BACKGROUND AND PURPOSE: Accurate and reliable detection of medium-vessel occlusions is important to establish the diagnosis of acute ischemic stroke and initiate appropriate treatment with intravenous thrombolysis or endovascular thrombectomy. However, medium-vessel occlusions are often challenging to detect, especially for unexperienced readers. We aimed to evaluate the accuracy and interrater agreement of the detection of medium-vessel occlusions using single-phase and multiphase CTA. MATERIALS AND METHODS: Single-phase and multiphase CTA of 120 patients with acute ischemic stroke (20 with no occlusion, 44 with large-vessel occlusion, and 56 with medium-vessel occlusion in the anterior and posterior circulation) were assessed by 3 readers with varying levels of experience (session 1: single-phase CTA; session 2: multiphase CTA). Interrater agreement for occlusion type (large-vessel occlusion versus medium-vessel occlusion versus no occlusion) and for detailed occlusion sites was calculated using the Fleiss κ with 95% confidence intervals. Accuracy for the detection of medium-vessel occlusions was calculated for each reader using classification tables. RESULTS: Interrater agreement for occlusion type was moderate for single-phase CTA (κ = 0.58; 95% CI, 0.56-0.62) and almost perfect for multiphase CTA (κ = 0.81; 95% CI, 0.78-0.83). Interrater agreement for detailed occlusion sites was moderate for single-phase CTA (κ = 0.55; 95% CI, 0.53-0.56) and substantial for multiphase CTA (κ = 0.71; 95% CI, 0.67-0.74). On single-phase CTA, readers 1, 2, and 3 classified 33/56 (59%), 34/56 (61%), and 32/56 (57%) correctly as medium-vessel occlusions. On multiphase CTA, 48/56 (86%), 50/56 (89%), and 50/56 (89%) medium-vessel occlusions were classified correctly. CONCLUSIONS: Interrater agreement for medium-vessel occlusions is moderate when using single-phase CTA and almost perfect with multiphase CTA. Detection accuracy is substantially higher with multiphase CTA compared with single-phase CTA, suggesting that multiphase CTA might be a valuable tool for assessment of medium-vessel occlusion stroke.
- MeSH
- cévní mozková příhoda * diagnostické zobrazování MeSH
- CT angiografie MeSH
- ischemická cévní mozková příhoda * MeSH
- ischemie mozku * MeSH
- lidé MeSH
- mozková angiografie MeSH
- retrospektivní studie MeSH
- trombektomie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
PURPOSE: Infarct lesion volume (ILV) may serve as an imaging biomarker for clinical outcomes in the early post-treatment stage in patients with acute ischemic stroke. The aim of this study was to evaluate the inter- and intra-rater reliability of manual segmentation of ILV on follow-up non-contrast CT (NCCT) scans. METHODS: Fifty patients from the Prove-IT study were randomly selected for this analysis. Three raters manually segmented ILV on 24-h NCCT scans, slice by slice, three times. The reference standard for ILV was generated by the Simultaneous Truth And Performance Level estimation (STAPLE) algorithm. Intra- and inter-rater reliability was evaluated, using metrics of intraclass correlation coefficient (ICC) regarding lesion volume and the Dice similarity coefficient (DSC). RESULTS: Median age of the 50 subjects included was 74.5 years (interquartile range [IQR] 67-80), 54% were women, median baseline National Institutes of Health Stroke Scale was 18 (IQR 11-22), median baseline ASPECTS was 9 (IQR 6-10). The mean reference standard ILV was 92.5 ml (standard deviation (SD) ± 100.9 ml). The manually segmented ILV ranged from 88.2 ± 91.5 to 135.5 ± 119.9 ml (means referring to the variation between readers, SD within readers). Inter-rater ICC was 0.83 (95%CI: 0.76-0.88); intra-rater ICC ranged from 0.85 (95%CI: 0.72-0.92) to 0.95 (95%CI: 0.91-0.97). The mean DSC among the three readers ranged from 65.5 ± 22.9 to 76.4 ± 17.1% and the mean overall DSC was 72.8 ± 23.0%. CONCLUSION: Manual ILV measurements on follow-up CT scans are reliable to measure the radiological outcome despite some variability.
- MeSH
- algoritmy MeSH
- cévní mozková příhoda * diagnostické zobrazování MeSH
- ischemická cévní mozková příhoda * MeSH
- lidé MeSH
- počítačová rentgenová tomografie metody MeSH
- reprodukovatelnost výsledků MeSH
- senioři MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
PURPOSE: CT angiography (CTA) is the imaging standard for large vessel occlusion (LVO) detection in patients with acute ischemic stroke. StrokeSENS LVO is an automated tool that utilizes a machine learning algorithm to identify anterior large vessel occlusions (LVO) on CTA. The aim of this study was to test the algorithm's performance in LVO detection in an independent dataset. METHODS: A total of 400 studies (217 LVO, 183 other/no occlusion) read by expert consensus were used for retrospective analysis. The LVO was defined as intracranial internal carotid artery (ICA) occlusion and M1 middle cerebral artery (MCA) occlusion. Software performance in detecting anterior LVO was evaluated using receiver operator characteristics (ROC) analysis, reporting area under the curve (AUC), sensitivity, and specificity. Subgroup analyses were performed to evaluate if performance in detecting LVO differed by subgroups, namely M1 MCA and ICA occlusion sites, and in data stratified by patient age, sex, and CTA acquisition characteristics (slice thickness, kilovoltage tube peak, and scanner manufacturer). RESULTS: AUC, sensitivity, and specificity overall were as follows: 0.939, 0.894, and 0.874, respectively, in the full cohort; 0.927, 0.857, and 0.874, respectively, in the ICA occlusion cohort; 0.945, 0.914, and 0.874, respectively, in the M1 MCA occlusion cohort. Performance did not differ significantly by patient age, sex, or CTA acquisition characteristics. CONCLUSION: The StrokeSENS LVO machine learning algorithm detects anterior LVO with high accuracy from a range of scans in a large dataset.
- MeSH
- arteriální okluzní nemoci * MeSH
- cévní mozková příhoda * diagnostické zobrazování MeSH
- CT angiografie metody MeSH
- infarkt arteria cerebri media diagnostické zobrazování MeSH
- ischemická cévní mozková příhoda * MeSH
- ischemie mozku * MeSH
- lidé MeSH
- retrospektivní studie MeSH
- software MeSH
- strojové učení MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
BACKGROUND: Successful reperfusion determines the treatment effect of endovascular thrombectomy. We evaluated stent-retriever characteristics and their relation to reperfusion in the ESCAPE-NA1 trial. METHODS: Independent re-scoring of reperfusion grade for each attempt was conducted. The following characteristics were evaluated: stent-retriever length and diameter, thrombus position within stent-retriever, bypass effect, deployment in the superior or inferior MCA trunk, use of balloon guide catheter and distal access catheter. Primary outcome was successful reperfusion defined as expanded thrombolysis in cerebral infarction (eTICI) 2b-3 per attempt. The secondary outcome was successful reperfusion eTICI 2b-3 after the first attempt. Separate regression models for each stent-retriever characteristic and an exploratory multivariable modeling to test the impact of all characteristics on successful reperfusion were built. RESULTS: Of 1105 patients in the trial, 809 with the stent-retriever use (1241 attempts) were included in the primary analysis. The stent-retriever was used as the first-line approach in 751 attempts. A successful attempt was associated with thrombus position within the proximal or middle third of the stent (OR 2.06; 95% CI: 1.24-3.40 and OR 1.92; 95% CI: 1.16-3.15 compared to the distal third respectively) and with bypass effect (OR 1.7; 95% CI: 1.07-2.72). Thrombus position within the proximal or middle third (OR 2.80; 95% CI: 1.47-5.35 and OR 2.05; 95% CI: 1.09-3.84, respectively) was associated with first-pass eTICI 2b-3 reperfusion. In the exploratory analysis accounting for all characteristics, bypass effect was the only independent predictor of eTICI 2b-3 reperfusion (OR 1.95; 95% CI: 1.10-3.46). CONCLUSION: The presence of bypass effect and thrombus positioning within the proximal and middle third of the stent-retriever were strongly associated with successful reperfusion.
BACKGROUND AND PURPOSE: Various imaging paradigms are used for endovascular treatment (EVT) decision-making and outcome estimation in acute ischemic stroke (AIS). We aim to compare how these imaging paradigms perform for EVT patient selection and outcome estimation. METHODS: Prospective multi-center cohort study of patients with AIS symptoms with multi-phase computed tomography angiography (mCTA) and computed tomography perfusion (CTP) baseline imaging. mCTA-based EVT-eligibility was defined as presence of large vessel occlusion (LVO) and moderate-to-good collaterals on mCTA. CTP-based eligibility was defined as presence of LVO, ischemic core (defined on relative cerebral blood flow, absolute cerebral blood flow, and cerebral blood volume maps) <70 mL, mismatch-ratio >1.8, absolute mismatch >15 mL. EVT-eligibility and adjusted rates of good outcome (modified Rankin Scale 0-2) based on these imaging paradigms were compared. RESULTS: Of 289/464 patients with LVO, 263 (91%) were EVT-eligible by mCTA-criteria versus 63 (22%), 19 (7%) and 103 (36%) by rCBF, aCBF, and CBV-CTP-criteria. CTP and mCTA-criteria were discordant in 40% to 53%. Estimated outcomes were best in patients who met both mCTA and CTP eligibility-criteria and were treated with EVT (62% to 87% good outcome). Patients eligible for EVT by mCTA-criteria and not by CTP-criteria receiving EVT achieved good outcome rates of 53% to 57%. Few patients met CTP-criteria and not mCTA-criteria for EVT. CONCLUSIONS: Simpler imaging selection criteria that rely on little else than detection of the occluded blood vessel may be more sensitive and less specific, thus resulting in more patients being offered EVT and arguably benefiting from it.
- Publikační typ
- časopisecké články MeSH
BACKGROUND: Multiphase CTA (mCTA) is an established tool for endovascular treatment decision-making and outcome prediction in acute ischemic stroke, but its interpretation requires some degree of experience. We aimed to determine whether mCTA-based prediction of clinical outcome and final infarct volume can be improved by assessing collateral status on time-variant mCTA color maps rather than using a conventional mCTA display format. METHODS: Patients from the PRove-IT cohort study with anterior circulation large vessel occlusion were included in this study. Collateral status was assessed with a three-point scale using the conventional display format. Collateral extent and filling dynamics were then graded on a three-point scale using time-variant mCTA color-maps (FastStroke, GE Healthcare, Milwaukee, WI, USA). Multivariable logistic regression was performed to determine the association of conventional collateral score, color-coded collateral extent and color-coded collateral filling dynamics with good clinical outcome and final infarct volume (volume below vs. above median infarct volume in the study sample). RESULTS: A total of 285 patients were included in the analysis and 53% (152/285) of the patients achieved a good outcome. Median infarct volume on follow-up was 12.6 ml. Color-coded collateral extent was significantly associated with good outcome (adjusted odds ratio [adjOR] 0.53, 95% confidence interval [CI]:0.36-0.77) while color-coded collateral filling dynamics (adjOR 1.30 [95%CI:0.88-1.95]) and conventional collateral scoring (adjOR 0.72 [95%C:0.48-1.08]) were not. Both color-coded collateral extent (adjOR 2.67 [95%CI:1.80-4.00]) and conventional collateral scoring (adjOR 1.84 [95%CI:1.21-2.79]) were significantly associated with follow-up infarct volume, while color-coded collateral filling dynamics were not (adjOR 1.21 [95%CI:0.83-1.78]). CONCLUSION: In this study, collateral extent assessment on time-variant mCTA maps improved prediction of good outcome and has similar value in predicting follow-up infarct volume compared to conventional mCTA collateral grading.
- MeSH
- cévní mozková příhoda * diagnostické zobrazování MeSH
- CT angiografie MeSH
- ischemická cévní mozková příhoda * MeSH
- ischemie mozku * diagnostické zobrazování MeSH
- kohortové studie MeSH
- kolaterální oběh MeSH
- lidé MeSH
- mozková angiografie MeSH
- retrospektivní studie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
Background: Endovascular treatment (EVT) for stroke due to medium vessel occlusion (MeVO) can be technically challenging. Devices and tools are rapidly evolving. We aimed to gain insight into preferences and global perspectives on the usage of endovascular tools in treating MeVOs. Methods: We conducted an international survey with seven scenarios of patients presenting A3, M2/3, M3, M3/4, or P2/3 occlusions. Respondents were asked for their preferred first-line endovascular approach, and whether they felt that the appropriate endovascular tools were available to them. Answers were analyzed by occlusion location and geographical region of practice, using multinomial/binary logistic regression. Results: A total of 263 neurointerventionists provided 1836 responses. The first-line preferences of physicians were evenly distributed among stent-retrievers, combined approaches, and aspiration only (33.2, 29.8, and 26.8%, respectively). A3 occlusions were more often treated with stent-retrievers (RR 1.21, 95% CI: 1.07-1.36), while intra-arterial thrombolysis was more often preferred in M3 (RR 2.47, 95% CI: 1.53-3.98) and M3/4 occlusions (RR 7.71, 95% CI: 4.16-14.28) compared to M2/3 occlusions. Respondents who thought appropriate tools are currently not available more often chose stent retrievers alone (RR 2.07; 95% CI: 1.01-4.24) or intra-arterial thrombolysis (RR 3.35, 95% CI: 1.26-8.42). Physicians who stated that they do not have access to optimal tools opted more often not to treat at all (RR 3.41, 95% CI: 1.11-10.49). Stent-retrievers alone were chosen more often and contact aspiration alone less often as a first-line approach in Europe (RR 2.12, 95% CI: 1.38-3.24; and RR 0.49, 95% CI 0.34-0.70, respectively) compared to the United States and Canada. Conclusions: In EVT for MeVO strokes, neurointerventionalists choose a targeted vessel specific first-line approach depending on the occlusion location, region of practice, and availability of the appropriate tools.
- Publikační typ
- časopisecké články MeSH
Background The effect of infarct pattern on functional outcome in acute ischemic stroke is incompletely understood. Purpose To investigate the association of qualitative and quantitative infarct variables at 24-hour follow-up noncontrast CT and diffusion-weighted MRI with 90-day clinical outcome. Materials and Methods The Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke, or ESCAPE-NA1, randomized controlled trial enrolled patients with large-vessel-occlusion stroke undergoing mechanical thrombectomy from March 1, 2017, to August 12, 2019. In this post hoc analysis of the trial, qualitative infarct variables (predominantly gray [vs gray and white] matter involvement, corticospinal tract involvement, infarct structure [scattered vs territorial]) and total infarct volume were assessed at 24-hour follow-up noncontrast CT or diffusion-weighted MRI. White and gray matter infarct volumes were assessed in patients by using follow-up diffusion-weighted MRI. Infarct variables were compared between patients with and those without good outcome, defined as a modified Rankin Scale score of 0-2 at 90 days. The association of infarct variables with good outcome was determined with use of multivariable logistic regression. Separate regression models were used to report effect size estimates with adjustment for total infarct volume. Results Qualitative infarct variables were assessed in 1026 patients (mean age ± standard deviation, 69 years ± 13; 522 men) and quantitative infarct variables were assessed in a subgroup of 358 of 1026 patients (mean age, 67 years ± 13; 190 women). Patients with gray and white matter involvement (odds ratio [OR] after multivariable adjustment, 0.19; 95% CI: 0.14, 0.25; P < .001), corticospinal tract involvement (OR after multivariable adjustment, 0.06; 95% CI: 0.04, 0.10; P < .001), and territorial infarcts (OR after multivariable adjustment, 0.22; 95% CI: 0.14, 0.32; P < .001) were less likely to achieve good outcome, independent of total infarct volume. Conclusion Infarct confinement to the gray matter, corticospinal tract sparing, and scattered infarct structure at 24-hour noncontrast CT and diffusion-weighted MRI were highly predictive of good 90-day clinical outcome, independent of total infarct volume. Clinical trial registration no. NCT02930018 © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Mossa-Basha in this issue.
- MeSH
- arteriální okluzní nemoci diagnostické zobrazování patologie terapie MeSH
- diflukortolon MeSH
- difuzní magnetická rezonance * MeSH
- dvojitá slepá metoda MeSH
- fixní kombinace léků MeSH
- ischemická cévní mozková příhoda diagnostické zobrazování patologie terapie MeSH
- lidé MeSH
- lidokain MeSH
- neuroprotektivní látky terapeutické užití MeSH
- počítačová rentgenová tomografie * MeSH
- prognóza MeSH
- senioři MeSH
- trombektomie MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
- práce podpořená grantem MeSH
- randomizované kontrolované studie MeSH
BACKGROUND: Preventing errors and complications in neurointervention is crucial, particularly in the treatment of unruptured intracranial aneurysms (UIAs), where the natural history is generally benign, and the margin of treatment benefit small. We aimed to investigate how neurointerventionalists perceive the importance and frequency of errors and the resulting complications in endovascular UIA treatment, and which steps could be taken to prevent them. METHODS: An international multidisciplinary survey was conducted among neurointerventionalists. Participants provided their demographic characteristics and neurointerventional treatment volume. They were asked about their perceptions on the importance and frequency of different errors in endovascular UIA treatment, and which solutions they thought to be most effective in preventing these errors. RESULTS: Two-hundred-thirty-three neurointerventionalists from 38 countries participated in the survey. Participants identified errors in technical execution as the most common source of complications in endovascular UIA treatment (40.4% thought these errors constituted a relatively or very large proportion of all complication sources), closely followed by errors in decision-making/indication (32.2%) and errors related to management of unexpected events (28.4%). Simulation training was thought to be most effective in reducing technical errors, while cognitive errors were believed to be best minimized by abandoning challenging procedures, more honest discussion of complications and better standardization of procedure steps. CONCLUSION: Neurointerventionalists perceived both technical and cognitive errors to be important sources of complications in endovascular UIA treatment. Simulation training, a cultural change, higher acceptance of bail-out strategies and better standardization of procedures were perceived to be most effective in preventing these.
- MeSH
- chybná zdravotní péče prevence a kontrola MeSH
- endovaskulární výkony výchova normy MeSH
- intrakraniální aneurysma terapie MeSH
- lékařská praxe - způsoby provádění normy MeSH
- lidé středního věku MeSH
- lidé MeSH
- průzkumy a dotazníky MeSH
- tréninková simulace * MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- MeSH
- cerebrovaskulární poruchy chirurgie MeSH
- lidé MeSH
- neurochirurgické výkony metody MeSH
- roboticky asistované výkony * MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- úvodníky MeSH
