Automated detection of early signs of irreversible ischemic change on CTA source images in patients with large vessel occlusion.

PURPOSE: To create and validate an automated pipeline for detection of early signs of irreversible ischemic change from admission CTA in patients with large vessel occlusion (LVO) stroke. METHODS: We retrospectively included 368 patients for training and 143 for external validation. All patients had anterior circulation LVO stroke, endovascular therapy with successful reperfusion, and follow-up diffusion-weighted imaging (DWI). We devised a pipeline to automatically segment Alberta Stroke Program Early CT Score (ASPECTS) regions and extracted their relative Hounsfield unit (rHU) values. We determined the optimal rHU cut points for prediction of final infarction in each ASPECT region, performed 10-fold cross-validation in the training set, and measured the performance via external validation in patients from another institute. We compared the model with an expert neuroradiologist for prediction of final infarct volume and poor functional outcome. RESULTS: We achieved a mean area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity of 0.69±0.13, 0.69±0.09, 0.61±0.23, and 0.72±0.11 across all regions and folds in cross-validation. In the external validation cohort, we achieved a median [interquartile] AUC, accuracy, sensitivity, and specificity of 0.71 [0.68-0.72], 0.70 [0.68-0.73], 0.55 [0.50-0.63], and 0.74 [0.73-0.77], respectively. The rHU-based ASPECTS showed significant correlation with DWI-based ASPECTS (rS = 0.39, p<0.001) and final infarct volume (rS = -0.36, p<0.001). The AUC for predicting poor functional outcome was 0.66 (95%CI: 0.57-0.75). The predictive capabilities of rHU-based ASPECTS were not significantly different from the neuroradiologist's visual ASPECTS for either final infarct volume or functional outcome. CONCLUSIONS: Our study demonstrates the feasibility of an automated pipeline and predictive model based on relative HU attenuation of ASPECTS regions on baseline CTA and its non-inferior performance in predicting final infarction on post-stroke DWI compared to an expert human reader.

Radiomics-Based Prediction of Collateral Status from CT Angiography of Patients Following a Large Vessel Occlusion Stroke.

BACKGROUND: A major driver of individual variation in long-term outcomes following a large vessel occlusion (LVO) stroke is the degree of collateral arterial circulation. We aimed to develop and evaluate machine-learning models that quantify LVO collateral status using admission computed tomography angiography (CTA) radiomics. METHODS: We extracted 1116 radiomic features from the anterior circulation territories from admission CTAs of 600 patients experiencing an acute LVO stroke. We trained and validated multiple machine-learning models for the prediction of collateral status based on consensus from two neuroradiologists as ground truth. Models were first trained to predict (1) good vs. intermediate or poor, or (2) good vs. intermediate or poor collateral status. Then, model predictions were combined to determine a three-tier collateral score (good, intermediate, or poor). We used the receiver operating characteristics area under the curve (AUC) to evaluate prediction accuracy. RESULTS: We included 499 patients in training and 101 in an independent test cohort. The best-performing models achieved an averaged cross-validation AUC of 0.80 ± 0.05 for poor vs. intermediate/good collateral and 0.69 ± 0.05 for good vs. intermediate/poor, and AUC = 0.77 (0.67-0.87) and AUC = 0.78 (0.70-0.90) in the independent test cohort, respectively. The collateral scores predicted by the radiomics model were correlated with (rho = 0.45, p = 0.002) and were independent predictors of 3-month clinical outcome (p = 0.018) in the independent test cohort. CONCLUSIONS: Automated tools for the assessment of collateral status from admission CTA-such as the radiomics models described here-can generate clinically relevant and reproducible collateral scores to facilitate a timely treatment triage in patients experiencing an acute LVO stroke.

Role of PET/CT in Oropharyngeal Cancers.

Oropharyngeal squamous cell carcinoma (OPSCC) comprises cancers of the tonsils, tongue base, soft palate, and uvula. The staging of oropharyngeal cancers varies depending upon the presence or absence of human papillomavirus (HPV)-directed pathogenesis. The incidence of HPV-associated oropharyngeal cancer (HPV + OPSCC) is expected to continue to rise over the coming decades. PET/CT is a useful modality for the diagnosis, staging, and follow up of patients with oropharyngeal cancers undergoing treatment and surveillance.

Differences in the functional brain architecture of sustained attention and working memory in youth and adults.

Sustained attention (SA) and working memory (WM) are critical processes, but the brain networks supporting these abilities in development are unknown. We characterized the functional brain architecture of SA and WM in 9- to 11-year-old children and adults. First, we found that adult network predictors of SA generalized to predict individual differences and fluctuations in SA in youth. A WM model predicted WM performance both across and within children-and captured individual differences in later recognition memory-but underperformed in youth relative to adults. We next characterized functional connections differentially related to SA and WM in youth compared to adults. Results revealed 2 network configurations: a dominant architecture predicting performance in both age groups and a secondary architecture, more prominent for WM than SA, predicting performance in each age group differently. Thus, functional connectivity (FC) predicts SA and WM in youth, with networks predicting WM performance differing more between youths and adults than those predicting SA.

Dataset on acute stroke risk stratification from CT angiographic radiomics.

With advances in high-throughput image processing technologies and increasing availability of medical mega-data, the growing field of radiomics opened the door for quantitative analysis of medical images for prediction of clinically relevant information. One clinical area in which radiomics have proven useful is stroke neuroimaging, where rapid treatment triage is vital for patient outcomes and automated decision assistance tools have potential for significant clinical impact. Recent research, for example, has applied radiomics features extracted from CT angiography (CTA) images and a machine learning framework to facilitate risk-stratification in acute stroke. We here provide methodological guidelines and radiomics data supporting the referenced article "CT angiographic radiomics signature for risk-stratification in anterior large vessel occlusion stroke." The data were extracted from the stroke center registry at Yale New Haven Hospital between 1/1/2014 and 10/31/2020; and Geisinger Medical Center between 1/1/2016 and 12/31/2019. It includes detailed radiomics features of the anterior circulation territories on admission CTA scans in stroke patients with large vessel occlusion stroke who underwent thrombectomy. We also provide the methodological details of the analysis framework utilized for training, optimization, validation and external testing of the machine learning and feature selection algorithms. With the goal of advancing the feasibility and quality of radiomics-based analyses to improve patient care within and beyond the field of stroke, the provided data and methodological support can serve as a baseline for future studies applying radiomics algorithms to machine-learning frameworks, and allow for analysis and utilization of radiomics features extracted in this study.

Impact of collateral flow on cost-effectiveness of endovascular thrombectomy.

OBJECTIVE: Acute ischemic stroke patients with large-vessel occlusion and good collateral blood flow have significantly better outcomes than patients with poor collateral circulation. The purpose of this study was to evaluate the cost-effectiveness of endovascular thrombectomy (EVT) based on collateral status and, in particular, to analyze its effectiveness in ischemic stroke patients with poor collaterals. METHODS: A decision analysis study was performed with Markov modeling to estimate the lifetime quality-adjusted life-years (QALYs) and associated costs of EVT based on collateral status. The study was performed over a lifetime horizon with a societal perspective in the US setting. Base-case analysis was done for good, intermediate, and poor collateral status. One-way, two-way, and probabilistic sensitivity analyses were performed. RESULTS: EVT resulted in greater effectiveness of treatment compared to no EVT/medical therapy (2.56 QALYs in patients with good collaterals, 1.88 QALYs in those with intermediate collaterals, and 1.79 QALYs in patients with poor collaterals), which was equivalent to 1050, 771, and 734 days, respectively, in a health state characterized by a modified Rankin Scale (mRS) score of 0-2. EVT also resulted in lower costs in patients with good and intermediate collaterals. For patients with poor collateral status, the EVT strategy had higher effectiveness and higher costs, with an incremental cost-effectiveness ratio (ICER) of $44,326/QALY. EVT was more cost-effective as long as it had better outcomes in absolute numbers in at least 4%-8% more patients than medical management. CONCLUSIONS: EVT treatment in the early time window for good outcome after ischemic stroke is cost-effective irrespective of the quality of collateral circulation, and patients should not be excluded from thrombectomy solely on the basis of collateral status. Despite relatively lower benefits of EVT in patients with poor collaterals, even smaller differences in better outcomes have significant long-term financial implications that make EVT cost-effective.

CT angiographic radiomics signature for risk stratification in anterior large vessel occlusion stroke.

BACKGROUND AND PURPOSE: As "time is brain" in acute stroke triage, the need for automated prognostication tools continues to increase, particularly in rapidly expanding tele-stroke settings. We aimed to create an automated prognostication tool for anterior circulation large vessel occlusion (LVO) stroke based on admission CTA radiomics. METHODS: We automatically extracted 1116 radiomics features from the anterior circulation territory on admission CTAs of 829 acute LVO stroke patients who underwent mechanical thrombectomy in two academic centers. We trained, optimized, validated, and compared different machine-learning models to predict favorable outcome (modified Rankin Scale ≤ 2) at discharge and 3-month follow-up using four different input sets: "Radiomics", "Radiomics + Treatment" (radiomics, post-thrombectomy reperfusion grade, and intravenous thrombolysis), "Clinical + Treatment" (baseline clinical variables and treatment), and "Combined" (radiomics, treatment, and baseline clinical variables). RESULTS: For discharge outcome prediction, models were optimized/trained on n = 494 and tested on an independent cohort of n = 100 patients from Yale. Receiver operating characteristic analysis of the independent cohort showed no significant difference between best-performing Combined input models (area under the curve, AUC = 0.77) versus Radiomics + Treatment (AUC = 0.78, p = 0.78), Radiomics (AUC = 0.78, p = 0.55), or Clinical + Treatment (AUC = 0.77, p = 0.87) models. For 3-month outcome prediction, models were optimized/trained on n = 373 and tested on an independent cohort from Yale (n = 72), and an external cohort from Geisinger Medical Center (n = 232). In the independent cohort, there was no significant difference between Combined input models (AUC = 0.76) versus Radiomics + Treatment (AUC = 0.72, p = 0.39), Radiomics (AUC = 0.72, p = 0.39), or Clinical + Treatment (AUC = 76, p = 0.90) models; however, in the external cohort, the Combined model (AUC = 0.74) outperformed Radiomics + Treatment (AUC = 0.66, p < 0.001) and Radiomics (AUC = 0.68, p = 0.005) models for 3-month prediction. CONCLUSION: Machine-learning signatures of admission CTA radiomics can provide prognostic information in acute LVO stroke candidates for mechanical thrombectomy. Such objective and time-sensitive risk stratification can guide treatment decisions and facilitate tele-stroke assessment of patients. Particularly in the absence of reliable clinical information at the time of admission, models solely using radiomics features can provide a useful prognostication tool.

A brain-based general measure of attention.

Attention is central to many aspects of cognition, but there is no singular neural measure of a person's overall attentional functioning across tasks. Here, using original data from 92 participants performing three different attention-demanding tasks during functional magnetic resonance imaging, we constructed a suite of whole-brain models that can predict a profile of multiple attentional components (sustained attention, divided attention and tracking, and working memory capacity) for novel individuals. Multiple brain regions across the salience, subcortical and frontoparietal networks drove accurate predictions, supporting a common (general) attention factor across tasks, distinguished from task-specific ones. Furthermore, connectome-to-connectome transformation modelling generated an individual's task-related connectomes from rest functional magnetic resonance imaging, substantially improving predictive power. Finally, combining the connectome transformation and general attention factor, we built a standardized measure that shows superior generalization across four independent datasets (total N = 495) of various attentional measures, suggesting broad utility for research and clinical applications.

Similar admission NIHSS may represent larger tissue-at-risk in patients with right-sided versus left-sided large vessel occlusion.

BACKGROUND: We investigated the effects of the side of large vessel occlusion (LVO) on post-thrombectomy infarct volume and clinical outcome with regard to admission National Institutes of Health Stroke Scale (NIHSS) score. METHODS: We retrospectively identified patients with anterior LVO who received endovascular thrombectomy and follow-up MRI. Applying voxel-wise general linear models and multivariate analysis, we assessed the effects of occlusion side, admission NIHSS, and post-thrombectomy reperfusion (modified Thrombolysis in Cerebral Infarction, mTICI) on final infarct distribution and volume as well as discharge modified Rankin Scale (mRS) score. RESULTS: We included 469 patients, 254 with left-sided and 215 with right-sided LVO. Admission NIHSS was higher in those with left-sided LVO (median (IQR) 16 (10-22)) than in those with right-sided LVO (14 (8-16), p>0.001). In voxel-wise analysis, worse post-thrombectomy reperfusion, lower admission NIHSS score, and poor discharge outcome were associated with right-hemispheric infarct lesions. In multivariate analysis, right-sided LVO was an independent predictor of larger final infarct volume (p=0.003). There was a significant three-way interaction between admission stroke severity (based on NIHSS), LVO side, and mTICI with regard to final infarct volume (p=0.041). Specifically, in patients with moderate stroke (NIHSS 6-15), incomplete reperfusion (mTICI 0-2b) was associated with larger final infarct volume (p<0.001) and worse discharge outcome (p=0.02) in right-sided compared with left-sided LVO. CONCLUSIONS: When adjusted for admission NIHSS, worse post-thrombectomy reperfusion is associated with larger infarct volume and worse discharge outcome in right-sided versus left-sided LVO. This may represent larger tissue-at-risk in patients with right-sided LVO when applying admission NIHSS as a clinical biomarker for penumbra.

Using functional connectivity models to characterize relationships between working and episodic memory.

INTRODUCTION: Working memory is a critical cognitive ability that affects our daily functioning and relates to many cognitive processes and clinical conditions. Episodic memory is vital because it enables individuals to form and maintain their self-identities. Our study analyzes the extent to which whole-brain functional connectivity observed during completion of an N-back memory task, a common measure of working memory, can predict both working memory and episodic memory. METHODS: We used connectome-based predictive models (CPMs) to predict 502 Human Connectome Project (HCP) participants' in-scanner 2-back memory test scores and out-of-scanner working memory test (List Sorting) and episodic memory test (Picture Sequence and Penn Word) scores based on functional magnetic resonance imaging (fMRI) data collected both during rest and N-back task performance. We also analyzed the functional brain connections that contributed to prediction for each of these models. RESULTS: Functional connectivity observed during N-back task performance predicted out-of-scanner List Sorting scores and to a lesser extent out-of-scanner Picture Sequence scores, but did not predict out-of-scanner Penn Word scores. Additionally, the functional connections predicting 2-back scores overlapped to a greater degree with those predicting List Sorting scores than with those predicting Picture Sequence or Penn Word scores. Functional connections with the insula, including connections between insular and parietal regions, predicted scores across the 2-back, List Sorting, and Picture Sequence tasks. CONCLUSIONS: Our findings validate functional connectivity observed during the N-back task as a measure of working memory, which generalizes to predict episodic memory to a lesser extent. By building on our understanding of the predictive power of N-back task functional connectivity, this work enhances our knowledge of relationships between working memory and episodic memory.

Connectome-based neurofeedback: A pilot study to improve sustained attention.

Real-time functional magnetic resonance imaging (rt-fMRI) neurofeedback is a non-invasive, non-pharmacological therapeutic tool that may be useful for training behavior and alleviating clinical symptoms. Although previous work has used rt-fMRI to target brain activity in or functional connectivity between a small number of brain regions, there is growing evidence that symptoms and behavior emerge from interactions between a number of distinct brain areas. Here, we propose a new method for rt-fMRI, connectome-based neurofeedback, in which intermittent feedback is based on the strength of complex functional networks spanning hundreds of regions and thousands of functional connections. We first demonstrate the technical feasibility of calculating whole-brain functional connectivity in real-time and provide resources for implementing connectome-based neurofeedback. We next show that this approach can be used to provide accurate feedback about the strength of a previously defined connectome-based model of sustained attention, the saCPM, during task performance. Although, in our initial pilot sample, neurofeedback based on saCPM strength did not improve performance on out-of-scanner attention tasks, future work characterizing effects of network target, training duration, and amount of feedback on the efficacy of rt-fMRI can inform experimental or clinical trial designs.

Functional connectivity predicts changes in attention observed across minutes, days, and months.

The ability to sustain attention differs across people and changes within a single person over time. Although recent work has demonstrated that patterns of functional brain connectivity predict individual differences in sustained attention, whether these same patterns capture fluctuations in attention within individuals remains unclear. Here, across five independent studies, we demonstrate that the sustained attention connectome-based predictive model (CPM), a validated model of sustained attention function, generalizes to predict attentional state from data collected across minutes, days, weeks, and months. Furthermore, the sustained attention CPM is sensitive to within-subject state changes induced by propofol as well as sevoflurane, such that individuals show functional connectivity signatures of stronger attentional states when awake than when under deep sedation and light anesthesia. Together, these results demonstrate that fluctuations in attentional state reflect variability in the same functional connectivity patterns that predict individual differences in sustained attention.

Distributed Patterns of Functional Connectivity Predict Working Memory Performance in Novel Healthy and Memory-impaired Individuals.

Individual differences in working memory relate to performance differences in general cognitive ability. The neural bases of such individual differences, however, remain poorly understood. Here, using a data-driven technique known as connectome-based predictive modeling, we built models to predict individual working memory performance from whole-brain functional connectivity patterns. Using n-back or rest data from the Human Connectome Project, connectome-based predictive models significantly predicted novel individuals' 2-back accuracy. Model predictions also correlated with measures of fluid intelligence and, with less strength, sustained attention. Separate fluid intelligence models predicted working memory score, as did sustained attention models, again with less strength. Anatomical feature analysis revealed significant overlap between working memory and fluid intelligence models, particularly in utilization of prefrontal and parietal regions, and less overlap in predictive features between working memory and sustained attention models. Furthermore, showing the generality of these models, the working memory model developed from Human Connectome Project data generalized to predict memory in an independent data set of 157 older adults (mean age = 69 years; 48 healthy, 54 amnestic mild cognitive impairment, 55 Alzheimer disease). The present results demonstrate that distributed functional connectivity patterns predict individual variation in working memory capability across the adult life span, correlating with constructs including fluid intelligence and sustained attention.

Hippocampal-neocortical interactions sharpen over time for predictive actions.

When an action is familiar, we are able to anticipate how it will change the state of the world. These expectations can result from retrieval of action-outcome associations in the hippocampus and the reinstatement of anticipated outcomes in visual cortex. How does this role for the hippocampus in action-based prediction change over time? We use high-resolution fMRI and a dual-training behavioral paradigm to examine how the hippocampus interacts with visual cortex during predictive and nonpredictive actions learned either three days earlier or immediately before the scan. Just-learned associations led to comparable background connectivity between the hippocampus and V1/V2, regardless of whether actions predicted outcomes. However, three-day-old associations led to stronger background connectivity and greater differentiation between neural patterns for predictive vs. nonpredictive actions. Hippocampal prediction may initially reflect indiscriminate binding of co-occurring events, with action information pruning weaker associations and leading to more selective and accurate predictions over time.