A. Lapostolle, Chloé Loyer, M. Elhorany, T. Chaigneau, F. Bielle, S. Alamowitch, F. Clarençon, C. Elbim
Acute ischemic stroke is a neurologic emergency associated with severe disability and death. There is growing evidence that neutrophil extracellular traps (NETs) contribute to the pathogenesis of acute stroke. By mechanical removal of the occluding thrombus from the patient's vasculature, endovascular thrombectomy enables the collection of thrombus material for immunohistologic analysis. The aim of our study was to strengthen the association of NET content in ischemic thrombi with clinical outcome and guide future therapeutics. We performed an immunohistologic analysis of thrombi from 101 patients with acute ischemic stroke, focusing on the association between NET content and clinical and interventional indicators. NETs were present in every patient with acute ischemic stroke. Their abundance in thrombi was associated with interventional markers of thrombus stability. NET‐rich thrombi were associated with unsuccessful recanalization (modified Thrombolysis in Cerebral Infarction <2B) and longer procedure time, and NET abundance in acute ischemic stroke thrombi was associated with outcomes evaluated by patients’ postassessment National Institutes of Health Stroke Scale and modified Rankin Scale scores. These findings suggest that NET content is critically important to thrombus stability and clinical outcome in acute stroke. They should open new perspectives for innovative immunotherapy strategies based on neutrophil modulation.
{"title":"Neutrophil Extracellular Traps in Ischemic Stroke Thrombi Are Associated Wth Poor Clinical Outcome","authors":"A. Lapostolle, Chloé Loyer, M. Elhorany, T. Chaigneau, F. Bielle, S. Alamowitch, F. Clarençon, C. Elbim","doi":"10.1161/svin.122.000639","DOIUrl":"https://doi.org/10.1161/svin.122.000639","url":null,"abstract":"\u0000 \u0000 Acute ischemic stroke is a neurologic emergency associated with severe disability and death. There is growing evidence that neutrophil extracellular traps (NETs) contribute to the pathogenesis of acute stroke. By mechanical removal of the occluding thrombus from the patient's vasculature, endovascular thrombectomy enables the collection of thrombus material for immunohistologic analysis. The aim of our study was to strengthen the association of NET content in ischemic thrombi with clinical outcome and guide future therapeutics.\u0000 \u0000 \u0000 \u0000 We performed an immunohistologic analysis of thrombi from 101 patients with acute ischemic stroke, focusing on the association between NET content and clinical and interventional indicators.\u0000 \u0000 \u0000 \u0000 NETs were present in every patient with acute ischemic stroke. Their abundance in thrombi was associated with interventional markers of thrombus stability. NET‐rich thrombi were associated with unsuccessful recanalization (modified Thrombolysis in Cerebral Infarction <2B) and longer procedure time, and NET abundance in acute ischemic stroke thrombi was associated with outcomes evaluated by patients’ postassessment National Institutes of Health Stroke Scale and modified Rankin Scale scores.\u0000 \u0000 \u0000 \u0000 These findings suggest that NET content is critically important to thrombus stability and clinical outcome in acute stroke. They should open new perspectives for innovative immunotherapy strategies based on neutrophil modulation.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-04-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48511852","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
J. Vargas, S. Majidi, H. Hawk, S. Nimjee, A. Zakeri, M. Mokin, R. Kellogg, G. Cortez, A. Aghaebrahim, E. Sauvageau, R. Hanel, R. Deleacy, A. Siddiqui, M. Oselkin, Evan Marlin, R. Turner, I. Chaudry, J. Milburn
In addition to enlarging the catheter tip diameter, recent aspiration catheters were designed with a novel angled‐tip design. We aimed to evaluate the efficacy of new‐generation angled‐tip aspiration catheters in comparison to commonly used straight‐tip large‐bore aspiration catheters. We performed a multicenter retrospective analysis of consecutive cases with M1 occlusion treated with aspiration thrombectomy from July 2016 to February 2021. Patients were divided into 2 cohorts: those in whom a 0.071‐inch angled‐tip catheter was used and those in whom a 0.068‐ to 0.074‐inch flat‐tip catheter was used. A total of 384 patients were identified. The angled‐tip catheter was used in 129 (33.6%) patients, whereas 255 (66.4%) patients were treated with flat‐tip catheters. There was no significant difference in age, sex, baseline modified Rankin scale score, side of occlusion, initial National Institutes of Health Stroke Scale score, time from last known normal to access, or rate of intravenous recombinant tPA (tissue‐type plasminogen activator) administration. Use of the angled‐tip reperfusion catheter was associated with average 5‐minute faster time to Thrombolysis in Cerebral Infarction 2B or better (22.13±21.05 versus 27±24.54 minutes; P =0.012) and 7‐minute faster time to final recanalization (25.85±25.22 versus 32.96±29.26 minutes; P =0.011). There was no difference in the rate of good outcome or hemorrhagic transformation. We report a multicenter, retrospective review of patients treated with current generation large‐bore aspiration catheters. Angled‐tipped catheters were associated with shorter times to Thrombolysis in Cerebral Infarction 2B and final reperfusion. There were no differences in 90‐day modified Rankin scale score, rates of intracranial hemorrhage, or complications.
{"title":"Factors Associated With Improved Technical Outcomes When Using 0.068‐ to 0.074‐Inch Aspiration Catheters: Analysis From a Multicenter Retrospective Cohort","authors":"J. Vargas, S. Majidi, H. Hawk, S. Nimjee, A. Zakeri, M. Mokin, R. Kellogg, G. Cortez, A. Aghaebrahim, E. Sauvageau, R. Hanel, R. Deleacy, A. Siddiqui, M. Oselkin, Evan Marlin, R. Turner, I. Chaudry, J. Milburn","doi":"10.1161/svin.122.000580","DOIUrl":"https://doi.org/10.1161/svin.122.000580","url":null,"abstract":"\u0000 \u0000 In addition to enlarging the catheter tip diameter, recent aspiration catheters were designed with a novel angled‐tip design. We aimed to evaluate the efficacy of new‐generation angled‐tip aspiration catheters in comparison to commonly used straight‐tip large‐bore aspiration catheters.\u0000 \u0000 \u0000 \u0000 We performed a multicenter retrospective analysis of consecutive cases with M1 occlusion treated with aspiration thrombectomy from July 2016 to February 2021. Patients were divided into 2 cohorts: those in whom a 0.071‐inch angled‐tip catheter was used and those in whom a 0.068‐ to 0.074‐inch flat‐tip catheter was used.\u0000 \u0000 \u0000 \u0000 \u0000 A total of 384 patients were identified. The angled‐tip catheter was used in 129 (33.6%) patients, whereas 255 (66.4%) patients were treated with flat‐tip catheters. There was no significant difference in age, sex, baseline modified Rankin scale score, side of occlusion, initial National Institutes of Health Stroke Scale score, time from last known normal to access, or rate of intravenous recombinant tPA (tissue‐type plasminogen activator) administration. Use of the angled‐tip reperfusion catheter was associated with average 5‐minute faster time to Thrombolysis in Cerebral Infarction 2B or better (22.13±21.05 versus 27±24.54 minutes;\u0000 P\u0000 =0.012) and 7‐minute faster time to final recanalization (25.85±25.22 versus 32.96±29.26 minutes;\u0000 P\u0000 =0.011). There was no difference in the rate of good outcome or hemorrhagic transformation.\u0000 \u0000 \u0000 \u0000 \u0000 We report a multicenter, retrospective review of patients treated with current generation large‐bore aspiration catheters. Angled‐tipped catheters were associated with shorter times to Thrombolysis in Cerebral Infarction 2B and final reperfusion. There were no differences in 90‐day modified Rankin scale score, rates of intracranial hemorrhage, or complications.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-04-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44234615","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
In this article regarding leadership as a vascular specialist, we describe how to understand personal strengths and weaknesses as a leader and what resources are available to assist in leadership, particularly in the neurosciences. We discuss how to assemble a team, build its culture, and get the most out of a group in such settings as running a successful meeting and setting goals for the group. We delve into the importance of diversity and setting an inclusive vision for a group so that all feel valued and respected. We explore such difficult topics as how to have difficult conversations with a team or its members, how to align financial goals and mission with the hospital and medical school, and how to lead through a crisis.
{"title":"Leadership in the Neurosciences","authors":"","doi":"10.1161/svin.122.000599","DOIUrl":"https://doi.org/10.1161/svin.122.000599","url":null,"abstract":"In this article regarding leadership as a vascular specialist, we describe how to understand personal strengths and weaknesses as a leader and what resources are available to assist in leadership, particularly in the neurosciences. We discuss how to assemble a team, build its culture, and get the most out of a group in such settings as running a successful meeting and setting goals for the group. We delve into the importance of diversity and setting an inclusive vision for a group so that all feel valued and respected. We explore such difficult topics as how to have difficult conversations with a team or its members, how to align financial goals and mission with the hospital and medical school, and how to lead through a crisis.","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-04-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41881013","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A. Pan, T. Potter, A. Bako, Jonika Tannous, C. D. McCane, T. Garg, R. Gadhia, V. Misra, John Volpi, D. Chiu, F. Vahidy
Impact of mediating factors on the relationship between socioeconomic disadvantage and outcomes among patients with acute ischemic stroke has not been well characterized. Data on patients with acute ischemic stroke were extracted from electronic medical records, and 90‐day modified Rankin scale (mRS) scores were collected as part of a prospective stroke registry. Exact patient addresses were geocoded and characterized using Area Deprivation Index (ADI) ranks. The 90‐day modified Rankin scale scores ≥3 were categorized as poor outcomes. Logistic regression models (adjusted for treatment with intravenous tissue plasminogen activator or intraarterial therapy, sociodemographics, and comorbidities) were fitted to compute adjusted odds ratios (aORs) and 95% CIs for total effect of high ADI on poor outcomes. In‐hospital mortality (versus survived) and unfavorable (versus favorable) discharge disposition were also evaluated as outcomes. Structural equation modeling was used to report the average causal mediation effects of stroke severity (National Institutes of Health Stroke Scale [NIHSS]) and treatment (intravenous tissue plasminogen activator or intraarterial therapy). Between May 2016 and December 2021, 13 641 patients with acute ischemic stroke (median age, 69 years; 50.1% women) were included. Among 3002 patients with functional outcomes data, a high ADI was significantly associated with poor 90‐day modified Rankin scale score (aOR, 1.16 [95% CI, 1.04–1.29]). Patients in higher ADI neighborhoods had increased odds of having higher NIHSS scores (aOR, 1.19 [95% CI, 1.07–1.32]). Likewise, a higher NIHSS score was associated with poor 90‐day modified Rankin scale score (aOR, 9.34 [95% CI, 7.64–11.5]). The effect of neighborhood disadvantage on poor 90‐day modified Rankin scale score was 59% mediated by NIHSS score (average causal mediation effects: P <0.001). NIHSS score also accounted for 93% of the pathway for unfavorable discharges. In‐hospital mortality was not associated with ADI, and treatment did not significantly mediate any outcomes. Neighborhood disadvantage leads to unfavorable hospital discharges and worse 90‐day disability, mediated via stroke severity. Tracking social determinants of health may identify opportunities for reducing the onset of severe strokes and poor outcomes.
{"title":"Stroke Severity Mediates the Association Between Socioeconomic Disadvantage and Poor Outcomes Among Patients With Acute Ischemic Stroke","authors":"A. Pan, T. Potter, A. Bako, Jonika Tannous, C. D. McCane, T. Garg, R. Gadhia, V. Misra, John Volpi, D. Chiu, F. Vahidy","doi":"10.1161/svin.122.000487","DOIUrl":"https://doi.org/10.1161/svin.122.000487","url":null,"abstract":"\u0000 \u0000 Impact of mediating factors on the relationship between socioeconomic disadvantage and outcomes among patients with acute ischemic stroke has not been well characterized.\u0000 \u0000 \u0000 \u0000 Data on patients with acute ischemic stroke were extracted from electronic medical records, and 90‐day modified Rankin scale (mRS) scores were collected as part of a prospective stroke registry. Exact patient addresses were geocoded and characterized using Area Deprivation Index (ADI) ranks. The 90‐day modified Rankin scale scores ≥3 were categorized as poor outcomes. Logistic regression models (adjusted for treatment with intravenous tissue plasminogen activator or intraarterial therapy, sociodemographics, and comorbidities) were fitted to compute adjusted odds ratios (aORs) and 95% CIs for total effect of high ADI on poor outcomes. In‐hospital mortality (versus survived) and unfavorable (versus favorable) discharge disposition were also evaluated as outcomes. Structural equation modeling was used to report the average causal mediation effects of stroke severity (National Institutes of Health Stroke Scale [NIHSS]) and treatment (intravenous tissue plasminogen activator or intraarterial therapy).\u0000 \u0000 \u0000 \u0000 \u0000 Between May 2016 and December 2021, 13 641 patients with acute ischemic stroke (median age, 69 years; 50.1% women) were included. Among 3002 patients with functional outcomes data, a high ADI was significantly associated with poor 90‐day modified Rankin scale score (aOR, 1.16 [95% CI, 1.04–1.29]). Patients in higher ADI neighborhoods had increased odds of having higher NIHSS scores (aOR, 1.19 [95% CI, 1.07–1.32]). Likewise, a higher NIHSS score was associated with poor 90‐day modified Rankin scale score (aOR, 9.34 [95% CI, 7.64–11.5]). The effect of neighborhood disadvantage on poor 90‐day modified Rankin scale score was 59% mediated by NIHSS score (average causal mediation effects:\u0000 P\u0000 <0.001). NIHSS score also accounted for 93% of the pathway for unfavorable discharges. In‐hospital mortality was not associated with ADI, and treatment did not significantly mediate any outcomes.\u0000 \u0000 \u0000 \u0000 \u0000 Neighborhood disadvantage leads to unfavorable hospital discharges and worse 90‐day disability, mediated via stroke severity. Tracking social determinants of health may identify opportunities for reducing the onset of severe strokes and poor outcomes.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41696609","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Niklas Helwig, F. Şeker, M. Möhlenbruch, R. Deichmann, U. Nöth, R. Gracien, E. Hattingen, Marlies Wagner, A. Seiler
Collaterals are the main determinants of the severity of cerebral ischemia and control the pace of the ischemic tissue damage in acute ischemic stroke. Assessment of collateral status remains a major challenge in stroke imaging. We evaluated a signal variance–based collateral vessel index in perfusion‐weighted imaging (CVI PWI ) in terms of its association with initial stroke severity, presence of a mismatch for endovascular thrombectomy (EVT), and early functional outcome in patients with large‐vessel occlusion. T2*‐weighted time series from dynamic susceptibility contrast perfusion imaging were processed to calculate the CVI PWI . Ischemic cores were segmented automatically on apparent diffusion coefficient maps. The relationship between collateral status and the fulfilment of mismatch criteria for EVT as well as the association between the CVI PWI and functional outcome in patients undergoing EVT were analyzed. Furthermore, spatial patterns of pial collateralization were investigated. A total of 156 patients with large‐vessel occlusion were included in the final analysis. Higher CVI PWI and thus better collateral supply was associated with lower baseline National Institutes of Health Stroke Scale and smaller baseline infarct volumes ( P =0.022 and P =0.002, respectively), and the CVI PWI varied significantly among groups according to fulfillment of mismatch criteria for EVT ( P <0.001). In patients undergoing EVT (n=105), the CVI PWI was an independent predictor of favorable functional outcome (modified Rankin scale score of 0–2) at discharge in multivariate analysis ( P =0.031). In patients with EVT who had successful reperfusion (n=79), good collateral status was associated with a higher rate of early neurological improvement ( P =0.026) and better functional outcome at discharge ( P =0.04) in shift analysis. Signal variance–based CVI PWI represents a semiquantitative and objective, thus observer‐independent parameter for direct assessment of collateral status with clinical relevance. Its use may inform clinical decision‐making and may be of interest for clinical stroke trials.
{"title":"Leptomeningeal Collateral Status by Signal Variance in Perfusion Magnetic Resonance Imaging: Association With Initial Stroke Severity and Early Functional Outcome After Thrombectomy","authors":"Niklas Helwig, F. Şeker, M. Möhlenbruch, R. Deichmann, U. Nöth, R. Gracien, E. Hattingen, Marlies Wagner, A. Seiler","doi":"10.1161/svin.122.000776","DOIUrl":"https://doi.org/10.1161/svin.122.000776","url":null,"abstract":"\u0000 \u0000 \u0000 Collaterals are the main determinants of the severity of cerebral ischemia and control the pace of the ischemic tissue damage in acute ischemic stroke. Assessment of collateral status remains a major challenge in stroke imaging. We evaluated a signal variance–based collateral vessel index in perfusion‐weighted imaging (CVI\u0000 PWI\u0000 ) in terms of its association with initial stroke severity, presence of a mismatch for endovascular thrombectomy (EVT), and early functional outcome in patients with large‐vessel occlusion.\u0000 \u0000 \u0000 \u0000 \u0000 \u0000 T2*‐weighted time series from dynamic susceptibility contrast perfusion imaging were processed to calculate the CVI\u0000 PWI\u0000 . Ischemic cores were segmented automatically on apparent diffusion coefficient maps. The relationship between collateral status and the fulfilment of mismatch criteria for EVT as well as the association between the CVI\u0000 PWI\u0000 and functional outcome in patients undergoing EVT were analyzed. Furthermore, spatial patterns of pial collateralization were investigated.\u0000 \u0000 \u0000 \u0000 \u0000 \u0000 A total of 156 patients with large‐vessel occlusion were included in the final analysis. Higher CVI\u0000 PWI\u0000 and thus better collateral supply was associated with lower baseline National Institutes of Health Stroke Scale and smaller baseline infarct volumes (\u0000 P\u0000 =0.022 and\u0000 P\u0000 =0.002, respectively), and the CVI\u0000 PWI\u0000 varied significantly among groups according to fulfillment of mismatch criteria for EVT (\u0000 P\u0000 <0.001). In patients undergoing EVT (n=105), the CVI\u0000 PWI\u0000 was an independent predictor of favorable functional outcome (modified Rankin scale score of 0–2) at discharge in multivariate analysis (\u0000 P\u0000 =0.031). In patients with EVT who had successful reperfusion (n=79), good collateral status was associated with a higher rate of early neurological improvement (\u0000 P\u0000 =0.026) and better functional outcome at discharge (\u0000 P\u0000 =0.04) in shift analysis.\u0000 \u0000 \u0000 \u0000 \u0000 \u0000 Signal variance–based CVI\u0000 PWI\u0000 represents a semiquantitative and objective, thus observer‐independent parameter for direct assessment of collateral status with clinical relevance. Its use may inform clinical decision‐making and may be of interest for clinical stroke trials.\u0000 \u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42078013","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
C. Beaman, Smit D. Patel, K. Nael, G. Colby, D. Liebeskind
Vascular imaging is an essential tool to appropriately diagnose and treat intracranial saccular aneurysms. There is extensive heterogeneity in aneurysm characteristics including location, size, shape, patient demographics, and clinical status that leads to a great diversity in both surgical and endovascular treatment options. This variability may elicit confusion when deciding the most appropriate imaging paradigm for an individual patient at particular time points. A collection of pre‐ and posttreatment scales and grades exist, but there is no current consensus on which one to implement. In this review, we discuss the key advantages and disadvantages of the available imaging modalities and how each can guide management. We also review novel imaging tools that are likely to alter the diagnostic landscape of intracranial aneurysms in the coming years.
{"title":"Imaging of Intracranial Saccular Aneurysms","authors":"C. Beaman, Smit D. Patel, K. Nael, G. Colby, D. Liebeskind","doi":"10.1161/svin.122.000757","DOIUrl":"https://doi.org/10.1161/svin.122.000757","url":null,"abstract":"Vascular imaging is an essential tool to appropriately diagnose and treat intracranial saccular aneurysms. There is extensive heterogeneity in aneurysm characteristics including location, size, shape, patient demographics, and clinical status that leads to a great diversity in both surgical and endovascular treatment options. This variability may elicit confusion when deciding the most appropriate imaging paradigm for an individual patient at particular time points. A collection of pre‐ and posttreatment scales and grades exist, but there is no current consensus on which one to implement. In this review, we discuss the key advantages and disadvantages of the available imaging modalities and how each can guide management. We also review novel imaging tools that are likely to alter the diagnostic landscape of intracranial aneurysms in the coming years.","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43146831","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
F. Benali, Jianhai Zhang, Najratun Nayem Pinky, F. Bala, I. Alhabli, Rotem Golan, Luis A Souto Maior Neto, Ibukun Elebute, Chris C. Duszynski, Wu Qiu, B. Menon
We recently developed a novel machine learning‐based algorithm using multiphase computed tomography angiography (mCTA) to generate perfusion maps of the brain, similar to computed tomography perfusion (CTP) (ie, multiphase CTA perfusion [mCTAp]). Here, we aim to validate the clinical utility of mCTAp in detection of brain ischemia and its side, extent, and location. In this prospective multi‐reader‐multi‐case analysis, we included baseline images: mCTAp ( StrokeSENS ‐algorithm) and CTP (4D; GE Healthcare) from 121 randomly selected patients whose scans were not part of algorithm‐development. After excluding 2/121 scans because of poor image‐quality, 3 experienced radiologists read time to maximum, and relative cerebral blood flow‐maps generated by the test (mCTAp) and reference (CTP) modality. The 2 reading sessions were separated by 5 days although the reading order was randomized. Core laboratory imaging assessments – that used non contrast computed tomography, mCTA, and CTP – were considered as ground‐truth. A mixed‐effects statistical model with “reader” as random effects variable was used to calculate the area under the curve (with 95% CI), sensitivity, and specificity for both modalities (mCTAp/CTP) for ischemia detection, affected side, and occlusion location. The time required for interpretation and inter‐rater variability in assessments were compared across the 2 modalities. Area under the curves (95% CI) for detecting ischemia using mCTAp and CTP were 0.85 (95% CI, 0.8–0.9) and 0.84 (0.8–0.9) respectively ( P =0.43). Area under the curves for the affected side were 0.94 (0.92–0.97) and 0.96 (0.94–0.98) ( P =0.69), respectively; for detecting large vessel occlusion were 0.84 (0.8–0.9) and 0.86 (0.8–0.9), ( P =0.31), respectively; M2‐or‐distal occlusion were 0.79 (0.73–0.84) and 0.88 (0.83–0.92) ( P =0.22), respectively, for anterior cerebral artery‐occlusion 0.82 (0.66–0.98) and 0.93 (0.82–1.00) ( P =0.15), respectively, and for posterior cerebral artery‐occlusions 0.9 (0.8–1) and 0.99 (0.98–0.99) ( P =0.01), respectively. The median (interquartile range [IQR]) time for image interpretation was 62 seconds (IQR, 46–78) and 59 seconds (IQR, 42–69) for mCTAp and CTP, respectively, ( P =0.15). Fleiss` Kappa‐values for inter‐rater reliability in detecting ischemia were 0.5 and 0.8 for mCTAp and CTP, respectively. mCTAp shows similar performance and interpretation times compared to CTP in assisting readers to detect brain ischemia, affected side, and occlusion location, but mainly as it relates to proximal vessel occlusions. The proposed tool still needs further refinement for distal vessel occlusions. Nonetheless, mCTAp is a promising tool as it allows for acquisition of brain perfusion maps with lower radiation exposure, acquisition time, and contrast dose compared with additional CTP.
{"title":"Validation of a Novel Multiphase CTA Perfusion Tool Compared to CTP in Patients With Suspected Acute Ischemic Stroke","authors":"F. Benali, Jianhai Zhang, Najratun Nayem Pinky, F. Bala, I. Alhabli, Rotem Golan, Luis A Souto Maior Neto, Ibukun Elebute, Chris C. Duszynski, Wu Qiu, B. Menon","doi":"10.1161/svin.122.000811","DOIUrl":"https://doi.org/10.1161/svin.122.000811","url":null,"abstract":"\u0000 \u0000 We recently developed a novel machine learning‐based algorithm using multiphase computed tomography angiography (mCTA) to generate perfusion maps of the brain, similar to computed tomography perfusion (CTP) (ie, multiphase CTA perfusion [mCTAp]). Here, we aim to validate the clinical utility of mCTAp in detection of brain ischemia and its side, extent, and location.\u0000 \u0000 \u0000 \u0000 \u0000 In this prospective multi‐reader‐multi‐case analysis, we included baseline images: mCTAp (\u0000 StrokeSENS\u0000 ‐algorithm) and CTP (4D; GE Healthcare) from 121 randomly selected patients whose scans were not part of algorithm‐development. After excluding 2/121 scans because of poor image‐quality, 3 experienced radiologists read time to maximum, and relative cerebral blood flow‐maps generated by the test (mCTAp) and reference (CTP) modality. The 2 reading sessions were separated by 5 days although the reading order was randomized. Core laboratory imaging assessments – that used non contrast computed tomography, mCTA, and CTP – were considered as ground‐truth. A mixed‐effects statistical model with “reader” as random effects variable was used to calculate the area under the curve (with 95% CI), sensitivity, and specificity for both modalities (mCTAp/CTP) for ischemia detection, affected side, and occlusion location. The time required for interpretation and inter‐rater variability in assessments were compared across the 2 modalities.\u0000 \u0000 \u0000 \u0000 \u0000 \u0000 Area under the curves (95% CI) for detecting ischemia using mCTAp and CTP were 0.85 (95% CI, 0.8–0.9) and 0.84 (0.8–0.9) respectively (\u0000 P\u0000 =0.43). Area under the curves for the affected side were 0.94 (0.92–0.97) and 0.96 (0.94–0.98) (\u0000 P\u0000 =0.69), respectively; for detecting large vessel occlusion were 0.84 (0.8–0.9) and 0.86 (0.8–0.9), (\u0000 P\u0000 =0.31), respectively; M2‐or‐distal occlusion were 0.79 (0.73–0.84) and 0.88 (0.83–0.92) (\u0000 P\u0000 =0.22), respectively, for anterior cerebral artery‐occlusion 0.82 (0.66–0.98) and 0.93 (0.82–1.00) (\u0000 P\u0000 =0.15), respectively, and for posterior cerebral artery‐occlusions 0.9 (0.8–1) and 0.99 (0.98–0.99) (\u0000 P\u0000 =0.01), respectively. The median (interquartile range [IQR]) time for image interpretation was 62 seconds (IQR, 46–78) and 59 seconds (IQR, 42–69) for mCTAp and CTP, respectively, (\u0000 P\u0000 =0.15). Fleiss` Kappa‐values for inter‐rater reliability in detecting ischemia were 0.5 and 0.8 for mCTAp and CTP, respectively.\u0000 \u0000 \u0000 \u0000 \u0000 mCTAp shows similar performance and interpretation times compared to CTP in assisting readers to detect brain ischemia, affected side, and occlusion location, but mainly as it relates to proximal vessel occlusions. The proposed tool still needs further refinement for distal vessel occlusions. Nonetheless, mCTAp is a promising tool as it allows for acquisition of brain perfusion maps with lower radiation exposure, acquisition time, and contrast dose compared with additional CTP.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41385669","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
J. Catapano, Katriel E. Lee, S. Desai, India C. Rangel, H. Stonnington, K. Rumalla, C. Rutledge, V. Srinivasan, J. Baranoski, T. Cole, E. Winkler, A. Ducruet, F. Albuquerque, A. Jadhav
Endovascular thrombectomy is the gold‐standard treatment for large vessel occlusions (LVOs). A novel metric is introduced: the number needing review (NNR) to assess the triage efficiency of LVO detection systems. Patients with suspected ischemic stroke and images processed by RapidAI LVO detection software over 6 months were reviewed. Only patients with LVOs of the M1 segment were included. The NNR was calculated for an M1 occlusion. Of 559 patients, M1 occlusion was detected in 42 patients (7.5%). RapidAI LVO had a sensitivity of 71%, specificity of 94%, positive predictive value of 49%, and negative predictive value of 92% for M1 occlusion. When gaze deviation and hyperdense sign were combined with RapidAI LVO, the specificity and positive predictive value increased to 100% for an M1 occlusion. A negative RapidAI LVO result combined with a low (<15 mL, T max >6 seconds) or high (<50 mL, T max >6 seconds) T max threshold was found to have a specificity and positive predictive value of 100% for no occlusion. The combination of gaze deviation, hyperdense sign, positive RapidAI LVO, and negative RapidAI LVO with low T max threshold yielded an NNR of 24 per 100 cases. When combined with a negative RapidAI LVO and a high T max threshold, the NNR was 16 per 100 cases. Adding National Institutes of Health Stroke Scale score <7 decreased the NNR to 9 per 100 cases. Adding gaze deviation and hyperdense sign to the RapidAI LVO increases the specificity and positive predictive value for an M1 occlusion. When combined with a negative RapidAI LVO detection and either a low or high T max >6 seconds threshold, the NNR is significantly reduced.
{"title":"Number Needing Review: A Novel Metric to Assess Triage Efficiency of Large Vessel Occlusion Detection Systems","authors":"J. Catapano, Katriel E. Lee, S. Desai, India C. Rangel, H. Stonnington, K. Rumalla, C. Rutledge, V. Srinivasan, J. Baranoski, T. Cole, E. Winkler, A. Ducruet, F. Albuquerque, A. Jadhav","doi":"10.1161/svin.122.000527","DOIUrl":"https://doi.org/10.1161/svin.122.000527","url":null,"abstract":"\u0000 \u0000 Endovascular thrombectomy is the gold‐standard treatment for large vessel occlusions (LVOs). A novel metric is introduced: the number needing review (NNR) to assess the triage efficiency of LVO detection systems.\u0000 \u0000 \u0000 \u0000 Patients with suspected ischemic stroke and images processed by RapidAI LVO detection software over 6 months were reviewed. Only patients with LVOs of the M1 segment were included. The NNR was calculated for an M1 occlusion.\u0000 \u0000 \u0000 \u0000 \u0000 Of 559 patients, M1 occlusion was detected in 42 patients (7.5%). RapidAI LVO had a sensitivity of 71%, specificity of 94%, positive predictive value of 49%, and negative predictive value of 92% for M1 occlusion. When gaze deviation and hyperdense sign were combined with RapidAI LVO, the specificity and positive predictive value increased to 100% for an M1 occlusion. A negative RapidAI LVO result combined with a low (<15 mL, T\u0000 max\u0000 >6 seconds) or high (<50 mL, T\u0000 max\u0000 >6 seconds) T\u0000 max\u0000 threshold was found to have a specificity and positive predictive value of 100% for no occlusion. The combination of gaze deviation, hyperdense sign, positive RapidAI LVO, and negative RapidAI LVO with low T\u0000 max\u0000 threshold yielded an NNR of 24 per 100 cases. When combined with a negative RapidAI LVO and a high T\u0000 max\u0000 threshold, the NNR was 16 per 100 cases. Adding National Institutes of Health Stroke Scale score <7 decreased the NNR to 9 per 100 cases.\u0000 \u0000 \u0000 \u0000 \u0000 \u0000 Adding gaze deviation and hyperdense sign to the RapidAI LVO increases the specificity and positive predictive value for an M1 occlusion. When combined with a negative RapidAI LVO detection and either a low or high T\u0000 max\u0000 >6 seconds threshold, the NNR is significantly reduced.\u0000 \u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48981893","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jennifer L. Patterson, Wendy Dusenbury, A. Stanfill, B. Brewer, A. Alexandrov, A. Alexandrov
Transfer times from primary stroke centers and acute stroke–ready hospitals to higher levels of care are often excessive, prompting some to suggest ambulance bypass regulations. Since barriers to rapid transfer have never been fully explored, we sought to understand stroke coordinators’ experiences with transfer of patients with hyperacute stroke from lower to higher levels of stroke centers. We conducted a national focus group study with primary stroke center stroke coordinators who had recent experience overseeing transfer of a patient with hyperacute stroke to a higher‐level stroke center. Interviews were conducted using prescripted open‐ended questions; information was recorded and data were transcribed for theme identification. A total of 23 stroke coordinators participated representing the Northeast, Mid‐Atlantic, Southeast, Midwest, and Western United States. Findings were grouped into 3 main categories: Internal Primary Stroke Center Factors, Transport Factors, and External Comprehensive Stroke Center Factors. Within the primary stroke center group, themes slowing transfer were exclusively physician based, whereas themes emerging from the transport category were associated with poor transport company processes. Within the comprehensive stroke center category, themes were all associated with complex hospital processes and communication. Important contributors to efficient transfer of patients with hyperacute stroke are beyond the control of stroke coordinators, requiring cross‐system collaboration and improved administrative management to resolve. Quantification of these factors is warranted to support transfer system redesign for rapid access to care for patients with stroke.
{"title":"Transferring Patients From a Primary Stroke Center to Higher Levels of Care: A Qualitative Study of Stroke Coordinators’ Experiences","authors":"Jennifer L. Patterson, Wendy Dusenbury, A. Stanfill, B. Brewer, A. Alexandrov, A. Alexandrov","doi":"10.1161/svin.122.000678","DOIUrl":"https://doi.org/10.1161/svin.122.000678","url":null,"abstract":"\u0000 \u0000 Transfer times from primary stroke centers and acute stroke–ready hospitals to higher levels of care are often excessive, prompting some to suggest ambulance bypass regulations. Since barriers to rapid transfer have never been fully explored, we sought to understand stroke coordinators’ experiences with transfer of patients with hyperacute stroke from lower to higher levels of stroke centers.\u0000 \u0000 \u0000 \u0000 We conducted a national focus group study with primary stroke center stroke coordinators who had recent experience overseeing transfer of a patient with hyperacute stroke to a higher‐level stroke center. Interviews were conducted using prescripted open‐ended questions; information was recorded and data were transcribed for theme identification.\u0000 \u0000 \u0000 \u0000 A total of 23 stroke coordinators participated representing the Northeast, Mid‐Atlantic, Southeast, Midwest, and Western United States. Findings were grouped into 3 main categories: Internal Primary Stroke Center Factors, Transport Factors, and External Comprehensive Stroke Center Factors. Within the primary stroke center group, themes slowing transfer were exclusively physician based, whereas themes emerging from the transport category were associated with poor transport company processes. Within the comprehensive stroke center category, themes were all associated with complex hospital processes and communication.\u0000 \u0000 \u0000 \u0000 Important contributors to efficient transfer of patients with hyperacute stroke are beyond the control of stroke coordinators, requiring cross‐system collaboration and improved administrative management to resolve. Quantification of these factors is warranted to support transfer system redesign for rapid access to care for patients with stroke.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48843227","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
F. Benali, J. Fladt, T. Jaroenngarmsamer, F. Bala, N. Singh, I. Alhabli, J. Ospel, M. Tymianski, Michael D. Hill, M. Goyal, A. Ganesh
Patients with white matter disease (WMD) – a key marker of cerebral small vessel disease – may have less brain reserve to cope with ischemic injury. The relationship of WMD to functional recovery after endovascular thrombectomy is uncertain. We aim to explore the association between WMD and functional outcome, assessed at multiple time‐points postendovascular thrombectomy. In this post hoc analysis, we analyzed noncontrast computed tomography‐imaging from the ESCAPE‐NA1 (Safety and Efficacy of Nerinetide [NA‐1] in Subjects Undergoing Endovascular Thrombectomy for Stroke) trial and assessed WMD by using the total Fazekas‐score (score range: 0–6). The primary outcome was repeated measurements of the modified Rankin scale (mRS) scores (i.e., day‐5/discharge, day‐30, and day‐90). Secondary outcome measures were the ordinal‐mRS at 90‐days, 90‐day‐mRS0–2, and 90‐day‐mortality. Mixed‐linear and binary/ordinal logistic regressions were performed, adjusting for age, sex, baseline National Institutes of Health Stroke Scale, cortical atrophy, chronic infarctions, stroke laterality, follow‐up infarct volume, and alteplase–nerinetide interaction. Sensitivity analyses were done including only those patients for whom magnetic resonance imaging was available. We included 1102 patients with noncontrast computed tomography (median age 71, interquartile range: 61–80; median National Institutes of Health Stroke Scale 17, interquartile range: 12–21). The median total Fazekas‐score was 1(interquartile range: 0–2). Out of 1202 patients, 566 had follow‐up magnetic resonance imaging. We observed heterogeneity in functional recovery with varying degrees of WMD‐burden ( P <0.001). Patients with Fazekas=3–6 fared worse at every time‐point after endovascular thrombectomy, compared with patients with Fazekas=0–1. At 30‐days, the adjusted difference of the mean mRS=0.47; 95% CI, 0.22–0.72 and at 90‐days: adjusted difference=0.60 (95% CI, 0.36–0.85). Higher WMD‐burdens were also associated with worse 90‐day mRS (adjusted common odds ratio for Fazekas=3–6 versus 0–1: 1.42; 95% CI, 1.03–1.96). Similar results were found in magnetic resonance imaging‐only sensitivity analyses. Patients with more WMD showed worse functional recovery after endovascular thrombectomy, compared with patients without WMD, even after adjusting for age and chronic disease markers like atrophy and chronic infarctions. These data may further help inform treatment expectations and recovery‐related planning, by using simple visual ratings on routinely acquired noncontrast computed tomography.
{"title":"Association of White Matter Disease With Functional Recovery and 90‐Day Outcome After EVT: Beyond Chronological Age","authors":"F. Benali, J. Fladt, T. Jaroenngarmsamer, F. Bala, N. Singh, I. Alhabli, J. Ospel, M. Tymianski, Michael D. Hill, M. Goyal, A. Ganesh","doi":"10.1161/svin.122.000734","DOIUrl":"https://doi.org/10.1161/svin.122.000734","url":null,"abstract":"\u0000 \u0000 Patients with white matter disease (WMD) – a key marker of cerebral small vessel disease – may have less brain reserve to cope with ischemic injury. The relationship of WMD to functional recovery after endovascular thrombectomy is uncertain. We aim to explore the association between WMD and functional outcome, assessed at multiple time‐points postendovascular thrombectomy.\u0000 \u0000 \u0000 \u0000 In this post hoc analysis, we analyzed noncontrast computed tomography‐imaging from the ESCAPE‐NA1 (Safety and Efficacy of Nerinetide [NA‐1] in Subjects Undergoing Endovascular Thrombectomy for Stroke) trial and assessed WMD by using the total Fazekas‐score (score range: 0–6). The primary outcome was repeated measurements of the modified Rankin scale (mRS) scores (i.e., day‐5/discharge, day‐30, and day‐90). Secondary outcome measures were the ordinal‐mRS at 90‐days, 90‐day‐mRS0–2, and 90‐day‐mortality. Mixed‐linear and binary/ordinal logistic regressions were performed, adjusting for age, sex, baseline National Institutes of Health Stroke Scale, cortical atrophy, chronic infarctions, stroke laterality, follow‐up infarct volume, and alteplase–nerinetide interaction. Sensitivity analyses were done including only those patients for whom magnetic resonance imaging was available.\u0000 \u0000 \u0000 \u0000 \u0000 We included 1102 patients with noncontrast computed tomography (median age 71, interquartile range: 61–80; median National Institutes of Health Stroke Scale 17, interquartile range: 12–21). The median total Fazekas‐score was 1(interquartile range: 0–2). Out of 1202 patients, 566 had follow‐up magnetic resonance imaging. We observed heterogeneity in functional recovery with varying degrees of WMD‐burden (\u0000 P\u0000 <0.001). Patients with Fazekas=3–6 fared worse at every time‐point after endovascular thrombectomy, compared with patients with Fazekas=0–1. At 30‐days, the adjusted difference of the mean mRS=0.47; 95% CI, 0.22–0.72 and at 90‐days: adjusted difference=0.60 (95% CI, 0.36–0.85). Higher WMD‐burdens were also associated with worse 90‐day mRS (adjusted common odds ratio for Fazekas=3–6 versus 0–1: 1.42; 95% CI, 1.03–1.96). Similar results were found in magnetic resonance imaging‐only sensitivity analyses.\u0000 \u0000 \u0000 \u0000 \u0000 Patients with more WMD showed worse functional recovery after endovascular thrombectomy, compared with patients without WMD, even after adjusting for age and chronic disease markers like atrophy and chronic infarctions. These data may further help inform treatment expectations and recovery‐related planning, by using simple visual ratings on routinely acquired noncontrast computed tomography.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45587396","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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