Both ASPECTS and core volume on CTP are used to estimate infarct volume in acute ischemic stroke. To evaluate the potential role of ASPECTS for acute endovascular treatment decisions, we studied the ...correlation between ASPECTS and CTP core, depending on the timing and the presence of large-vessel occlusion.
We retrospectively reviewed all MCA acute ischemic strokes with standardized reconstructions of CTP maps entered in the Acute STroke Registry and Analysis of Lausanne (ASTRAL) registry. Correlation between ASPECTS and CTP core was determined for early (<6 hours) versus late (6-24 hours) times from stroke onset and in the presence versus absence of large-vessel occlusion. We used correlation coefficients and adjusted multiple linear regression models.
We included 1046 patients with a median age of 71.4 years (interquartile range, IQR = 59.8-79.4 years), an NIHSS score of 12 (IQR, 6-18), an ASPECTS of 9 (IQR, 7-10), and a CTP core of 13.6 mL (IQR, 0.6-52.8 mL). The overall correlation between ASPECTS and CTP core was moderate (ρ = -0.49,
< .01) but significantly stronger in the late-versus-early window (ρ = -0.56 and ρ = -0.48, respectively;
= .05) and in the presence versus absence of large-vessel occlusion (ρ = -0.40 and ρ = -0.20, respectively;
< .01). In the regression model, the independent association between ASPECTS and CTP core was confirmed and was twice as strong in late-arriving patients with large-vessel occlusion (β = -0.21 per 10 mL; 95% CI, -0.27 to -0.15;
< .01) than in the overall population (β = -0.10; 95% CI, -0.14 to -0.07;
< .01).
In a large cohort of patients with acute ischemic stroke, we found a moderate correlation between ASPECTS and CTP core. However, this was stronger in patients with large-vessel occlusion and longer delay from stroke onset. Our results could support the use of ASPECTS as a surrogate marker of CTP core in late-arriving patients with acute ischemic stroke with large-vessel occlusion.
Introduction
PCT is used in the diagnosis of acute neurological syndromes, particularly stroke. We aimed to evaluate PCT abnormalities in patients with acute epileptic seizures or status epilepticus ...(SE).
Methods
We collected patients undergoing acute PCT for the suspicion of acute ischemic stroke (AIS), who received a final diagnosis of focal seizures or generalised seizures with a post-ictal deficit, with or without concomitant AIS. PCTs were retrospectively analysed for the presence of hyper- and hypoperfusion, and results correlated with delay from seizure onset, aetiology, type of seizures and the presence of electrical SE.
Results
Half of the 43 consecutively identified patients had regional PCT abnormalities—hyperperfusion in 13 (30%) and hypoperfusion in 8 (19%)—and 4 (9%) had AIS. Among patients with hyperperfusion, six (46%) had a focal deficit during imaging acquisition (two a normal clinical status, one altered consciousness and four ongoing seizure); nine (69%) of these patients had a SE; none had a stroke. All patients with hypoperfusion had focal neurological deficit; three (37%) of them a simultaneous ischemic stroke (in the remaining five, hypoperfusion was considered to be related to the seizure post-ictal phase). In the 22 with normal perfusion, 9 had a focal deficit (10 a normal clinical status, 2 altered consciousness and 1 ongoing seizure); 3 had a SE, and 1 had a stroke. Patients with SE featured a higher prevalence of hyperperfusion (9/13 69% vs. 4/30 13% without SE,
p
= 0.00).
Conclusion
In patients with acute epileptic seizures, regional hyperperfusion on PCT may suggest an ongoing or recently resolved SE, whereas hypoperfusion may be due to post-ictal state or simultaneous AIS. These observations might help attributing focal deficits to epileptic seizures rather than stroke, allowing for targeted therapy.
Endovascular treatment of acute ischemic stroke is now performed more frequently in the late window in radiologically selected patients. However, little is known about whether the frequency and ...clinical impact of incomplete recanalization and postprocedural cerebrovascular complications differ between early and late windows in the real world.
We retrospectively reviewed all patients with acute ischemic stroke receiving endovascular treatment within 24 hours from 2015 to 2019 and included in the Acute STroke Registry and Analysis of Lausanne. We compared rates of incomplete recanalization and postprocedural cerebrovascular complications (parenchymal hematoma, ischemic mass effect, and 24-hour re-occlusion) in the early (<6 hours) versus late window (6-24 hours, including patients with unknown onset) populations and correlated them with the 3-month clinical outcome.
Among 701 patients with acute ischemic stroke receiving endovascular treatment, 29.2% had late endovascular treatment. Overall, incomplete recanalization occurred in 56 patients (8%), and 126 patients (18%) had at least 1 postprocedural cerebrovascular complication. The frequency of incomplete recanalization was similar in early and late endovascular treatment (7.5% versus 9.3%, adjusted
=.66), as was the occurrence of any postprocedural cerebrovascular complication (16.9% versus 20.5%, adjusted
= .36). When analyzing single postprocedural cerebrovascular complications, rates of parenchymal hematoma and ischemic mass effect were similar (adjusted
= .71, adjusted
= .79, respectively), but 24-hour re-occlusion seemed somewhat more frequent in late endovascular treatment (4% versus 8.3%, unadjusted
= .02, adjusted
= .40). The adjusted 3-month clinical outcome in patients with incomplete recanalization or postprocedural cerebrovascular complications was comparable between early and late groups (adjusted
= .67, adjusted
= .23, respectively).
The frequency of incomplete recanalization and of cerebrovascular complications occurring after endovascular treatment is similar in early and well-selected late patients receiving endovascular treatment. Our results demonstrate the technical success and safety of endovascular treatment in well-selected late patients with acute ischemic stroke.
Procedural complications occur in 4%-29% of endovascular treatments in acute ischemic stroke. However, little is known about their predictors and clinical impact in the real world. We aimed to ...investigate the frequency and clinical impact of procedural complications of endovascular treatment and identify associated risk factors.
From 2015-2019, we retrospectively reviewed all patients with acute ischemic stroke receiving endovascular treatment within 24 hours included in the Acute STroke Registry and Analysis of Lausanne. We identified patients having an endovascular treatment procedural complication (local access complication, arterial perforation, dissection or vasospasm, and embolization in a previously nonischemic territory) and performed logistic regression analyses to identify associated predictors. We also correlated procedural complications with long-term clinical outcome.
Of the 684 consecutive patients receiving endovascular treatment, 113 (16.5%) had at least 1 procedural complication. The most powerful predictors were groin puncture off-hours (OR = 2.24), treatment of 2 arterial sites (OR = 2.71), and active smoking (OR = 1.93). Patients with a complication had a significantly less favorable short-term clinical outcome (Δ-NIHSS score of -2.2 versus -4.33,
-value adjusted < .001), but a similar long-term clinical outcome (mRS at 3 months = 3 versus 2,
-value adjusted = .272).
Procedural complications are quite common in endovascular treatment and lead to a less favorable short-term but similar long-term outcome. Their association with treatment off-hours and at 2 arterial sites requires particular attention in these situations to optimize the overall benefit of endovascular treatment.
We studied the respective added value of the quantitative myocardial blood flow (MBF) and the myocardial flow reserve (MFR) as assessed with (82)Rb positron emission tomography (PET)/CT in predicting ...major adverse cardiovascular events (MACEs) in patients with suspected myocardial ischaemia.
Myocardial perfusion images were analysed semi-quantitatively (SDS, summed difference score) and quantitatively (MBF, MFR) in 351 patients. Follow-up was completed in 335 patients and annualized MACE (cardiac death, myocardial infarction, revascularization, or hospitalization for congestive heart failure or de novo stable angor) rates were analysed with the Kaplan-Meier method in 318 patients after excluding 17 patients with early revascularizations (<60 days). Independent predictors of MACEs were identified by multivariate analysis. During a median follow-up of 624 days (inter-quartile range 540-697), 35 MACEs occurred. An annualized MACE rate was higher in patients with ischaemia (SDS >2) (n = 105) than those without 14% (95% CI = 9.1-22%) vs. 4.5% (2.7-7.4%), P < 0.0001. The lowest MFR tertile group (MFR <1.8) had the highest MACE rate 16% (11-25%) vs. 2.9% (1.2-7.0%) and 4.3% (2.1-9.0%), P < 0.0001. Similarly, the lowest stress MBF tertile group (MBF <1.8 mL/min/g) had the highest MACE rate 14% (9.2-22%) vs. 7.3% (4.2-13%) and 1.8% (0.6-5.5%), P = 0.0005. Quantitation with stress MBF or MFR had a significant independent prognostic power in addition to semi-quantitative findings. The largest added value was conferred by combining stress MBF to SDS. This holds true even for patients without ischaemia.
Perfusion findings in (82)Rb PET/CT are strong MACE outcome predictors. MBF quantification has an added value allowing further risk stratification in patients with normal and abnormal perfusion images.
Perfusion CT may improve the diagnostic performance of noncontrast CT in acute ischemic stroke. We assessed predictors of focal hypoperfusion in acute ischemic stroke and perfusion CT performance in ...predicting infarction on follow-up imaging.
Patients from the Acute STroke Registry and Analysis of Lausanne data base with acute ischemic stroke and perfusion CT were included. Clinical and radiologic data were collected. We identified predictors of focal hypoperfusion using multivariate analyses.
From the 2216 patients with perfusion CT, 38.2% had an acute ischemic lesion on NCCT and 73.3% had focal hypoperfusion on perfusion CT. After we analyzed 104 covariates, high-admission NIHSS, visual field defect, aphasia, hemineglect, sensory deficits, and impaired consciousness were positively associated with focal hypoperfusion. Negative associations were pure posterior circulation, lacunar strokes, and anticoagulation. After integrating radiologic variables into the multivariate analyses, we found that visual field defect, sensory deficits, hemineglect, early ischemic changes on NCCT, anterior circulation, cardioembolic etiology, and arterial occlusion were positively associated with focal hypoperfusion, whereas increasing onset-to-CT delay, chronic vascular lesions, and lacunar etiology showed negative association. Sensitivity, specificity, and positive and negative predictive values of focal hypoperfusion on perfusion CT for infarct detection on follow-up MR imaging were 66.5%, 79.4%, 96.2%, and 22.8%, respectively, with an overall accuracy of 76.8%.
Compared with NCCT, perfusion CT doubles the sensitivity in detecting acute ischemic stroke. Focal hypoperfusion is independently predicted by stroke severity, cortical clinical deficits, nonlacunar supratentorial strokes, and shorter onset-to-imaging delays. A high proportion of patients with focal hypoperfusion developed infarction on subsequent imaging, as did some patients without focal hypoperfusion, indicating the complementarity of perfusion CT and MR imaging in acute ischemic stroke.
Neurovascular compression of the rostral ventrolateral medulla (RVLM) has been described as a possible cause of refractory essential hypertension. We present the case of a patient affected by ...episodes of severe paroxysmal hypertension, some episodes associated with vago-glossopharyngeal neuralgia. Classical secondary forms of hypertension were excluded. Imaging revealed a neurovascular conflict between the posterior inferior cerebellar artery (PICA) and the ventrolateral medulla at the level of the root entry zone of the ninth and tenth cranial nerves (CN IX-X REZ). A MVD of a conflict between the PICA and the RVLM and adjacent CN IX-X REZ was performed, resulting in reduction of the frequency and severity of the episodes. Brain MRI should be performed in cases of paroxysmal hypertension. MVD can be considered in selected patients.
Background and purpose
The aim was to determine the predictors of focal hypoperfusion on computed tomography (CT) perfusion (CTP) in patients with acute posterior circulation stroke and its ...association with long‐term outcome.
Methods
Patients with posterior circulation stroke were selected from the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) who underwent CTP within 24 h of stroke onset as part of the stroke imaging protocol. Hypoperfusion was defined as an area of visually well demarcated mean transit time prolongation corresponding to an arterial territory on standard reconstruction CTP imaging maps. Areas of hypoperfusion were assessed with the posterior circulation Acute Stroke Prognosis Early CT Score. Clinical and imaging associations with focal hypoperfusion were identified using multiple imputation analyses, and the adjusted functional outcome measured by the modified Rankin Scale at 3 and 12 months was determined.
Results
Of the 3595 consecutive patients from the ASTRAL registry between 2003 and 2014, 1070 (29.7%) had a posterior circulation stroke and 436 of these (40.7%) patients had a good quality baseline CTP. 23.1% had early ischaemic changes and 37.4% had focal hypoperfusion. In multiple imputation analysis, visual field deficits, reduced level of consciousness, cardiac and multiple stroke mechanisms, significant vessel pathology and ischaemic changes visible on plain CT were associated with focal hypoperfusion. Focal hypoperfusion was independently associated with outcome at 12 months (odds ratio 2.04, 95% confidence interval 1.22–3.42, P < 0.01).
Conclusions
In posterior circulation stroke patients undergoing acute CTP, multiple clinical, aetiological and radiological variables were associated with focal hypoperfusion. Patients with focal hypoperfusion had a worse 12‐month outcome.
Patients with vascular parkinsonism have higher cognitive decline and more basal ganglia lesions. We aimed to evaluate the relationship of cognitive impairment with functional connectivity between ...the basal ganglia and cingulate cortex in vascular parkinsonism.
Thirty patients (8 with vascular parkinsonism and 22 with Parkinson disease) and 23 controls were enrolled. The Mattis Dementia Rating Scale and the Stroop Task were used to assess cognitive decline. MR imaging examinations included T1-MPRAGE, FLAIR, and resting-state fMRI sequences. MPRAGE was segmented to obtain basal ganglia and cingulate cortex volumes. FLAIR was segmented to obtain white matter hyperintensity lesion volume. Resting-state fMRI sequences were used to compare basal ganglia functional connectivity with the cingulate cortex between patients and controls.
Patients with vascular parkinsonism exhibited impaired attention, resistance to interference, and inhibitory control and an increased number of errors on the Stroop Task. They also had higher caudate nucleus and white matter hyperintensity lesion volumes, which were positively correlated (ρ = 0.75, P < .0001). Caudate nucleus functional connectivity with the perigenual anterior cingulate cortex was increased in patients with vascular parkinsonism compared with controls and patients with Parkinson disease, and it was positively correlated with the caudate nucleus volume (ρ = 0.44, P = .016). Caudate nucleus functional connectivity with the posterior cingulate cortex was decreased in patients with vascular parkinsonism compared with controls and negatively correlated with the number of errors on the Stroop test (ρ = -0.51, P = .0003).
In patients with vascular parkinsonism, cognitive decline could be related to changes of caudate nucleus functional connectivity with the cingulate cortex at resting-state, which may be induced by ischemia-related remodelling.
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