomes After Endovascular Treatment for Acute Ischemic Stroke: MR CLEAN Registry Results

Background: Cerebral white matter lesions (WMLs) have been associated with a greater risk of poor functional outcome after ischemic stroke. We assessed the relations between WML burden and radiological and clinical outcomes in patients treated with endovascular treatment in routine practice. Methods: We analyzed data from the MR CLEAN Registry (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischaemic Stroke in the Netherlands)—a prospective, multicenter, observational cohort study of patients treated with endovascular treatment in the Netherlands. WMLs were graded on baseline noncontrast computed tomography using a visual grading scale. The primary outcome was the score on the modified Rankin Scale at 90 days. Secondary outcomes included early neurological recovery, successful reperfusion (extended Thrombolysis in Cerebral Infarction ≥2b), futile recanalization (modified Rankin Scale score ≥3 despite successful reperfusion), and occurrence of symptomatic intracranial hemorrhage. We used multivariable logistic regression models to assess associations between WML severity and outcomes, taking the absence of WML on noncontrast computed tomography as the reference category. Results: Of 3180 patients included in the MR CLEAN Registry between March 2014 and November 2017, WMLs were graded for 3046 patients and categorized as none (n=1855; 61%), mild (n=608; 20%), or moderate to severe (n=588; 19%). Favorable outcome (modified Rankin Scale score, 0–2) was achieved in 838 patients (49%) without WML, 192 patients (34%) with mild WML, and 130 patients (24%) with moderate-to-severe WML. Increasing WML grades were associated with a shift toward poorer functional outcome in a dose-dependent manner (adjusted common odds ratio, 1.34 [95% CI, 1.13–1.60] for mild WML and 1.67 [95% CI, 1.39–2.01] for moderate-to-severe WML; P trend , <0.001). Increasing WML grades were associated with futile recanalization ( P trend , <0.001) and were inversely associated with early neurological recovery ( P trend , 0.041) but not with the probability of successful reperfusion or symptomatic intracranial hemorrhage. Conclusions: An increasing burden of WML at baseline is associated with poorer clinical outcomes after endovascular treatment for acute ischemic stroke but not with the probability of successful reperfusion or symptomatic intracranial hemorrhage.

Artificial Intelligence Can Effectively Predict Early Hematoma Expansion of Intracerebral Hemorrhage Analyzing Noncontrast Computed Tomography Image

This study aims to develop and validate an artificial intelligence model based on deep learning to predict early hematoma enlargement (HE) in patients with intracerebral hemorrhage. A total of 1,899 noncontrast computed tomography (NCCT) images of cerebral hemorrhage patients were retrospectively analyzed to establish a predicting model and 1,117 to validate the model. And a total of 118 patients with intracerebral hemorrhage were selected based on inclusion and exclusion criteria so as to validate the value of the model for clinical prediction. The baseline noncontrast computed tomography images within 6 h of intracerebral hemorrhage onset and the second noncontrast computed tomography performed at 24 ± 3 h from the onset were used to evaluate the prediction of intracerebral hemorrhage growth. In validation dataset 1, the AUC was 0.778 (95% CI, 0.768–0.786), the sensitivity was 0.818 (95% CI, 0.790–0.843), and the specificity was 0.601 (95% CI, 0.565–0.632). In validation dataset 2, the AUC was 0.780 (95% CI, 0.761–0.798), the sensitivity was 0.732 (95% CI, 0.682–0.788), and the specificity was 0.709 (95% CI, 0.658–0.759). The sensitivity of intracerebral hemorrhage hematoma expansion as predicted by an artificial intelligence imaging system was 89.3%, with a specificity of 77.8%, a positive predictive value of 55.6%, a negative predictive value of 95.9%, and a Yoden index of 0.671, which were much higher than those based on the manually labeled noncontrast computed tomography signs. Compared with the existing prediction methods through computed tomographic angiography (CTA) image features and noncontrast computed tomography image features analysis, the artificial intelligence model has higher specificity and sensitivity in the prediction of early hematoma enlargement in patients with intracerebral hemorrhage.