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  • 1
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    Abstract W P49: Optimizing Ct Perfusion for Prediction of Ischemic Core in Acute Stroke With an Open-source Benchmarking Tool to Standardize Stroke Imaging Research
    Ovid Technologies (Wolters Kluwer Health) ; 2015
    In:  Stroke Vol. 46, No. suppl_1 ( 2015-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 46, No. suppl_1 ( 2015-02)
    Abstract: Background: Multiple studies have investigated the optimal CT perfusion (CTP) parameter for identification of the ischemic core. Differences in methodology have led to results that are not easily comparable. The aim of this project was to create and test a benchmarking tool that will standardize the evaluation of CTP-software. Methods: We developed a tool consisting of: 1) an imaging library and 2) a statistical analysis algorithm. The imaging library includes pre-processed DWI and CTP scans from a large cohort of 104 acute stroke patients from 2 centers who underwent DWI within 2 hours of CTP. Pre-processing included manual delineation of the acute infarct on DWI (DWI-ROIs) and motion-correction, time-correction, and co-registration of the CTP images. The statistical analysis algorithm evaluates the performance of CTP-software by determining the sensitivity, specificity and volumetric accuracy of the CTP-software’s ischemic core (CTP-ROIs). The tool was tested with CTP-ROIs based on relative CBF (rCBF) thresholds (ranging from 0.00 to 1.00 in 0.02 increments), generated by in-house developed CTP-software (RAPID). Results: We successfully pre-processed the DWI and CTP data of 104 patients. Median time between CT and start of MR was 36 min (IQR 25-77). The tool’s statistical analysis algorithm successfully determined the performance metrics of our in-house CTP-software: Volumetric accuracy of the CTP-ROIs was optimal at an rCBF threshold of 0.36. At this threshold the median absolute volumetric difference between the CTP- and DWI-ROIs was 10 ml (4-17 IQR), sensitivity 64% and specificity 90%.Conclusion: This open-source CTP benchmarking tool provides the scientific community, for the first time, with a method to directly compare the accuracy of CTP-software packages. This may lead to major improvements in CTP-software, as researchers worldwide can use it to determine the optimal algorithm for identifying the ischemic core with CTP.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.46.suppl_1.wp49
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2015
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  • 2
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    Lower Extremity CT Angiography (CTA)
    Elsevier BV ; 2009
    In:  Academic Radiology Vol. 16, No. 6 ( 2009-6), p. 646-653
    Details
    In: Academic Radiology, Elsevier BV, Vol. 16, No. 6 ( 2009-6), p. 646-653
    Type of Medium: Online Resource
    ISSN: 1076-6332
    URL: Article
    DOI: 10.1016/j.acra.2009.01.015
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2009
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  • 3
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    Effect of Collateral Blood Flow on Patients Undergoing Endovascular Therapy for Acute Ischemic Stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2014
    In:  Stroke Vol. 45, No. 4 ( 2014-04), p. 1035-1039
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 45, No. 4 ( 2014-04), p. 1035-1039
    Abstract: Our aim was to determine the relationships between angiographic collaterals and diffusion/perfusion findings, subsequent infarct growth, and clinical outcome in patients undergoing endovascular therapy for ischemic stroke. Methods— Sixty patients with a thrombolysis in cerebral infarction (TICI) score of 0 or 1 and internal carotid artery/M1 occlusion at baseline were evaluated. A blinded reader assigned a collateral score using a previous 5-point scale, from 0 (no collateral flow) to 4 (complete/rapid collaterals to the entire ischemic territory). The analysis was dichotomized to poor flow (0–2) versus good flow (3–4). Collateral score was correlated with baseline National Institutes of Health Stroke Scale, diffusion-weighted imaging volume, perfusion-weighted imaging volume (Tmax ≥6 seconds), TICI reperfusion, infarct growth, and modified Rankin Scale score at day 90. Results— Collateral score correlated with baseline National Institutes of Health Stroke Scale ( P =0.002) and median volume of tissue at Tmax ≥6 seconds ( P =0.009). Twenty-nine percent of patients with poor collateral flow had TICI 2B–3 reperfusion versus 65.5% with good flow ( P =0.009). Patients with poor collaterals who reperfused (TICI 2B–3) were more likely to have a good functional outcome (modified Rankin Scale score 0–2 at 90 days) compared with patients who did not reperfuse (odds ratio, 12; 95% confidence interval, 1.6–98). There was no difference in the rate of good functional outcome after reperfusion in patients with poor collaterals versus good collaterals ( P =1.0). Patients with poor reperfusion (TICI 0–2a) showed a trend toward greater infarct growth if they had poor collaterals versus good collaterals ( P =0.06). Conclusions— Collaterals correlate with baseline National Institutes of Health Stroke Scale, perfusion-weighted imaging volume, and good reperfusion. However, target mismatch patients who reperfuse seem to have favorable outcomes at a similar rate, irrespective of the collateral score. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01349946.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.113.004085
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2014
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  • 4
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    Automated Perfusion Imaging for the Evaluation of Transient Ischemic Attack
    Ovid Technologies (Wolters Kluwer Health) ; 2012
    In:  Stroke Vol. 43, No. 6 ( 2012-06), p. 1556-1560
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 43, No. 6 ( 2012-06), p. 1556-1560
    Abstract: Diffusion-weighted imaging (DWI) is recommended for the evaluation of transient ischemic attack. Perfusion imaging can increase the yield of MRI in transient ischemic attack. We evaluated automated bolus perfusion (the time when the residue function reaches its maximum [TMax] and mean transit time [MTT] ) and arterial spin labeling (ASL) sequences for the detection of ischemic lesions in patients with transient ischemic attack. Methods— We enrolled consecutive patients evaluated for suspicion of acute transient ischemic attack by multimodal MRI within 36 hours of symptom onset. Two independent raters assessed the presence and location of ischemic lesions blinded to the clinical presentation. The prevalence of ischemic lesions and the interrater agreement were1410 assessed. Results— From January 2010 to 2011, 93 patients were enrolled and 90 underwent perfusion imaging (69 bolus perfusion and 76 ASL). Overall, 25 of 93 patients (27%) were DWI-positive and 14 (15%) were perfusion-positive but DWI-negative (ASL n=9; TMax n=9; MTT n=2). MTT revealed an ischemic lesion in fewer patients than TMax (7 versus 20, P =0.004). Raters agreed on 89% of diffusion-weighted imaging cases, 89% of TMax, 87% o10f010 MTT, and 90% of ASL cases. The interrater agreement was good for DWI, TMax, and ASL (κ=0.73, 0.72, and 0.74, respectively) and fair for MTT (κ=0.43). Diffusion and/or perfusion were positive in 39 of 69 (57%) patients with a discharge diagnosis of possible ischemic event. Conclusions— Our results suggest that in patients referred for suspicion of transient ischemic attack, automated TMax is more sensitive than MTT, and both ASL and TMax increase the yield of MRI for the detection of ischemic lesions.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.111.644971
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2012
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  • 5
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    MRI profile and response to endovascular reperfusion after stroke (DEFUSE 2): a prospective cohort study
    Elsevier BV ; 2012
    In:  The Lancet Neurology Vol. 11, No. 10 ( 2012-10), p. 860-867
    Details
    In: The Lancet Neurology, Elsevier BV, Vol. 11, No. 10 ( 2012-10), p. 860-867
    Type of Medium: Online Resource
    ISSN: 1474-4422
    URL: Article
    DOI: 10.1016/S1474-4422(12)70203-X
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2012
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  • 6
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    Abstract 50: A Novel Method for Quantification of Brain Edema in Ischemic Stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2012
    In:  Stroke Vol. 43, No. suppl_1 ( 2012-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 43, No. suppl_1 ( 2012-02)
    Abstract: Background: Measurement of final infarct volumes are typically done on MRI or CT scans obtained at 30 or 90 days after symptom onset. At these delayed time points, true infarct volume is often underestimated because of atrophy. Moreover, late imaging leads to a high percentage of missing data due to early mortality and poor compliance with late imaging. Obtaining an early assessment of infarct volume avoids these limitations; however, it overestimates the true infarct volume because of vasogenic edema. The aim of this study was to develop a novel approach to quantify brain edema so that final infarct volumes can be approximated on day 5 scans. Method: We analyzed MRI scans from 15 acute stroke patients enrolled in the DEFUSE 2 study. The edema volume was determined by comparing spatially-coregistered ADC maps obtained at baseline and at day 5. Edema displaces CSF from the sulci and the ventricles. We therefore estimated the edema volume as the change in CSF volume between baseline and follow-up. CSF displacement was determined by analyzing ADC maps; a voxel by voxel comparison was performed and voxels with ADC values that shifted from the CSF range (2.0-4.4 x 10 -3 mm 2 /s) to the parenchymal range (0.60-1.05 x 10 -3 mm 2 /s) were considered to represent edema (yellow region in figure ). The analysis was performed on 5 control patients with no or very small lesions (2.4±2.0 mL on FLAIR) and 10 patients with large lesions (240±115 mL on FLAIR). Results: The mean volume of CSF displacement in the control group was 1.6±2.4 mL. CSF displacement (edema volume) in the large infarct group ranged from 33 to 152 mL. The estimated edema volume, as a percentage of the overall day 5 FLAIR lesion volume, ranged from 15% to 52%. Linear regression analysis performed between day 5 FLAIR lesion volumes and the estimated edema volumes produced a correlation coefficient (r)of 0.78 (P 〈 0.01) with a slope of 0.31. Conclusion: Vasogenic edema can be measured based on assessment of CSF displacement. Using this novel technique we determined that the day 5 FLAIR lesion volume, on average, overestimates the final infarct volume by 31%. These findings suggest that the final infarct volume can be accurately estimated from an MRI scan obtained during the vasogenic edema phase. Validation of this technique, using data sets that have infarct volume determinations at multiple time points, is in progress and results will be presented.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.43.suppl_1.A50
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2012
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  • 7
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    Abstract 95: Regional Very Low Cerebral Blood Volume with Subsequent Local Reperfusion Predicts Hemorrhagic Transformation in Acute Ischemic Stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2012
    In:  Stroke Vol. 43, No. suppl_1 ( 2012-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 43, No. suppl_1 ( 2012-02)
    Abstract: Background and Purpose Regions of very low cerebral blood volume (VLCBV) on MR perfusion imaging have been shown to predict hemorrhagic transformation (HT) following stroke thrombolysis. We tested the hypothesis that local reperfusion in a region of VLCBV is a pre-requisite for hemorrhagic transformation using pooled imaging data from the EPITHET and DEFUSE studies. Methods Standard CBV maps were calculated and smoothed (Gaussian) to reduce noise. The volume of VLCBV was calculated within the acute Tmax 〉 4sec perfusion lesion using fully automated techniques and a range of VLCBV thresholds relative to CBV values in the non-stroke hemisphere. Receiver operating characteristic (ROC) analysis was used to determine the optimal definition and threshold of VLCBV to predict parenchymal hematoma (PH, ECASS definition). Regional reperfusion was assessed using co-registered subacute Tmax perfusion images (DEFUSE 3-6hrs post thrombolysis, EPITHET 3-5 days post thrombolysis/placebo). The risk of PH associated with VLCBV was assessed with and without exclusion of regions of VLCBV within persistently hypoperfused regions. Results Of 145 patients with baseline perfusion imaging, 22 (15.2%) had PH (13 PH1, 9 PH2). A VLCBV definition of either 〈 2.5 th percentile of the contralateral CBV distribution (VLCBV 〈 2.5pctile) or 〈 15% of the mean contralateral CBV (VLCBV 〈 15%) had similar performance in predicting PH (AUC 0.73 for both). To achieve sensitivity of 95% required a VLCBV 〈 2.5pctile threshold of 〉 2mL (specificity 47%) or a VLCBV 〈 15% threshold of 〉 0.5mL (specificity 41%). There were 130 patients with subacute perfusion imaging, at which time 15 (11.5%) had developed PH. A further 3 patients (without reperfusion at subacute MRI) later developed PH and were excluded as reperfusion status at the time of PH was unknown. In the remaining 127 patients, the AUC for PH increased from 0.77 to 0.92 (p 〈 0.001, VLCBV 〈 2.5pctile definition) when regions of VLCBV without reperfusion on subacute imaging were excluded. The specificity of the 〉 2mL threshold (VLCBV 〈 2.5pctile) increased from 46 to 75%, positive predictive value increased from 20 to 35%, likelihood ratio for PH increased from 1.9 to 4.0 (sensitivity and negative predictive value were both 100% in these 127 patients). No patient developed PH at the time of subacute imaging in the absence of local reperfusion, including one patient where reperfusion of basal ganglia infarction had occurred (with CBV normalisation) prior to thrombolysis. Conclusions Local reperfusion is a critical factor in determining the risk of HT associated with regional VLCBV. This is consistent with the hypothesis that the severe ischemia represented by VLCBV is associated with focal blood-brain-barrier disruption and potential HT should reperfusion subsequently occur. Assessment of VLCBV can be automated and may be useful in clinical risk-benefit decisions regarding thrombolysis.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.43.suppl_1.A95
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2012
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  • 8
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    Abstract 2697: Fully-automated Identification of Acute Stroke Lesion Volumes with CT Perfusion
    Ovid Technologies (Wolters Kluwer Health) ; 2012
    In:  Stroke Vol. 43, No. suppl_1 ( 2012-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 43, No. suppl_1 ( 2012-02)
    Abstract: Purpose: Mismatch between volumes of infarct core and critically hypoperfused tissue (CHT) may be used to identify acute stroke patients who could benefit from reperfusion therapies. We present a fully-automated, operator-free approach for identifying the core and CHT lesion volumes with CT perfusion (CTP). Methods: 31 scans of 25 acute stroke patients who underwent CTP followed by MRI (range: 23-120 min) were analyzed. CTP was obtained as a one or two 2cm slabs. MRI included DWI and PWI. Reference stroke lesion metrics were MRI-based: core via DWI (ADC 〈 615x10 -6 mm 2 /s), and CHT via PWI (Tmax 〉 6s). CTP and PWI scans were processed with an automated image analysis program (RAPID) with delay-independent deconvolution. MRI maps were coregistered to CTP. Contralaterally-relative CBV CT and CBF CT ( cr CBF CT , cr CBF CT ) maps were computed by putting into ratio the original and corresponding laterally-mirrored and smoothed rCBV CT and rCBF CT maps (obtained by vertical flip and coregistration of the anatomic images, see Fig). Stroke core in CTP was delineated by thresholding cr CBV CT and cr CBF CT , and CHT by thresholding Tmax CT . Optimal thresholds were obtained by ROC analysis and minimization of lesion volume differences between CT and MRI. Results: For identification of stroke core in CTP, cr CBF CT performed better than cr CBV CT . Optimal threshold was cr CBF CT 〈 0.30 with sensitivity 60% (CI 95% 57-63%) and specificity 88%, (CI 95% 87-89%); median volume difference between CBF CT and DWI lesions was 0 ml (IQR: -6ml to 6 ml); correlation of volumes was r 2 =0.72 ( p 〈 0.0001). For identification of CHT, reference MRI lesions (Tmax MR 〉 6s) were most accurately identified by Tmax CT 〉 6s with sensitivity 72% (CI 95% 70-74%), specificity 97% (CI 95% 96-97%); median volume difference between Tmax CT and Tmax MR was -3ml (IQR: -10ml to 0ml); correlation of CHT volumes r 2 =0.89 (p 〈 0.0001). Conclusions: The processing methods and CTP thresholds presented in this study show a great promise for fully-automated outlining of stroke lesions using CTP. Such a technique could be of great value for CTP-based patient selection in clinical trials and clinical practice.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.43.suppl_1.A2697
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2012
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  • 9
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    Abstract 135: Correlation of TICI Reperfusion with MR Reperfusion, Infarct Growth and Clinical Outcome in the DEFUSE 2 Trial
    Ovid Technologies (Wolters Kluwer Health) ; 2012
    In:  Stroke Vol. 43, No. suppl_1 ( 2012-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 43, No. suppl_1 ( 2012-02)
    Abstract: Background: The Thrombolysis In Cerebral Infarction (TICI) score is a widely used angiographic score in endovascular stroke studies. Assessment of reperfusion based on perfusion weighted MRI (PWI reperfusion) has been used more commonly in patients treated with intravenous thrombolysis. This analysis of the DEFUSE 2 study data was undertaken to 1) determine the association between TICI and PWI reperfusion and 2) assess the association between TICI-reperfusion and clinical and radiographic outcomes. Methods: Patients undergoing acute endovascular stroke therapy of anterior circulation strokes were enrolled in a prospective multi-center study (DEFUSE 2) if an MRI could be obtained within 90 minutes before endovascular treatment and repeated within 12 hours after the intervention. Only patients with a TICI score of 0 or 1 on baseline digital subtraction angiography (DSA) were included in this analysis. A single blinded reader at the core imaging facility determined pre- and post-procedure TICI scores. TICI-reperfusion was defined as a TICI score of 2B or 3. PWI lesion volumes were assessed using fully automated software (RAPID). PWI-reperfusion was defined as a reduction in PWI(Tmax 〉 6s) lesion volume of 〉 50% between baseline and early follow-up. Infarct growth was defined as the difference between baseline DWI and 5-day FLAIR lesion volume. Favorable clinical response was defined as a NIHSS score of 0-1 at day 30 or an improvement in NIHSS score of ≥8 points between baseline and day 30. Results: This preliminary analysis includes 68 of 101 patients who underwent endovascular therapy and had adequate PWI data to assess reperfusion (final results will be presented at the meeting). At completion of endovascular treatment 30% of the patients remained TICI 0 or 1, 27% improved to TICI 2A, 29% to TICI 2B, and 13% had complete reperfusion (TICI 3). Better TICI-reperfusion scores were associated with higher rates of reperfusion assessed by PWI. PWI-reperfusion was seen in 32% of patients who remained TICI 0-1, 53% with TICI 2A, 98% with TICI 2B, and 100% with TICI 3 reperfusion. Agreement between TICI-reperfusion and PWI-reperfusion was moderate (kappa 0.51). The incidence of favorable clinical response increased with higher TICI scores: 35% with TICI 0-1, 44% with TICI 2A, 72% with TICI 2B, and 67% with TICI 3. Patients who met pre-specified DEFUSE 2 criteria for reperfusion (TICI 2B/3) were more likely to have a favorable clinical response (70% vs 40%; p=0.015), and had less median [IQR] lesion growth (10 [2-56] ml vs 67 [28-122] ml; p=0.001) than patients without TICI-reperfusion. Conclusion: TICI 2B or 3 reperfusion following endovascular therapy for acute anterior circulation stroke is highly correlated with PWI reperfusion. Patients with TICI 2B or 3 reperfusion show less infarct growth and are more likely to have a favorable clinical response.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.43.suppl_1.A135
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2012
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  • 10
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    Abstract TP21: Impact Of Complete Recanalization On The Relationships Between Pretreatment Dwi Volume And Clinical Outcome In Patients Treated By Endovascular Treatment.
    Ovid Technologies (Wolters Kluwer Health) ; 2013
    In:  Stroke Vol. 44, No. suppl_1 ( 2013-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 44, No. suppl_1 ( 2013-02)
    Abstract: Objectives: To evaluate the relationships between pre-treatment DWI volume and clinical outcome following endovascular therapy. Methods: Patients from the REcanalisation using Combined intravenous Alteplase and Neurointerventional ALgorithm for acute Ischemic StrokE (RECANALISE) study who suffered an acute hemispheric infarction with a large vessel occlusion and underwent DWI before endovascular treatment were enrolled. DWI volumes were automatically calculated by the RAPID software. Recanalization was graded using the TIMI scale. Outcomes assessed were favorable outcome (mRS 0-2) and death at 90 days. Findings: 66% (138/210) of the patients were eligible for this substudy. Mean age was 69.6 years (+/-17.6), median NIHSS 16 (IQR: 10-21) median time to MRI 110 min (IQR 77-178), and median time to treatment 149 min (IQR: 115-250). Median DWI volume was 14mL (IQR: 5 to 43) and was categorized into tertiles.Median volume per tertile were: Small: 3mL(IQR:1-5); Moderate 14mL(IQR:10-20) and Large 60mL(IQR:43-104)including 19 patients with a very large DWI lesion ( 〉 70mL). TIMI 3 was achieved in 47%[median delay 238 min, (IQR, 206 to 285)]and TIMI 2 in 38%; [median delay 269 min, (IQR, 219 to 350)] . Overall, the rate of favorable outcome decreased and the death rate increased gradually with DWI volume.( cf Table) After adjustment for age and NIHSS, complete recanalization was associated with a higher rate of favorable outcome and decreased death rate in the moderate and large DWI volume tertiles.(cf table)This relationship was not observed in patients with very large ( 〉 70 mL) or small DWI volumes. Conclusion: In patients undergoing endovascular treatment, our results demonstrate that increasing DWI volumes were associated with a worse outcome while a complete recanalization was associated with a significant better clinical outcome in patients with a moderate to large DWI lesion. This relationship was not observed in small or very large DWI lesion volume ( 〉 70 mL). / 〉
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.44.suppl_1.ATP21
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2013
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