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OBJECTIVES: Individual subcortical infarct scoring for the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) can be difficult and is subjected to higher inter-reader variability. This study compares performance of the 10-point ASPECTS with a new 7-point cortically-weighted score in predicting post-thrombectomy functional outcomes. MATERIALS AND METHODS: Prospective registry data from two comprehensive stroke centers (Site 1 2016-2021; Site 2: 2019-2021) included patients with either M1 segment of middle cerebral artery or internal carotid artery occlusions who underwent thrombectomy. Two multivariate proportional odds training models utilizing either 10-point or 7-point ASPECTS predicting 90-day shift in modified Rankin score were generated using Site 1 data and validated with Site 2 data. Models were compared using multiclass receiver operator characteristics, corrected Akaike's Information Criterion, and likelihood ratio test. RESULTS: Of 328 patients (Site 1 = 181, Site 2 = 147), median age was 71y (IQR 61-82), 119 (36%) had internal carotid artery occlusions, and median 10-point ASPECTS was 9 (IQR 8-10). There was no difference in performance between models using either total or cortically-weighted ASPECTS (p=0.14). Validation cohort data were correctly (i.e., predicting modified Rankin score within one point) classified 50% (cortically-weighted score model) and 56% (total score model) of the time. CONCLUSIONS: The 7-point cortically-weighted ASPECTS was similarly predictive of post-thrombectomy functional outcome as 10-point ASPECTS. Given noninferior performance, the cortically-weighted score is a potentially reliable, but simplified, alternative to the traditional scoring paradigm, with potential implications in automated image analysis tool development.
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Isquemia Encefálica , Acidente Vascular Cerebral , Humanos , Idoso , Alberta , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Trombectomia/efeitos adversos , Tomografia Computadorizada por Raios X , Artéria Cerebral Média , Resultado do Tratamento , Estudos RetrospectivosRESUMO
OBJECTIVES: To determine hospital-level factors associated with thrombectomy uptake. MATERIALS AND METHODS: The Nationwide Emergency Department Sample was retrospectively queried to determine the total number of thrombectomies performed based on different hospital characteristics. Joint point analysis was used to determine which years were associated with significant increases in the number of high-volume thrombectomy centers (ostensibly defined as >50 thrombectomies/year), thrombectomy-capable centers (>15 thrombectomies/year), and total number of thrombectomies performed. Multivariable logistic regression was used to determine hospital factors associated with having an increased odds of performing thrombectomies, and of being classified as a high-volume thrombectomy or a thrombectomy-capable center. RESULTS: Between 2007-2020 there was a stepwise increase in the number of thrombectomy-capable and high-volume thrombectomy centers in the United States. In 2020, there were a total of 15,705 thrombectomies performed, with 89 high-volume thrombectomy centers, and 359 thrombectomy-capable centers. The number of thrombectomy-capable centers significantly increased after 2011. After 2013 and 2016 there was a significant change in the growth rate of high-volume thrombectomy centers. There was also a significant increase in the total number of thrombectomies performed after 2016. Hospital characteristics that were associated with an increased likelihood of being classified as thrombectomy-capable or high-volume included trauma level 1 and 2 hospitals. CONCLUSIONS: Between 2007 and 2020, there was a marked growth in thrombectomy utilization for acute ischemic stroke. This growth outpaced new diagnoses of ischemic stroke, and was driven largely by certain hospital types, with the greatest rises following seminal publications of positive randomized thrombectomy trials.
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Isquemia Encefálica , AVC Isquêmico , Acidente Vascular Cerebral , Humanos , Estados Unidos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Isquemia Encefálica/diagnóstico , Estudos Retrospectivos , Trombectomia/efeitos adversos , Hospitais , Resultado do TratamentoRESUMO
BACKGROUND: Prior studies have elucidated a relationship between nonstenotic plaque in patients with cryptogenic embolic infarcts with a largely cortical topology, however, it is unclear if nonstenotic cervical internal carotid artery (ICA) plaque is relevant in subcortical cryptogenic infarct patterns. METHODS: A nested cohort of consecutive patients with anterior, unilateral, and subcortical infarcts without an identifiable embolic source were identified from a prospective stroke registry (September 2019 - June 2021). Patients with extracranial stenosis >50% or cardiac sources of embolism were excluded. Patients with computed tomography angiography were included and comparisons were made according to the infarct pattern being lacunar versus non-lacunar. Prevalence estimates for cervical internal carotid artery (ICA) plaque presence were estimated with 95% confidence intervals (CI), and differences in plaque thickness and features were compared between sides. RESULTS: Of the 1684 who were screened, 141 met inclusion criteria (n=80 due to small vessel disease, n=61 cryptogenic). The median age was 66y (interquartile range, IQR 58-73) and the National Institutes of Health Stroke Scale score was 3 (IQR 1-5). There was a higher probability of finding excess plaque ipsilateral to the stroke (41.1%, 95% CI 33.3-49.3%) than finding excess contralateral plaque (29.1%, 95% CI 22.2-37.1%; p=0.03), but this was driven by patients with non-lacunar infarcts (excess ipsilateral vs. contralateral plaque frequency of 49.2% vs. 14.8%, p<0.001) rather than lacunar infarcts (35.0% vs. 40.0%, p=0.51). CONCLUSIONS: The probability of finding ipsilateral, nonstenotic carotid plaque in patients with subcortical cryptogenic strokes exceeds the probability of contralateral plaque and is driven by larger subcortical infarcts, classically defined as being cryptogenic. Approximately 1 in 3 unilateral anterior subcortical infarcts may be due to nonstenotic ICA plaque.
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Estenose das Carótidas , Placa Aterosclerótica , Acidente Vascular Cerebral , Humanos , Idoso , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Infarto Cerebral/diagnóstico por imagem , Infarto Cerebral/epidemiologia , Infarto Cerebral/etiologia , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/epidemiologia , Artérias CarótidasRESUMO
Investigating skeletal adaptations to bipedalism informs our understanding of form-function relationships. The calcaneus is an important skeletal element to study because it is a weight-bearing bone with a critical locomotor role. Although other calcaneal regions have been well studied, we lack a clear understanding of the functional role of the lateral plantar process (LPP). The LPP is a bony protuberance on the inferolateral portion of the calcaneus thought to aid the tuberosity in transmission of ground reaction forces during heel-strike. Here, we analyze LPP internal trabecular structure relative to other calcaneal regions to investigate its potential functional affinities. Human calcanei (n = 20) were micro-CT scanned, and weighted spherical harmonic analysis outputs were used to position 251 volumes of interest (VOI) within each bone. Trabecular thickness (Tb.Th), spacing (Tb.Sp), degree of anisotropy (DA), and bone volume fraction (BV/TV) were calculated for each VOI. Similarities in BV/TV and DA (p = 0.2741) between the LPP and inferior tuberosity support suggestions that the LPP is a weight-bearing structure that may transmit forces in a similar direction. The LPP significantly differs from the inferior tuberosity in Tb.Th and Tb.Sp (p < 0.05). Relatively thinner, more closely spaced trabeculae in the LPP may serve to increase internal surface area to compensate for its relatively small size compared to the tuberosity. Significant differences in all parameters between LPP and joint articular surfaces indicate that trabecular morphology is differently adapted for the transmission of forces associated with body mass through joints.
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Calcâneo , Microtomografia por Raio-X , Humanos , Calcâneo/anatomia & histologia , Calcâneo/fisiologia , Calcâneo/diagnóstico por imagem , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , Osso Esponjoso/anatomia & histologia , Osso Esponjoso/fisiologia , Osso Esponjoso/diagnóstico por imagem , Suporte de Carga/fisiologia , AdultoRESUMO
INTRODUCTION: Total ankle replacement is indicated for end-stage ankle osteoarthritis. Periprosthetic radiolucency, from separation between the bone and implant, is suggested to be indicative of potential prosthesis failure risk. Anchoring implants with cement may mitigate this. This study aimed to compare rates of periprosthetic radiolucency between patients with cement-affixed and cementless implants. METHODS: A retrospective analysis was performed on 28 patients who underwent total ankle replacement with the INFINITY Total Ankle System (Wright Medical, Memphis, Tennessee) implant between January 2016 and May 2022. Anteroposterior, mortise, and lateral ankle X-rays were reviewed by 2 independent reviewers for tibiotalar angle, talar tilt, and periprosthetic radiolucency. The Wilcoxon rank-sum test and chi-square test were performed. RESULTS: The incidence of periprosthetic radiolucency at the most recent follow-up did not significantly differ between cement and cementless groups (57.1% in both groups, P = 1.0). Follow-up tibiotalar and talar tilt angles were not significantly different (P > .51 for all comparisons). CONCLUSIONS: Patients with cemented implants had a similar incidence of periprosthetic radiolucency compared with patients with cementless prostheses. Understanding of long-term clinical outcomes will help inform optimal operative approaches for ankle prostheses. LEVELS OF EVIDENCE: Therapeutic, Level III, Retrospective cohort study.
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BACKGROUND: Histotripsy is a novel, ultrasound-based ablative technique that was recently approved by the Food and Drug Administration for hepatic targets. It has several promising additional theoretical applications that need to be further investigated. Its basis as a nonthermal cavitational technology presents a unique advantage over existing thermal ablation techniques in maximizing local effects while minimizing adjacent tissue destruction. This review discusses the technical basis and current preclinical and clinical data surrounding histotripsy. METHODS: This was a comprehensive review of the literature surrounding histotripsy and the clinical landscape of existing ablative techniques using the PubMed database. A technical summary of histotripsy's physics and cellular effect was described. Moreover, data from recent clinical trials, including Hope4Liver, and future implications regarding its application in various benign and malignant conditions were discussed. RESULTS: Preclinical data demonstrated the efficacy of histotripsy ablation in various organ systems with minimal tissue destruction when examined at the histologic level. The first prospective clinical trial involving histotripsy in hepatocellular carcinoma and liver metastases, Hope4Liver, demonstrated a primary efficacy of 95.5% with minimal complications (6.8%). This efficacy was replicated in similar trials involving the treatment of benign prostatic hypertrophy. DISCUSSION: In addition to the noninvasive ability to ablate lesions in the liver, histotripsy offers additional therapeutic potential. Early data suggest a potential complementary therapeutic effect when combining histotripsy with existing immunologic therapies because of the technology's theoretical ability to sensitize tumors to adaptive immunity. As with most novel therapies, the effect of histotripsy on the oncologic therapeutic landscape remains uncertain.
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Neoplasias Hepáticas , Humanos , Neoplasias Hepáticas/terapia , Ablação por Ultrassom Focalizado de Alta Intensidade/métodos , Carcinoma Hepatocelular/terapia , Carcinoma Hepatocelular/patologia , Animais , PrevisõesRESUMO
INTRODUCTION: Collaboration between the health care industry and surgeons is critical in modern medicine. Conflict of interest (COI) has the risk of introducing bias into research studies. We investigated the accuracy of self-disclosed COI for studies that researched the use of microwave ablation for liver metastasis. METHODS: A literature search identified studies that investigated the use of microwave ablation for liver cancer between 2016 and 2022. We utilized the Open Payments Database to query individual authors' financial contributions from the industry. The accuracy of the disclosure statement and financial contribution for each study and author was calculated. We compared the amount of financial contribution authors received based on the accuracy of their COI statement. RESULTS: Twenty-five studies of interest were identified. The mean number of authors was 8.24. A disclosure statement was present in 52% of studies. Of those, 28% had an incongruent disclosure statement. 9/25 (36%) of studies had a conflict of interest based on financial payments provided by industry. Overall, authors received an average of $440,483.41 (SD $1,889,375.34). We did not find a difference in the financial contribution's value based on the disclosure statement's accuracy (P = .55). CONCLUSIONS: Over a quarter of studies in our review of microwave ablation literature had discrepancies in the reporting of conflicts of interest, highlighting the need for improved reporting of potential conflicts of interest to protect the integrity of clinical research. Compared to other fields of surgery, we found a lower rate of undisclosed COI, suggesting that the scope of cancer-directed surgery may be more resistant to industry influence.
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Conflito de Interesses , Neoplasias Hepáticas , Humanos , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/secundário , Micro-Ondas/uso terapêutico , Revelação/ética , Técnicas de Ablação/ética , Técnicas de Ablação/economiaRESUMO
Background The etiology of rotator cuff tears is thought to be multifactorial with current literature that varies with regard to identifiable risk factors. The purpose of this retrospective review was to identify risk factors for full-thickness rotator cuff tears and determine whether they differ in young versus older individuals. Methods To determine the presence or absence of a rotator cuff tear, 1,561 patients with a shoulder MRI were reviewed. If a tear was present, it was further classified into a partial or full-thickness tear. Demographic variables and clinical data were collected and analyzed with a two-sided Student's t-test or Wilcoxon rank sum test for continuous variables and a Chi-square test or Fisher's exact test for categorical variables. Age and BMI were dichotomized using receiver operator curves. Results Charlson Comorbidity Index, age, BMI, sex, race, and work status were all factors that variably affected a patient's risk of experiencing a rotator cuff tear, with different factors carrying more influence on outcomes within those who are older versus those who are younger. Gender and race were found to differ as risk factors between young and older individuals. Conclusion We were able to identify risk factors overall associated with increased odds of sustaining a full-thickness rotator cuff tear. Our analyses also showed differences in the effect of gender and race as risk factors between young and older patients with rotator cuff tears. This finding may aid clinicians in counseling patients on more specific risks for their given age.
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Objective Identifying ischemic stroke is a diagnostic challenge in the trauma subpopulation. We describe our early experience with artificial intelligence-assisted image analysis software for automatically identifying acute ischemic stroke in trauma patients. Methods Patients were retrospectively screened for (i) admission to the trauma service at a level one trauma center between 2020 and 2022, (ii) radiologist-confirmed intracranial occlusion, (iii) occlusion identified on computed tomography angiography performed within 24 hours of admission, (iv) no intracranial hemorrhage, and (v) contemporaneous analysis with the large vessel occlusion (LVO) detection program. Baseline characteristics, stroke detection, response-activation, and outcome data were summarized. Results Of 9893 trauma patients admitted, 88 (0.89%) patients had a cerebral stroke diagnosis, of which 10 patients (10/88; 11.4%) met inclusion criteria. Most patients were admitted following a fall (8/10; 80%). Six (6/10; 60.0%) patients had LVOs. The program correctly detected 83.3% (5/6) of patients, and these patients were triaged in less than one hour from arrival on average. The program did not falsely identify non-LVOs as LVOs for any patients. Conclusions Identifying adjunct tools to aid timely identification and treatment of ischemic stroke in trauma patients is necessary to increase the chances for meaningful neurological recovery. Our early experience exhibited potential for using automated software to aid occlusion identification and subsequent stroke team mobilization. Future studies in larger cohorts will expand upon these preliminary findings to establish the accuracy and clinical benefit of automated stroke detection tool integration for the trauma population.
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OBJECTIVE: Decision for intervention in acute subdural hematoma patients is based on a combination of clinical and radiographic factors. Age has been suggested as a factor to be strongly considered when interpreting midline shift (MLS) and hematoma volume data for assessing critical clinical severity during operative intervention decisions for acute subdural hematoma patients. The objective of this study was to demonstrate the use of an automated volumetric analysis tool to measure hematoma volume and MLS and quantify their relationship with age. METHODS: A total of 1789 acute subdural hematoma patients were analyzed using qER-Quant software (Qure.ai, Mumbai, India) for MLS and hematoma volume measurements. Univariable and multivariable regressions analyzed association between MLS, hematoma volume, age, and MLS:hematoma volume ratio. RESULTS: In comparison to young patients (≤ 70 years), old patients (>70 years) had significantly higher average hematoma volume (old: 62.2 mL vs. young 46.8 mL, P < 0.0001), lower average MLS (old: 6.6 mm vs. young: 7.4 mm, P = 0.025), and lower average MLS:hematoma volume ratio (old: 0.11 mm/mL vs. young 0.15 mm/mL, P < 0.0001). Young patients had an average of 1.5 mm greater MLS for a given hematoma volume in comparison to old patients. With increasing age, the ratio between MLS and hematoma volume significantly decreases (P = 0.0002). CONCLUSIONS: Commercially available, automated, artificial intelligence (AI)-based tools may be used for obtaining quantitative radiographic measurement data in patients with acute subdural hematoma. Our quantitative results are consistent with the qualitative relationship previously established between age, hematoma volume, and MLS, which supports the validity of using AI-based tools for acute subdural hematoma volume estimation.
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Inteligência Artificial , Hematoma Subdural Agudo , Humanos , Hematoma Subdural Agudo/diagnóstico por imagem , Hematoma Subdural Agudo/cirurgia , Idoso , Feminino , Masculino , Pessoa de Meia-Idade , Adulto , Idoso de 80 Anos ou mais , Fatores Etários , Adulto Jovem , Tomografia Computadorizada por Raios X/métodos , Adolescente , Estudos RetrospectivosRESUMO
BACKGROUND/PURPOSE: Distal medium vessel occlusions (DMVOs) account for a large percentage of vessel occlusions resulting in acute ischemic stroke (AIS) with disabling symptoms. We aim to assess whether pretreatment quantitative CTP collateral status (CS) parameters can serve as imaging biomarkers for good clinical outcomes prediction in successfully recanalized middle cerebral artery (MCA) DMVOs. METHODS: We performed a retrospective analysis of consecutive patients with AIS secondary to primary MCA-DMVOs who were successfully recanalized by mechanical thrombectomy (MT) defined as modified thrombolysis in cerebral infarction (mTICI) 2b, 2c, or 3. We evaluated the association between the CBV index and HIR independently with good clinical outcomes (modified Rankin score 0-2) using Spearman rank correlation, logistic regression, and ROC analyses. RESULTS: From 22 August 2018 to 18 October 2022 8/22/2018 to 10/18/2022, 60 consecutive patients met our inclusion criteria (mean age 71.2⯱ 13.9 years old [mean⯱ SD], 35 female). The CBV index (râ¯= -0.693, pâ¯< 0.001) and HIR (0.687, pâ¯< 0.001) strongly correlated with 90-day mRS. A CBV indexâ¯≥ 0.7 (odds ratio, OR, 2.27, range 6.94-21.23 [OR] 2.27 [6.94-21.23], pâ¯= 0.001)) and lower likelihood of prior stroke (0.13 [0.33-0.86]), pâ¯= 0.024)) were independently associated with good outcomes. The ROC analysis demonstrated good performance of the CBV index in predicting good 90-day mRS (AUC 0.73, pâ¯= 0.003) with a threshold of 0.7 for optimal sensitivity (71% [52.0-85.8%]) and specificity (76% [54.9-90.6%]). The HIR also demonstrated adequate performance in predicting good 90-day mRS (AUC 0.77, pâ¯= 0.001) with a threshold of 0.3 for optimal sensitivity (64.5% [45.4-80.8%]) and specificity (76.0% [54.9-90.6%]). CONCLUSION: A CBV indexâ¯≥ 0.7 may be independently associated with good clinical outcomes in our cohort of AIS caused by MCA-DMVOs that were successfully treated with MT. Furthermore, a HIRâ¯< 0.3 is also associated with good clinical outcomes. This is the first study of which we are aware to identify a CBV index threshold for MCA-DMVOs.
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Infarto da Artéria Cerebral Média , Humanos , Feminino , Masculino , Idoso , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Circulação Colateral/fisiologia , Pessoa de Meia-Idade , AVC Isquêmico/diagnóstico por imagem , AVC Isquêmico/cirurgia , AVC Isquêmico/fisiopatologia , Angiografia Cerebral , Trombectomia/métodos , Circulação Cerebrovascular/fisiologiaRESUMO
BACKGROUND AND PURPOSE: Acute ischemic stroke due to large vessel occlusion (AIS-LVO) is a major cause of functional dependence. Collateral status (CS) is an important determinant of functional outcomes. Pretreatment CT perfusion (CTP) parameters serve as reliable surrogates of CS. Penumbra Salvage Index (PSI) is another parameter predictive of functional outcomes in AIS-LVO. The aim of this study is to assess the relationship of pretreatment CTP parameters with PSI. METHODS: In this prospectively collected, retrospectively reviewed multicenter analysis, inclusion criteria were as follows: (1) CT angiography confirmed middle cerebral artery (MCA) M1-segment and proximal M2-segment occlusion from 9/1/2017 to 9/22/2022; (2) diagnostic CTP; and (3) available diagnostic Magnetic resonance Imaging (MRI) diffusion-weighted images. Pearson correlation analysis was performed to assess the association between cerebral blood volume (CBV) index and hypoperfusion intensity ratio (HIR) with PSI. p value ≤.05 was considered statistically significant. RESULTS: In total, 131 patients (n = 86, M1 and n = 45, proximal M2 occlusion) met our inclusion criteria. CBV index showed a modest positive correlation with PSI (r = 0.34, p<.001) in patients with proximal MCA occlusion. Similar trends were noted in subgroup analysis of patients with M1 occlusion, and proximal M2 occlusion. Whereas, HIR did not have a strong trend or correlation with PSI. CONCLUSION: CBV index correlates with PSI, whereas HIR does not. Future studies are needed to expand our understanding of the adjunct role of CBV index with other similar pretreatment CTP-based markers in clinical evaluation and decision-making in patients with MCA occlusion.
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Isquemia Encefálica , AVC Isquêmico , Acidente Vascular Cerebral , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Estudos Retrospectivos , Angiografia Cerebral/métodos , Angiografia por Tomografia Computadorizada , Perfusão , Acidente Vascular Cerebral/diagnóstico , Isquemia Encefálica/diagnóstico , Circulação CerebrovascularRESUMO
BACKGROUND: Collateral status (CS) is an important biomarker of functional outcomes in patients with acute ischemic stroke secondary to large vessel occlusion (AIS-LVO). Pretreatment CT perfusion (CTP) parameters serve as reliable surrogates of collateral status (CS). In this study, we aim to assess the relationship between the relative cerebral blood flow less than 38% (rCBF <38%), with the reference standard American Society of Interventional and Therapeutic Neuroradiology (ASITN) collateral score (CS) on DSA. METHODS: In this prospectively collected, retrospectively reviewed analysis, inclusion criteria were as follows: (a) CT angiography (CTA) confirmed anterior circulation large vessel occlusion from 9/1/2017 to 10/01/2023; (b) diagnostic CT perfusion; and (c) underwent mechanical thrombectomy with documented ASITN CS. The ratios of the CTP-derived CBF values were calculated by dividing the values of the ischemic lesion by the corresponding values of the contralateral normal region (which were defined as rCBF). Spearman's rank correlation and logistic regression analysis were performed to determine the relationship of rCBF <38% lesion volume with DSA ASITN CS. p ≤ .05 was considered significant. RESULTS: In total, 223 patients [mean age: 67.77 ± 15.76 years, 56.1% (n = 125) female] met our inclusion criteria. Significant negative correlation was noted between rCBF <38% volume and DSA CS (ρ = -0.37, p < .001). On multivariate logistic regression analysis, rCBF <38% volume was found to be independently associated with worse ASITN CS (unadjusted OR: 3.03, 95% CI: 1.60-5.69, p < .001, and adjusted OR: 2.73, 95% CI: 1.34-5.50, p < .01). CONCLUSION: Greater volume of tissue with rCBF <38% is independently associated with better DSA CS. rCBF <38% is a useful adjunct tool in collateralization-based prognostication. Future studies are needed to expand our understanding of the role of rCBF <38% within the decision-making in patients with AIS-LVO.
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Angiografia Digital , Circulação Cerebrovascular , Circulação Colateral , Angiografia por Tomografia Computadorizada , Humanos , Feminino , Masculino , Angiografia Digital/métodos , Circulação Colateral/fisiologia , Idoso , Estudos Retrospectivos , Circulação Cerebrovascular/fisiologia , Angiografia por Tomografia Computadorizada/métodos , Pessoa de Meia-Idade , AVC Isquêmico/diagnóstico por imagem , Angiografia Cerebral/métodos , Idoso de 80 Anos ou maisRESUMO
BACKGROUND: Poor venous outflow (VO) profiles are associated with unfavorable outcomes in patients with acute ischemic stroke caused by large vessel occlusion (AIS-LVO), despite achieving successful reperfusion. The objective of this study is to assess the association between mortality and prolonged venous transit (PVT), a novel visual qualitative VO marker on CT perfusion (CTP) time to maximum (Tmax) maps. METHODS: We performed a retrospective analysis of prospectively collected data from consecutive adult patients with AIS-LVO with successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/2c/3). PVT+ was defined as Tmax ≥10 s timing on CTP Tmax maps in at least one of the following: superior sagittal sinus (proximal venous drainage) and/or torcula (deep venous drainage). PVT- was defined as lacking this in both regions. The primary outcome was mortality at 90 days. In a 1:1 propensity score-matched cohort, regressions were performed to determine the effect of PVT on 90-day mortality. RESULTS: In 127 patients of median (IQR) age 71 (64-81) years, mortality occurred in a significantly greater proportion of PVT+ patients than PVT- patients (32.5% vs 12.6%, P=0.01). This significant difference persisted after matching (P=0.03). PVT+ was associated with a significantly increased likelihood of 90-day mortality (OR 1.22 (95% CI 1.02 to 1.46), P=0.03) in the matched cohort. CONCLUSIONS: PVT+ was significantly associated with 90-day mortality despite successful reperfusion therapy in patients with AIS-LVO. PVT is a simple VO profile marker with potential as an adjunctive metric during acute evaluation of AIS-LVO patients. Future studies will expand our understanding of using PVT in the evaluation of patients with AIS-LVO.
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Background: The pretreatment CT perfusion (CTP) marker the relative cerebral blood volume (rCBV) < 42% lesion volume has recently been shown to predict 90-day functional outcomes; however, studies assessing correlations of the rCBV < 42% lesion volume with other outcomes remain sparse. Here, we aim to assess the relationship between the rCBV < 42% lesion volume and the reference standard digital subtraction angiography (DSA)-derived American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN) collateral score, hereby referred as the DSA CS. Methods: In this retrospective evaluation of our prospectively collected database, we included acute stroke patients triaged by multimodal CT imaging, including CT angiography and perfusion imaging, with confirmed anterior circulation large vessel occlusion between 1 September 2017 and 1 October 2023. Group differences were assessed using the Student's t test, Mann-Whitney U test and Chi-Square test. Spearman's rank correlation and logistic regression analyses were used to assess associations between rCBV < 42% and DSA CS. Results: In total, 222 patients (median age: 69 years, 56.3% female) met our inclusion criteria. In the multivariable logistic regression analysis, taking into account age, sex, race, hypertension, hyperlipidemia, diabetes, atrial fibrillation, prior stroke or transient ischemic attack, the admission National Institute of Health stroke scale, the premorbid modified Rankin score, the Alberta stroke program early CT score (ASPECTS), and segment occlusion, the rCBV < 42% lesion volume (adjusted OR: 0.98, p < 0.05) was independently associated with the DSA CS. Conclusion: The rCBV < 42% lesion volume is independently associated with the DSA CS.
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Although pretreatment radiographic biomarkers are well established for hemorrhagic transformation (HT) following successful mechanical thrombectomy (MT) in large vessel occlusion (LVO) strokes, they are yet to be explored for medium vessel occlusion (MeVO) acute ischemic strokes. We aim to investigate pretreatment imaging biomarkers representative of collateral status, namely the hypoperfusion intensity ratio (HIR) and cerebral blood volume (CBV) index, and their association with HT in successfully recanalized MeVOs. A prospectively collected registry of acute ischemic stroke patients with MeVOs successfully recanalized with MT between 2019 and 2023 was retrospectively reviewed. A multivariate logistic regression for HT of any subtype was derived by combining significant univariate predictors into a forward stepwise regression with minimization of Akaike information criterion. Of 60 MeVO patients successfully recanalized with MT, HT occurred in 28.3% of patients. Independent factors for HT included: diabetes mellitus history (p = 0.0005), CBV index (p = 0.0071), and proximal versus distal occlusion location (p = 0.0062). A multivariate model with these factors had strong diagnostic performance for predicting HT (area under curve [AUC] 0.93, p < 0.001). Lower CBV indexes, distal occlusion location, and diabetes history are significantly associated with HT in MeVOs successfully recanalized with MT. Of note, HIR was not found to be significantly associated with HT.
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Arteriopatias Oclusivas , Isquemia Encefálica , AVC Isquêmico , Acidente Vascular Cerebral , Humanos , Acidente Vascular Cerebral/complicações , Isquemia Encefálica/complicações , Estudos Retrospectivos , AVC Isquêmico/complicações , Arteriopatias Oclusivas/complicações , Biomarcadores , Trombectomia , Resultado do TratamentoRESUMO
Pretreatment CT Perfusion (CTP) parameter rCBV < 42% lesion volume has recently been shown to predict 90-day mRS. In this study, we aim to assess the relationship between rCBV < 42% and a radiographic follow-up infarct volume delineated on FLAIR images. In this retrospective evaluation of our prospectively collected database, we included acute stroke patients triaged by multimodal CT imaging, including CT angiography and perfusion imaging, with confirmed anterior circulation large vessel occlusion between 9 January 2017 and 10 January 2023. Follow-up FLAIR imaging was used to determine the final infarct volume. Student t, Mann-Whitney-U, and Chi-Square tests were used to assess differences. Spearman's rank correlation and linear regression analysis were used to assess associations between rCBV < 42% and follow-up infarct volume on FLAIR. In total, 158 patients (median age: 68 years, 52.5% female) met our inclusion criteria. rCBV < 42% (ρ = 0.56, p < 0.001) significantly correlated with follow-up-FLAIR infarct volume. On multivariable linear regression analysis, rCBV < 42% lesion volume (beta = 0.60, p < 0.001), ASPECTS (beta = -0.214, p < 0.01), mTICI (beta = -0.277, p < 0.001), and diabetes (beta = 0.16, p < 0.05) were independently associated with follow-up infarct volume. The rCBV < 42% lesion volume is independently associated with FLAIR follow-up infarct volume.
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BACKGROUND AND PURPOSE: In large vessel occlusion (LVO) stroke patients, relative cerebral blood flow (rCBF)<30% volume thresholds are commonly used in treatment decisions. In the early time window, nearly infarcted but salvageable tissue volumes may lead to pretreatment overestimates of infarct volume, and thus potentially exclude patients who may otherwise benefit from intervention. Our multisite analysis aims to explore the strength of relationships between widely used pretreatment CT parameters and clinical outcomes for early window stroke patients. METHODS: Patients from two sites in a prospective registry were analyzed. Patients with LVOs, presenting within 3 hours of last known well, and who were successfully reperfused were included. Primary short-term neurological outcome was percent National Institutes of Health Stroke Scale (NIHSS) change from admission to discharge. Secondary long-term outcome was 90-day modified Rankin score. Spearman's correlations were performed. Significance was attributed to p-value ≤.05. RESULTS: Among 73 patients, median age was 66 (interquartile range 54-76) years. Among all pretreatment imaging parameters, rCBF<30%, rCBF<34%, and rCBF<38% volumes were significantly, inversely correlated with percentage NIHSS change (p<.048). No other parameters significantly correlated with outcomes. CONCLUSIONS: Our multisite analysis shows that favorable short-term neurological recovery was significantly correlated with rCBF volumes in the early time window. However, modest strength of correlations provides supportive evidence that the applicability of general ischemic core estimate thresholds in this subpopulation is limited. Our results support future larger-scale efforts to liberalize or reevaluate current rCBF parameter thresholds guiding treatment decisions for early time window stroke patients.
Assuntos
Isquemia Encefálica , Acidente Vascular Cerebral , Humanos , Pessoa de Meia-Idade , Idoso , Isquemia Encefálica/terapia , Tomografia Computadorizada por Raios X/métodos , Perfusão , Trombectomia/métodos , Resultado do Tratamento , Estudos Retrospectivos , Imagem de Perfusão/métodosRESUMO
BACKGROUND AND AIM: The Los Angeles Motor Scale (LAMS) is an objective tool that has been used to rapidly assess and predict the presence of large vessel occlusion (LVO) in the pre-hospital setting successfully in several studies. However, studies assessing the relationship between LAMS score and CT perfusion collateral status (CS) markers such as cerebral blood volume (CBV) index, and hypoperfusion intensity ratio (HIR) are sparse. Our study therefore aims to assess the association of admission LAMS score with established CTP CS markers CBV Index and HIR in AIS-LVO cases. MATERIALS AND METHODS: In this prospectively collected, retrospectively reviewed analysis, inclusion criteria were as follows: a) CT angiography (CTA) confirmed anterior circulation LVO from 9/1/2017 to 10/01/2023, and b) diagnostic CT perfusion (CTP). Logistic regression analysis was performed to assess the relationship between admission LAMS with CTP CS markers HIR and CBV Index. p ≤ 0.05 was considered significant. RESULTS: In total, 285 consecutive patients (median age = 69 years; 56 % female) met our inclusion criteria. Multivariable logistic regression analysis adjusting for sex, age, ASPECTS, tPA, premorbid mRS, admission NIH stroke scale, prior history of TIA, stroke, atrial fibrillation, diabetes mellitus, hyperlipidemia, coronary artery disease and hypertension, admission LAMS was found to be independently associated with CBV Index (adjusted OR:0.82, p < 0.01), and HIR (adjusted OR:0.59, p < 0.05). CONCLUSION: LAMS is independently associated with CTP CS markers, CBV index and HIR. This finding suggests that LAMS may also provide an indirect estimate of CS.
Assuntos
Circulação Colateral , Humanos , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , Estudos Retrospectivos , Circulação Colateral/fisiologia , Angiografia por Tomografia Computadorizada/métodos , Circulação Cerebrovascular/fisiologia , Idoso de 80 Anos ou mais , Índice de Gravidade de Doença , Tomografia Computadorizada por Raios X/métodos , AVC Isquêmico/diagnóstico por imagem , AVC Isquêmico/fisiopatologiaRESUMO
BACKGROUND: Prolonged venous transit (PVT), defined as presence of time-to-maximum ≥ 10 s within the superior sagittal sinus (SSS) and/or torcula, is a novel, qualitatively assessed computed tomography perfusion surrogate parameter of venous outflow with potential utility in pretreatment acute ischemic stroke imaging for neuroprognostication. We aim to characterize the correlation between PVT and neurological functional outcomes in thrombectomy-treated patients. METHODS: A prospectively-collected database of large vessel occlusion acute ischemic stroke patients treated with thrombectomy was retrospectively analyzed. Spearman's rank correlation coefficient and point-biserial correlations were performed between PVT status (i.e., no region, either SSS or torcula, or both), 90-day modified Rankin score (mRS), mortality (mRS 6), and poor functional outcome (mRS 4-6 vs 0-3). RESULTS: Of 128 patients, correlation between PVT and 90-day mRS (ρ = 0.35, p < 0.0001), mortality (r = 0.26, p = 0.002), and poor functional outcome (r = 0.27, p = 0.002) were significant. CONCLUSION: There is a modest, significant correlation between PVT and severity of neurological functional outcome. Consequently, PVT is an easily-ascertained, qualitative metric that may be useful as an adjunct for anticipating a patient's clinical course. Future analyses will determine the significance of incorporating PVT in clinical decision-making.