Introduction PROMISE trial has shown high predictive accuracy of the N20 somatosensory evoked potential (SEP) response on functional recovery in patients with AIS undergoing endovascular thrombectomy ...(EVT). This secondary study aims to describe the association between the N20 response and imaging biomarkers of ischemic penumbra, infarct volume and collateral flow. Methods Presence and amplitude of the N20 response was recorded before EVT. At baseline, infarct core was automatically calculated establishing a threshold value of ADC<620x10‐6mm2/s in MR and of rCBF<30% in CTP; ischemic volume was estimated as Tmax >6 sec; and hypoperfusion intensity ratio (HIR) as the proportion of ischemic volume that also has a delay in Tmax>10s. Leptomeningeal collaterals were classified according to the Arterial Collateral Grading Scale in CTA as "poor" (absence and <50%) and optimal (>50%, equal to and greater than the contralateral), or according to the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology scale when the acquired image was dynamic MR angiography, dichotomized as incomplete collateral fill (poor collateral) (grades 0 to 2) and complete collateral fill (optimal collateral) (grades 3 and 4). Collaterals were not evaluated in the conventional angiography since we did not perform a full study to shorten the time to thrombus access. The adjusted predictive value of N20 for functional recovery was analyzed by logistic regression and compared with imaging variables by using receiver operating characteristic curves. Results From 223 patients studied, 99 patients had multimodal imaging with perfusion studies and N20 assessable recordings at baseline (mean age, 70y; median NIHSS, 18), 63 patients with present (N20+) and 36 with absent N20 response (N20‐). Median infarct core was 12 (0‐25) and 16 (3‐60) cc (p= 0,193), ischemic volume 81 (39‐132) and 111 (54‐188) cc (p=0,082) and the HIR 0,4 (0,2‐0,6) 0,4 (0,3‐0,6) (p=0,572), respectively. N20+ was associated to a better collateral flow (OR 2,5; 1,2‐5,3; p=0,01). N20+ showed the highest predictive capacity of functional recovery at day 7 compared to imaging variables (Table 1) and increased 15 (4‐103) fold the likelihood of good outcome after adjusting for collateral flow 2.94 (1.10‐8.40), ASPECT score (1,17 (0,74 ‐ 1,87) and infarct core 0.98 (0.95‐1.01). Conclusion N20 SEP response is a powerful biomarker of functional recovery that might surrogate advanced imaging in patients with AIS evaluated for endovascular thrombectomy.
Prognostic indexes are useful to guide tailored treatment strategies for cancer patients with brain metastasis (BM). We evaluated the new Graded Prognostic Assessment (GPA) scale in a prospective ...validation study to compare it with two published prognostic indexes.
A total of 285 newly diagnosed BM (n = 85 with synchronous BM) patients, accrued prospectively between 2000 and 2009, were included in this analysis. Mean age was 62 ± 12.0 years. The median KPS and number of BM was 70 (range, 20-100) and 3 (range, 1-50), respectively. The majority of primary tumours were lung (53%), or breast (17%) cancers. Treatment was administered to 255 (89.5%) patients. Only a minority of patients could be classified prospectively in a favourable prognostic class: GPA 3.5-4: 3.9%; recursive partitioning analysis (RPA) 1, 8.4% and Basic Score for BM (BSBM) 3, 9.1%. Mean follow-up (FU) time was 5.2 ± 4.7 months.
During the period of FU, 225 (78.9%) patients died. The 6 months- and 1 year-OS was 36.9% and 17.6%, respectively. On multivariate analysis, performance status (P < 0.001), BSBM (P < 0.001), Center (P = 0.007), RPA (P = 0.02) and GPA (P = 0.03) were statistically significant for OS. The survival prediction performances' of all indexes were identical. Noteworthy, the significant OS difference observed within 3 months of diagnosis between the BSBM, RPA and GPA classes/groups was not observed after this cut-off time point. Harrell's concordance indexes C were 0.58, 0.61 and 0.58 for the GPA, BSBM and RPA, respectively.
Our data suggest that the new GPA index is a valid prognostic index. In this prospective study, the prediction performance was as good as the BSBM or RPA systems. These published indexes may however have limited long term prognostication capability.
Background Somatosensory evoked potentials may add substantial prognostic value in patients with acute ischemic stroke and contribute to the selection of patients who may benefit from ...revascularization therapies beyond the accepted therapeutic time windows. We aimed to study the prognostic accuracy of the N20 somatosensory evoked potential component of the ischemic hemisphere in patients with anterior large‐vessel occlusion undergoing endovascular thrombectomy (EVT). Methods Presence and amplitude of the N20 response were recorded before and after EVT. Its adjusted predictive value for functional independence (modified Rankin scale score, ≤2) at day 7 was analyzed by binary logistic regression adjusting by age, mean arterial blood pressure, National Institute of Health Stroke Scale, Alberta Stroke Program Early CT Score, and serum glucose. N20 predictive power was compared with that of clinical and imaging models by using receiver operating characteristics curve analysis. Results A total of 223 consecutive patients were studied (mean age, 70 years; median National Institute of Health Stroke Scale score, 18). Somatosensory evoked potential recordings identified the presence of N20 in 110 (49.3%), absence in 58 (26%), and not assessable in 55 patients due to radiofrequency interferences in the angiography room. Before EVT, N20 predicted functional independence with a sensitivity of 93% (95% CI, 78%–98%) and negative predictive value of 93% (95% CI, 80%–98%). The adjusted odds ratio for functional independence was 9.9 (95% CI, 3.1–44.6). In receiver operating characteristics curve analysis, N20 amplitude showed a higher area under the curve than prehospital or in‐hospital variables, including advanced imaging. Sensitivity increased to 100% (95% CI, 0.85–1) when N20 was present after EVT. Conclusion Somatosensory evoked potential monitoring is a noninvasive and bedside technique that could help eligibility of patients with acute ischemic stroke for EVT and predict functional recovery.
Abstract Background context Longer life span has resulted in increased risk of vertebral osteoporotic fractures. Among minimally invasive procedures, percutaneous vertebroplasty (PV) has shown ...excellent results in the treatment of chronic vertebral pain. The role of preintervention bone single photon emission computed tomography–computed tomography (SPECT-CT) has not been clearly established for the management of these patients. Purpose To determine the value of bone SPECT-CT in patient selection, treatment planning, and prediction of response to PV. A comparison with magnetic resonance imaging (MRI) was also aimed. Study design Prospective consecutive series. Patient sample We studied the performance of bone SPECT-CT on 33 consecutive patients with chronic pain because of vertebral fracture intended for PV. Outcome measures Improvement of clinical status was based on comparison of preprocedure and postprocedure outcome measurements of pain, mobility, and analgesic use. Methods Bone SPECT was done using a dual-detector variable-angle gamma camera coupled with a two-slice CT scanner (Symbia T2 System; Siemens, Munich, Germany). Magnetic resonance imaging was done using a magnet of 1.5 T (Giroscan System ACS NT Intera; Philips, Amsterdam, The Netherlands). Results Of the 33 patients, 24 finally underwent PV. Positive SPECT-CT images predicted clinical improvement in 91% (21 of 23) of them. Agreement between SPECT-CT and MRI was 80% (20 of 25). Single photon emission computed tomography–computed tomography images showed an alternative cause of pain in some cases, such as new fractures or multiple coexisting fractures, persisting bone remodeling in a previous cemented vertebra, and facet or discal degenerative disease. Single photon emission computed tomography–computed tomography was mandatory in eight patients that could no receive MRI, all of whom improved after PV. Conclusions Positive bone SPECT-CT seems a good predictor of postprocedural response. It also adds valuable information as to the cause of back pain and facilitates complete patient evaluation in patients that can not receive MRI.
BACKGROUND AND PURPOSE:Reliable recognition of large vessel occlusion (LVO) on noncontrast computed tomography (NCCT) may accelerate identification of endovascular treatment candidates. We aim to ...validate a machine learning algorithm (MethinksLVO) to identify LVO on NCCT.
METHODS:Patients with suspected acute stroke who underwent NCCT and computed tomography angiography (CTA) were included. Software detection of LVO (MethinksLVO) on NCCT was tested against the CTA readings of 2 experienced radiologists (NR-CTA). We used a deep learning algorithm to identify clot signs on NCCT. The software image output trained a binary classifier to determine LVO on NCCT. We studied software accuracy when adding National Institutes of Health Stroke Scale and time from onset to the model (MethinksLVO+).
RESULTS:From 1453 patients, 823 (57%) had LVO by NR-CTA. The area under the curve for the identification of LVO with MethinksLVO was 0.87 (sensitivity83%, specificity71%, positive predictive value79%, negative predictive value76%) and improved to 0.91 with MethinksLVO+ (sensitivity83%, specificity85%, positive predictive value88%, negative predictive value79%).
CONCLUSIONS:In patients with suspected acute stroke, MethinksLVO software can rapidly and reliably predict LVO. MethinksLVO could reduce the need to perform CTA, generate alarms, and increase the efficiency of patient transfers in stroke networks.
To study computed tomography findings in Paget's disease of temporal bone (PDTB) and analyze the relations between otic capsule bone mineral density values measured in Hounsfield Units (HU) and ...hearing loss (HL).
Observational case-control study.
Tertiary referral center.
Radiographically confirmed PDTB cases and control group.
Diagnostic.
Hearing thresholds and computed tomography bone density values.
Twenty-three ears in the case group (PDTB) and 27 control ears were included. In the PDTB group, HL was found in 87% of the ears (43% mixed) and an air-conduction threshold of 50.7 dB (SD = 19.8). In the control group, 48% of the ears showed HL (7% mixed) and an air-conduction threshold of 34.5 dB (SD = 20.6) was found; the difference was statistically significant (p < 0.05). Measurements of bone density (HU) in the otic capsule (regions of interest ROI 1 and 2) and in the petrous bone (ROI 3) were significantly lower (p < 0.05) in the PDTB group than in controls.The PDTB group presented a significant association between otic capsule bone density in ROI 1 and mean otic capsule density with air and bone-conduction thresholds (p < 0.05). In controls, no association was observed between any density value and audiometric thresholds.
PDTB patients showed more frequent HL, lower thresholds, and a higher proportion of mixed HL than controls. Bone density (HU) was decreased in all ROIs in PDTB patients in comparison with controls. Bone density in the otic capsule was associated with HL in PDTB patients, but no association was observed between bone density and HL in controls.
IMPORTANCE: The positive treatment effect of endovascular therapy (EVT) is assumed to be caused by the preservation of brain tissue. It remains unclear to what extent the treatment-related reduction ...in follow-up infarct volume (FIV) explains the improved functional outcome after EVT in patients with acute ischemic stroke. OBJECTIVE: To study whether FIV mediates the relationship between EVT and functional outcome in patients with acute ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS: Patient data from 7 randomized multicenter trials were pooled. These trials were conducted between December 2010 and April 2015 and included 1764 patients randomly assigned to receive either EVT or standard care (control). Follow-up infarct volume was assessed on computed tomography or magnetic resonance imaging after stroke onset. Mediation analysis was performed to examine the potential causal chain in which FIV may mediate the relationship between EVT and functional outcome. A total of 1690 patients met the inclusion criteria. Twenty-five additional patients were excluded, resulting in a total of 1665 patients, including 821 (49.3%) in the EVT group and 844 (50.7%) in the control group. Data were analyzed from January to June 2017. MAIN OUTCOME AND MEASURE: The 90-day functional outcome via the modified Rankin Scale (mRS). RESULTS: Among 1665 patients, the median (interquartile range IQR) age was 68 (57-76) years, and 781 (46.9%) were female. The median (IQR) time to FIV measurement was 30 (24-237) hours. The median (IQR) FIV was 41 (14-120) mL. Patients in the EVT group had significantly smaller FIVs compared with patients in the control group (median IQR FIV, 33 11-99 vs 51 18-134 mL; P = .007) and lower mRS scores at 90 days (median IQR score, 3 1-4 vs 4 2-5). Follow-up infarct volume was a predictor of functional outcome (adjusted common odds ratio, 0.46; 95% CI, 0.39-0.54; P < .001). Follow-up infarct volume partially mediated the relationship between treatment type with mRS score, as EVT was still significantly associated with functional outcome after adjustment for FIV (adjusted common odds ratio, 2.22; 95% CI, 1.52-3.21; P < .001). Treatment-reduced FIV explained 12% (95% CI, 1-19) of the relationship between EVT and functional outcome. CONCLUSIONS AND RELEVANCE: In this analysis, follow-up infarct volume predicted functional outcome; however, a reduced infarct volume after treatment with EVT only explained 12% of the treatment benefit. Follow-up infarct volume as measured on computed tomography and magnetic resonance imaging is not a valid proxy for estimating treatment effect in phase II and III trials of acute ischemic stroke.
The post–COVID-19 condition (PCC) is a disabling syndrome affecting at least 5%–10% of subjects who survive COVID-19. SARS-CoV-2 mediated vagus nerve dysfunction could explain some PCC symptoms, such ...as dysphonia, dysphagia, dyspnea, dizziness, tachycardia, orthostatic hypotension, gastrointestinal disturbances, or neurocognitive complaints.
We performed a cross-sectional pilot study in subjects with PCC with symptoms suggesting vagus nerve dysfunction (n = 30) and compared them with subjects fully recovered from acute COVID-19 (n = 14) and with individuals never infected (n = 16). We evaluated the structure and function of the vagus nerve and respiratory muscles.
Participants were mostly women (24 of 30, 80%), and the median age was 44 years (interquartile range IQR 35–51 years). Their most prevalent symptoms were cognitive dysfunction 25 of 30 (83%), dyspnea 24 of 30 (80%), and tachycardia 24 of 30 (80%). Compared with COVID-19-recovered and uninfected controls, respectively, subjects with PCC were more likely to show thickening and hyperechogenic vagus nerve in neck ultrasounds (cross-sectional area CSA mean ± standard deviation: 2.4 ± 0.97mm2 vs. 2 ± 0.52mm2 vs. 1.9 ± 0.73 mm2; p 0.08), reduced esophageal-gastric-intestinal peristalsis (34% vs. 0% vs. 21%; p 0.02), gastroesophageal reflux (34% vs. 19% vs. 7%; p 0.13), and hiatal hernia (25% vs. 0% vs. 7%; p 0.05). Subjects with PCC showed flattening hemidiaphragms (47% vs. 6% vs. 14%; p 0.007), and reductions in maximum inspiratory pressure (62% vs. 6% vs. 17%; p ≤ 0.001), indicating respiratory muscle weakness. The latter findings suggest additional involvement of the phrenic nerve.
Vagus and phrenic nerve dysfunction contribute to the complex and multifactorial pathophysiology of PCC.
Abstract only Purpose: To validate a Machine Learning algorithm able to identify LVO on NCCT. Methods: Patients with suspected acute stroke who underwent NCCT+CT Angiography (CTA) from two ...comprehensive stroke centers were included. Patients with intracranial haemorrhage were excluded. Two experienced radiologists identified the presence of LVO on CTA (NR-CTA) tagging the clot location and manually segmenting the clot. Acute ischemia and clot signs on NCCT were also depicted with assistance of the CTA clot location. With this information a deep learning system was used to create an algorithm (Deepstroke) to identify and locate the presence/absence of acute ischaemia and clot signs in NCCT. Deepstroke image output was used to train a binary classifier to determine LVO on NCCT. Cross-validation was performed in a stratified 5-fold of the data, including deep learning training. We also studied the effect on Deepstroke accuracy when adding the patients NIHSS and time from onset to the model (Deepstroke+). Results: The data cohort included 1354 patients, 724 (53%) with LVO by NR-CTA. The accuracy of Deepstroke to identify LVO had an AUC of 0.81 (sensitivity 0.85; specificity 0.49, PPV 0.66, NPV 0.74), and improved combined with NIHSS and time from symptom onset to AUC 0.88 (sensitivity 0.87, specificity 0.68, PPV 0.76, NPV 0.82). Deepstroke performed better on larger occlusions (Table). Among patients identified as LVO by Deepstroke+ only 19% showed no findings on NR-CTA. The agreement in LVO detection between NR-CTA and Deepstroke+ was 0.78 (Deepstroke was 0.68). Process time per patient was below 120s. Conclusions: In patients with suspected acute stroke, Deepstroke identified LVO in NCCT with a high correlation with radiologist readings of CTAs. Deepstroke could reduce the need to perform CTA, generate alarms and increase the efficiency of patients transfers in the acute management in stroke networks. Deepstroke accuracy will improve as more cases are added to the training set.
Background
Currently available scores for predicting shunt dependency after aneurysmal spontaneous subarachnoid hemorrhage (aSAH) are limited and not widely accepted. The key purpose of this study ...was to validate a recently created score for shunt dependency in aSAH (SDASH) in an independent population of aSAH patients. We compared this new SDASH score based on a combination of the Hunt and Hess grade, Barrow Neurological Institute (BNI) score, and the presence or not of acute hydrocephalus with other published predictive scores.
Methods
The SDASH score, Hijdra score, BNI grading system, chronic hydrocephalus ensuing from SAH score (CHESS), Graeb score, and modified Graeb score (mGS) were calculated for a cohort of aSAH patients. Logistic regression analysis was used to determine the reliability of the SDASH score, and the area under the curve (AUC) of the receiver operating characteristics (ROC) curve was used to assess the discriminative ability of the model.
Results
In 214 patients with aSAH, 40 (18.7%) developed shunt-dependent hydrocephalus (SDHC). The AUC for the SDASH score was 0.816. The SDASH score reliably predicted SDHC in aSAH (odds ratio: 2.93, 95% CI: 1.99–4.31;
p
< 0.001) with no statistically significant differences being found between the SDASH score and the CHESS score (AUC: 0.816), radiological-based Graeb score (AUC: 0.742), or modified Graeb score (AUC: 0.741). However, the Hijdra score (AUC: 0.673) and BNI grading system (AUC: 0.616) showed lower predictive values than the SDASH score.
Conclusions
Our findings support the ability of the SDASH score to predict shunt dependency after SAH in a population independent to that used to develop the score. The SDASH score may aid in the early management of hydrocephalus in aSAH, and it does not differ greatly from other predictive scores.
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