Use of Imaging to Select Patients for Late Window Endovascular Therapy
2018; Lippincott Williams & Wilkins; Volume: 49; Issue: 9 Linguagem: Inglês
10.1161/strokeaha.118.021011
ISSN1524-4628
Autores Tópico(s)Venous Thromboembolism Diagnosis and Management
ResumoHomeStrokeVol. 49, No. 9Use of Imaging to Select Patients for Late Window Endovascular Therapy Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBUse of Imaging to Select Patients for Late Window Endovascular Therapy Gregory W. Albers, MD Gregory W. AlbersGregory W. Albers Correspondence to Gregory W. Albers, MD, Stanford Stroke Center, 780 Welch Rd, Suite 350, Palo Alto, CA 94035. Email E-mail Address: [email protected] From the Department of Neurology and Neurological Sciences, Stanford University Medical Center, Stanford Stroke Center, Palo Alto, CA. Originally published9 Aug 2018https://doi.org/10.1161/STROKEAHA.118.021011Stroke. 2018;49:2256–2260Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: August 9, 2018: Ahead of Print The substantial clinical benefits of late window thrombectomy that were recently documented in the DAWN (Triage of Wake-up and Late Presenting Strokes Undergoing Neurointervention With Trevo)1 and DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3)2 studies led to expansion of the treatment window for thrombectomy from 6 to 24 hours in the 2018 American Heart Association stroke guidelines.3 The new clinical trial data and guidelines have led a large number of stroke centers to begin using advanced imaging with computed tomography perfusion (CTP) or magnetic resonance imaging (MRI) to evaluate patients who present with a possible large vessel occlusion in an extended time window. These techniques can provide quantitative estimates of ischemic core and penumbra without user input and have excellent interobserver agreement. However, these techniques also have limitations, and therefore it is important to review all available imaging data before making a decision to proceed with thrombectomy. The purpose of this article is to discuss the recommended imaging options for selecting patients for late window thrombectomy and to review how to interpret CTP maps and MRI images both before and after reperfusion has occurred.The new AHA guidelines3 recommend that DAWN or DEFUSE 3 eligibility should be strictly adhered to in clinical practice; therefore, it is important to understand how these trials selected eligible patients. DEFUSE 3 enrolled patients who could be treated between 6 and 16 hours after last known well, and DAWN enrolled patients who could be treated between 6 and 24 hours. Patients in these trials rarely received tPA (tissue-type plasminogen activator; <10%) because they typically presented beyond the tPA time window. Both trials used the Rapid Processing of Perfusion and Diffusion (RAPID) automated software platform (iSchemaView, Menlo Park, CA) to determine imaging eligibility for all patients. Imaging selection for patients in both DEFUSE 3 and DAWN required either CTP or MRI, with the majority being selected by CTP. Ischemic core volumes were based on a RAPID relative cerebral blood flow (CBF) lesion volume using a <30% threshold or a RAPID diffusion-weighted lesion (DWI) lesion volume with an apparent diffusion coefficient (ADC) threshold of 6 seconds (Tmax >6 seconds) threshold on both CTP and MR perfusion imaging. Subtracting the ischemic core volume from the Tmax >6 seconds volume provides the mismatch volume and dividing the Tmax >6 seconds volume by the core volume provides the mismatch ratio. Table 1 summarizes the key imaging selection criteria for both studies.Table 1. Key Imaging-Based Inclusion Criterial for DEFUSE 3 and DAWNDEFUSE 3DAWNIschemic core volume≤70 mL≤20 mL if age >80≤30 mL if age <80 and NIHSS 10–20≤50 mL if age 20Mismatch volume≥15 mL and a mismatch ratio of ≥1.8Not requiredVessel occlusionM1 or ICA (cervical and intracranial)M1 or ICA (intracranial and cervical if stent not anticipated to be required)DAWN indicates Triage of Wake-up and Late Presenting Strokes Undergoing Neurointervention With Trevo); DEFUSE 3, Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3; ICA, internal carotid artery; M1, the first segment of the middle cerebral artery; and NIHSS, National Institutes of Health Stroke Scale.Estimating the Ischemic Core With CTPBoth DAWN and DEFUSE 3 had restrictions on the size of the estimated ischemic core volume that was eligible for enrollment. For patients screened with CTP, both studies used a relative CBF threshold of <30% of normally perfused tissue to identify ischemic core with the same perfusion analysis software installed at each site. It is important to appreciate that CTP maps do not identify infarcted tissue, they identify regions with blood flow abnormities that can predict tissue fate. For example, in patients with an acute arterial occlusion, CTP can identify tissue that is likely to be already irreversibly injured before this tissue can be identified as hypodense on a noncontrast CT. Several studies have shown that relative CBF maps can provide a reasonably accurate estimate of tissue that is likely to be irreversibly injured in acute stroke patients.4–6An important issue is which CBF threshold is most accurate for estimating the ischemic core in acute stroke patients because the choice of threshold can have a substantial impact on how much tissue is considered to be potentially irreversibly injured. There have been several studies that have addressed the question of which CBF threshold is the most appropriate, and in general, most studies have suggested that thresholds of around <30% to 35% are optimal. For example, in one study, 103 acute stroke patients immediately were taken to MRI after a CTP scan.5 The DWI lesion was used as the gold standard for identifying the ischemic core. In this study, a relative CBF threshold of <38% of normal best predicted the DWI volume. However, in a few patients (<5%), the 38% threshold significantly overestimated the size of the DWI lesion. For these few patients, the CTP results could give the impression that there was less salvageable tissue than may actually be present. The investigators determined that 30% provided the most accurate threshold that did not overcall the DWI lesion. The median absolute difference in the CBF-based core with the 30% threshold was only 9 mL smaller than the DWI lesion, and there were no significant overcalls.Prospective validation of the accuracy of the CBF <30% threshold was obtained in the SWIFT PRIME trial (Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke).4 In SWIFT PRIME, which used RAPID with the 6 seconds perfusion parameter can estimate tissue that is likely to be critically hypoperfused (CBF 6 seconds volume and the ischemic core volume was used to estimate the volume of salvageable tissue in DEFUSE 3.It is important to be aware that the Tmax maps are sensitive to delayed contrast arrival, and in some circumstances, delayed arrival does not imply critical hypoperfusion. For example, in a patient with a chronic carotid occlusion, Tmax delays may be present despite normal CBF, cerebral blood volume (CBV), and mean transit times.Evolution of Ischemic Core Estimates Over Time on CTPOne of the most important aspects of CTP to be aware of is that the maps reflect the hemodynamics at the moment that the scan is done. CTP does not provide information about what happened to the patient many hours before the scan. In addition, because ischemic core estimates are based on severe reductions in blood flow, once the blood flow abnormality has improved or resolved, CTP is no longer able to estimate the ischemic core. Figure 1 shows an example of a patient who presents with a left middle cerebral artery occlusion and is scanned at 2 hours after symptom onset. After reperfusion, the ischemic core is no longer visible because the CBF is no longer substantially reduced.Download figureDownload PowerPointFigure 1. Patient with a left middle cerebral artery (MCA) occlusion. On the baseline scan, the noncontrast computed tomography (CT) is normal. There is a small, deep region in the brain that has low cerebral blood flow (CBF) and is identified in pink (which denotes that the CBF is 6 s region, shown in green, reflecting the delayed arrival of the contrast agent in the MCA territory. After thrombectomy, there is a substantial increase in the CBF. The green Tmax lesion disappears and so does the pink CBF lesion; although the tissue is irreversibly injured, there is still blood flow in the irreversibly injured region after reperfusion. Therefore, the ischemic core is no longer visible on the CBF map obtained 24 hours after reperfusion.Under some circumstances, leptomeningeal reperfusion occurs even if recanalization does not. If spontaneous leptomeningeal reperfusion occurs after the tissue has already become irreversibly injured, CTP may not be able to identify the ischemic core in the region where leptomeningeal reperfusion has occurred because the CBF may no longer be severely reduced. Figure 2A shows the CTP mismatch map in a patient who was imaged 24 hours after last known to be well. At the time the stroke occurred, CBF was severely reduced in most of the left middle cerebral artery territory; however, by the time the CTP scan was performed, leptomeningeal collaterals had been recruited. Unfortunately, these collaterals came too late; the tissue was already irreversibly injured. However, because the CBF was no longer low in the frontal region, CTP was unable to identify the core in that area. This reinforces the notion that CTP does not image dead tissue, it can demonstrate low blood flow that is likely to be associated with tissue death.Download figureDownload PowerPointFigure 2. This 75-year-old man was last well 24 hours before presentation with a left middle cerebral artery (MCA) occlusion. His computed tomography (CT) perfusion mismatch map (A) demonstrates regions of severe reduction in cerebral blood flow (CBF) in the posterior MCA territory of 34 mL (shown in pink) and significant hypoperfusion of 78 mL (shown in green) resulting in a mismatch of 44 mL. B, shows the noncontrast CT scan coregistered to the perfusion images and demonstrates substantial volume of mild to moderate hypodensity in most of the MCA territory (yellow outline) representing a large subacute infarct. The CBF map demonstrates there has been substantial recruitment of leptomeningeal collaterals into the anterior region of infarct, which explains the underestimation of the ischemic core on the mismatch map. rCBV indicates relative cerebral blood volume.CTP maps are not sensitive for detecting brain hemorrhage. Therefore, a close evaluation of the noncontrast CT is essential to ensure that subacute or chronic infarcts, as well as acute hemorrhage, are not missed.Technical Issues With CTPTo be confident about the accuracy of CTP volumes, it is important to have a technically adequate scan. CTP analysis programs typically require identification of the flow in a normal vessel that has early arrival of the contrast bolus (known as the arterial input function) and the flow through a venous sinus where the bolus departs the brain (known as the venous outflow function). The scan needs to be long enough in duration to capture the full arterial input waveform, as well as the venous output. In general, a scan time of 55 to 60 seconds is required to account for delayed and dispersed bolus arrival in patients with reduced cardiac output.11Patient movement is the most common cause of CTP artifacts. Artifacts can be minimized by making sure that the patient is tightly secured in the scanner and is relatively calm at the time that perfusion imaging begins. An adequate contrast bolus, with a large bore IV, is also required.Estimating the Ischemic Core and Penumbra With MRIIf using MRI to select patients for late window thrombectomy, the DWI lesion is the recommended sequence to estimate the size of the ischemic core. Automated software programs typically use an ADC threshold to identify tissue with severely restricted water proton movement. Studies have suggested that an ADC threshold of 6 seconds perfusion parameter is often used to estimate tissue that is likely to progress to infarction if reperfusion does not occur. The mismatch between the acute DWI lesion volume and the Tmax >6 seconds lesion volume estimates salvageable tissue.8–10MRI Findings After ReperfusionAt stroke onset, early cytotoxic edema causes restricted water proton movement, which is reflected by an immediate decline in the ADC value. Reperfusion is associated with an increase in ADC values, even in regions of brain that are irreversibly injured (Figure 3). The magnitude of the rise in ADC values is variable and frequently is nonuniform within an individual ischemic lesion. Frequently, after reperfusion, the ADC increases to values >620×10-3 mm/s in part or all of the ischemic lesion. This increase in ADC typically does not indicate tissue salvage. Because of the variable rise in ADC after reperfusion, the volume of tissue with a low ADC frequently underestimates the ischemic lesion that is visible on the DWI or fluid-attenuated inversion recovery (FLAIR) after reperfusion has occurred. Therefore, after reperfusion, infarct volume should be assessed from the DWI or FLAIR maps rather than the ADC volumes.Download figureDownload PowerPointFigure 3. The first set of 3 images was obtained 2 hours after symptom onset in a patient with an acute right middle cerebral artery (MCA) occlusion. The top image, a FLAIR sequence is normal; however, the diffusion-weighted lesion (DWI) map, identifies regions of severe ischemia with low apparent diffusion coefficient (ADC) values adjacent to the right lateral ventricle (shown in pink). On the Tmax perfusion image, shown immediately below the DWI map, the green region corresponds to a large portion of the MCA vascular territory with severe hypoperfusion. Four hours after symptom onset, the patient experienced complete reperfusion of the MCA occlusion. After reperfusion, the ADC values (shown by the blue line) rise to levels above the ADC threshold (shown with a dotted yellow line) therefore the complete DWI lesion no longer has a low ADC (pink color almost disappears) but typically will still be visible as a bright lesion on both the DWI and FLAIR map.MRI Findings in Persistent OcclusionIn patients with large artery occlusion who do not experience recanalization, the DWI lesion typically expands into much or all of the persistent Tmax >6 seconds perfusion lesion.8–10 However, late window patients, who are selected based on having salvageable tissue, typically have good collaterals, and the final infarct volume may not be obtained for several days.13 Therefore, a follow-up scan at 24 hours will often underestimate infarct volume in patients who have a persistent occlusion.CollateralsCollaterals can be assessed noninvasively with either CT angiography or perfusion imaging. CT angiography was used in conjunction with Alberta Stroke Program Early CT (ASPECT) scores to select patients for the ESCAPE study (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times).14 This trial enrolled 49 patients beyond 6 hours after stroke onset. The treatment effect in this group favored the endovascular thrombectomy group but was not statically significant in this small group of patients.Studies have shown that both MRI and CTP maps can estimate the adequacy of the collateral circulation in acute stroke patients. Substantial delays in Tmax are typically because of poor collateral flow. For example, brain regions with >10 seconds of delay on Tmax are likely to have poor collateral flow. The ratio of the volume of tissue with Tmax >10 seconds compared with the Tmax >6 seconds volume is referred to as the hypoperfusion intensity ratio. A high hypoperfusion intensity ratio, such as ≈≥50%, correlates with poor angiographic collaterals, and these patients have larger baseline ischemic core volumes and more rapid infarct growth.15 For thrombectomy candidates who are being transferred from a primary center to a comprehensive center, repeat imaging may be warranted for patients with poor collaterals, significant changes in neurological examination, or those with long transfer times. Recent data suggest that an hypoperfusion intensity ratio of >50% can identify patients who are likely to have substantial core growth during transfer.Assessing the CBV within the ischemic lesion can also predict angiographic collaterals. By comparing the CBV within the Tmax lesion to the CBV in normally perfused brain regions, a relative CBV ratio can be obtained. Relative CBV has been shown to predict with angiographic collaterals and infarct growth.16MRI Versus CTP for Thrombectomy SelectionAmong the modern randomized thrombectomy trials that used advanced imaging for patient selection, both of the late window trials1,2 and one early window study (SWIFT PRIME) allowed the sites to use either CTP or MRI to select patients.17 The majority of the patients in these studies were included after CTP. Patients who were enrolled with MRI had similar hospital arrival to femoral puncture times, compared with the CTP selected patients, in all 3 trials. Overall, the MRI-selected patients had a slightly higher rate of favorable outcomes and treatment benefit (Table 2). Despite the small sample size in the MRI subgroups, the primary end point of the studies was statistically significant in both MRI- and CTP-selected patients in both SWIFT PRIME and DEFUSE 3. The treatment effect data has not been published for the MRI versus CTP subgroups in DAWN.Table 2. MRI Versus CTP in Early and Late Window Thrombectomy StudiesStudyN90-d mRS 0–290-d mRS 0–2AbsoluteControl (%)Thrombectomy (%)Benefit (%)SWIFT PRIME*MRI34336330CTP139406020DEFUSE 3†MRI49196142CTP133163923DAWNMRI8335‡NACTP12329‡NACTP indicates computed tomography perfusion; DAWN, Triage of Wake-up and Late Presenting Strokes Undergoing Neurointervention With Trevo; DEFUSE 3, Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3; MRI, magnetic resonance imaging; mRS, modified Rankin Scale; and SWIFT PRIME, Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke.*SWIFT PRIME was an early window ( 6 or MR ASPECT score >5. This study showed a substantial reduction in treatment efficacy over time, and favorable outcome rates dropped dramatically for patients with ASPECT scores of 6 to 7.20 Among these patients, even if reperfusion was achieved, favorable outcome (modified Rankin Scale score, 0–2 at 90 days) rates were 9 hours after the time the patient was last known to be well. In contrast, in DEFUSE 3, favorable outcome rates were 50% in patients who were treated between 9 to 12 hours after symptoms onset, and neither DEFUSE 3 or DAWN showed a decline in treatment effect up to the end of their treatment windows.1,2ConclusionsThe only imaging modalities that have been shown to be effective for selecting patients for late window thrombectomy are CTP and MRI. Previous trials using noncontrast CT or ASPECT score selection have documented low rates of good outcome in patients who were reperfused beyond 8 hours from symptom onset. Therefore, as use of advanced imaging increases in both primary and comprehensive centers, it is important to understand how to interpret these images in acute stroke patients both before and after reperfusion has occurred.DisclosuresDr Albers has an equity interest in iSchemaView and is a consultant for iSchemaView, Medtronic and Genentech. DEFUSE 3 was funded by the National Institutes of Health (Principal Investigator, Dr Albers).FootnotesCorrespondence to Gregory W. Albers, MD, Stanford Stroke Center, 780 Welch Rd, Suite 350, Palo Alto, CA 94035. Email [email protected]eduReferences1. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al; DAWN Trial Investigators. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct.N Engl J Med. 2018; 378:11–21. doi: 10.1056/NEJMoa1706442CrossrefMedlineGoogle Scholar2. Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al; DEFUSE 3 Investigators. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging.N Engl J Med. 2018; 378:708–718. doi: 10.1056/NEJMoa1713973CrossrefMedlineGoogle Scholar3. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al; American Heart Association Stroke Council. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke. 2018; 49:e46–e110. doi: 10.1161/STR.0000000000000158LinkGoogle Scholar4. Albers GW, Goyal M, Jahan R, Bonafe A, Diener HC, Levy EI, et al. Ischemic core and hypoperfusion volumes predict infarct size in SWIFT PRIME.Ann Neurol. 2016; 79:76–89. doi: 10.1002/ana.24543CrossrefMedlineGoogle Scholar5. Cereda CW, Christensen S, Campbell BC, Mishra NK, Mlynash M, Levi C, et al. A benchmarking tool to evaluate computer tomography perfusion infarct core predictions against a DWI standard.J Cereb Blood Flow Metab. 2016; 36:1780–1789. doi: 10.1177/0271678X15610586CrossrefMedlineGoogle Scholar6. Campbell BC, Christensen S, Levi CR, Desmond PM, Donnan GA, Davis SM, et al. Cerebral blood flow is the optimal CT perfusion parameter for assessing infarct core.Stroke. 2011; 34:35–40.Google Scholar7. Najm M, Al-Ajlan FS, Boesen ME, Hur L, Kim CK, Fainardi E, et al. Defining CT perfusion thresholds for infarction in the golden hour and with ultra-early reperfusion.Can J Neurol Sci. 2018; 19:1–4.Google Scholar8. Olivot JM, Mlynash M, Thijs VN, Kemp S, Lansberg MG, Wechsler L, et al. Optimal Tmax threshold for predicting penumbral tissue in acute stroke.Stroke. 2009; 40:469–475. doi: 10.1161/STROKEAHA.108.526954LinkGoogle Scholar9. Zaro-Weber O, Moeller-Hartmann W, Heiss WD, Sobesky J. Maps of time to maximum and time to peak for mismatch definition in clinical stroke studies validated with positron emission tomography.Stroke. 2010; 41:2817–2821. doi: 10.1161/STROKEAHA.110.594432LinkGoogle Scholar10. Wheeler HM, Mlynash M, Inoue M, Tipirneni A, Liggins J, Zaharchuk G, et al; DEFUSE 2 Investigators. Early diffusion-weighted imaging and perfusion-weighted imaging lesion volumes forecast final infarct size in DEFUSE 2.Stroke. 2013; 44:681–685. doi: 10.1161/STROKEAHA.111.000135LinkGoogle Scholar11. Kasasbeh AS, Christensen S, Straka M, Mishra N, Mlynash M, Bammer R, et al. Optimal computed tomographic perfusion scan duration for assessment of acute stroke lesion volumes.Stroke. 2016; 47:2966–2971. doi: 10.1161/STROKEAHA.116.014177LinkGoogle Scholar12. Purushotham A, Campbell BC, Straka M, Mlynash M, Olivot JM, Bammer R, et al. Apparent diffusion coefficient threshold for delineation of ischemic core.Int J Stroke. 2015; 10:348–353. doi: 10.1111/ijs.12068CrossrefMedlineGoogle Scholar13. Federau C, Mlynash M, Christensen S, Zaharchuk G, Cha B, Lansberg MG, et al. Evolution of volume and signal intensity on fluid-attenuated inversion recovery MR images after endovascular stroke therapy.Radiology. 2016; 280:184–192. doi: 10.1148/radiol.2015151586CrossrefMedlineGoogle Scholar14. Saver JL, Goyal M, van der Lugt A, Menon BK, Majoie CB, Dippel DW, et al; HERMES Collaborators. Time to treatment with endovascular thrombectomy and outcomes from ii schemic stroke: a meta-analysis.JAMA. 2016; 316:1279–1288. doi: 10.1001/jama.2016.13647CrossrefMedlineGoogle Scholar15. Olivot JM, Mlynash M, Inoue M, Marks MP, Wheeler HM, Kemp S, et al; DEFUSE 2 Investigators. Hypoperfusion intensity ratio predicts infarct progression and functional outcome in the DEFUSE 2 Cohort.Stroke. 2014; 45:1018–1023. doi: 10.1161/STROKEAHA.113.003857LinkGoogle Scholar16. Arenillas JF, Cortijo E, Garcia-Bermejo P, Levy EI, Jahan R, Goyal M, et al. Relative cerebral blood volume is associated with collateral status and infarct growth in stroke patients in SWIFT PRIME.J Cereb Blood Flow Metab. 2017; 271678X17740293. doi: 10.1177/0271678X17740293Google Scholar17. Menjot de Champfleur N, Saver JL, Goyal M, Jahan R, Diener HC, Bonafe A, et al. Efficacy of stent-retriever thrombectomy in magnetic resonance imaging versus computed tomographic perfusion-selected patients in SWIFT PRIME Trial (Solitaire FR With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke).Stroke. 2017; 48:1560–1566.LinkGoogle Scholar18. Austein F, Riedel C, Kerby T, Meyne J, Binder A, Lindner T, et al. Comparison of perfusion CT software to predict the final infarct volume after thrombectomy.Stroke. 2016; 47:2311–2317. doi: 10.1161/STROKEAHA.116.013147LinkGoogle Scholar19. Fransen PS, Berkhemer OA, Lingsma HF, Beumer D, van den Berg LA, Yoo AJ, et al; Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands Investigators. Time to reperfusion and treatment effect for acute ischemic stroke: a randomized clinical trial.JAMA Neurol. 2016; 73:190–196. doi: 10.1001/jamaneurol.2015.3886CrossrefMedlineGoogle Scholar20. Ribo M, Molina CA, Cobo E, Cerdà N, Tomasello A, Quesada H, et al; REVASCAT Trial Investigators. Association between time to reperfusion and outcome is primarily driven by the time from imaging to reperfusion.Stroke. 2016; 47:999–1004. doi: 10.1161/STROKEAHA.115.011721LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByKargiotis O, Psychogios K, Safouris A, Andrikopoulou A, Eleftheriou A, Spiliopoulos S, Magoufis G and Tsivgoulis G (2023) Computed Tomography Perfusion Imaging in Acute Ischemic Stroke: Accurate Interpretation Matters, Stroke, 54:3, (e104-e108), Online publication date: 1-Mar-2023.Nguyen T, Castonguay A, Siegler J, Nagel S, Lansberg M, de Havenon A, Sheth S, Abdalkader M, Tsai J, Albers G, Masoud H, Jovin T, Martins S, Nogueira R and Zaidat O (2022) Mechanical Thrombectomy in the Late Presentation of Anterior Circulation Large Vessel Occlusion Stroke: A Guideline From the Society of Vascular and Interventional Neurology Guidelines and Practice Standards Committee, Stroke: Vascular and Interventional Neurology, 3:1, Online publication date: 1-Jan-2023. Regenhardt R, Nolan N, Rosenthal J, McIntyre J, Bretzner M, Bonkhoff A, Snider S, Das A, Alotaibi N, Vranic J, Dmytriw A, Stapleton C, Patel A, Rost N and Leslie-Mazwi T (2022) Understanding Delays in MRI-based Selection of Large Vessel Occlusion Stroke Patients for Endovascular Thrombectomy, Clinical Neuroradiology, 10.1007/s00062-022-01165-y, 32:4, (979-986), Online publication date: 1-Dec-2022. Arora K, Gaekwad A, Evans J, O'Brien W, Ang T, Garcia-Esperon C, Blair C, Edwards L, Chew B, Delcourt C, Spratt N, Parsons M and Butcher K (2022) Diagnostic Utility of Computed Tomography Perfusion in the Telestroke Setting, Stroke, 53:9, (2917-2925), Online publication date: 1-Sep-2022. Virtanen P, Tomppo L, Martinez-Majander N, Kokkonen T, Sillanpää M, Lappalainen K and Strbian D (2022) Thrombectomy in Acute Ischemic Stroke in the Extended Time Window: Real-Life Experience in a High-Volume Center, Journal of Stroke and Cerebrovascular Diseases, 10.1016/j.jstrokecerebrovasdis.2022.106603, 31:8, (106603), Online publication date: 1-Aug-2022. Sequeiros J, Rodriguez-Calienes A, Chavez-Malpartida S, Morán-Mariños C, Alvarado-Gamarra G, Malaga M, Quincho-Lopez A, Hernadez-Fernandez W, Pacheco-Barrios K, Ortega-Gutierrez S, Hoit D, Arthur A, Alexandrov A, Alva-Diaz C and Elijovich L (2022) Stroke imaging modality for endovascular therapy in the extended window: systematic review and meta-analysis, Journal of NeuroInterventional Surgery, 10.1136/neurintsurg-2022-018896, (neurintsurg-2022-018896) Gwak D, Choi W, Shim D, Kim Y, Kang D, Son W and Hwang Y (2021) Role of Apparent Diffusion Coefficient Gradient Within Diffusion Lesions in Outcomes of Large Stroke After Thrombectomy, Stroke, 53:3, (921-929), Online publication date: 1-Mar-2022. Kim B, Lee Y, Kwon B, Chang J, Song Y, Lee D, Kwon S, Kim J and Kang D (2021) Clinical-Diffusion Mismatch Is Associated with Early Neurological Improvement after Late-Window Endovascular Treatment, Cerebrovascular Diseases, 10.1159/000519310, 51:3, (331-337), . Chung C, Hu R, Peterson R and Allen J (2021) Automated Processing of Head CT Perfusion Imaging for Ischemic Stroke Triage: A Practical Guide to Quality Assurance and Interpretation, American Journal of Roentgenology, 10.2214/AJR.21.26139, 217:6, (1401-1416), Online publication date: 1-Dec-2021. Grøan M, Ospel J, Ajmi S, Sandset E, Kurz M, Skjelland M and Advani R (2021) Time-Based Decision Making for Reperfusion in Acute Ischemic Stroke, Frontiers in Neurology, 10.3389/fneur.2021.728012, 12 Simpkins A, Tahsili-Fahadan P, Buchwald N, De Prey J, Farooqui A, Mugge L, Ranasinghe T, Senetar A, Echevarria F, Alvi M and Wu O (2021) Adapting Clinical Practice of Thrombolysis for Acute Ischemic Stroke Beyond 4.5 Hours: A Review of the Literature, Journal of Stroke and Cerebrovascular Diseases, 10.1016/j.jstrokecerebrovasdis.2021.106059, 30:11, (106059), Online publication date: 1-Nov-2021. Cirio J, Ciardi C, Buezas M, Diluca P, Caballero M, Lopez M, López J, Chasco M, Lammertyn P and Lylyk P (2021) Implementación de la inteligencia artificial en el tratamiento hiperagudo de reperfusión arterial en un centro integral de ataque cerebrovascular, Neurología Argentina, 10.1016/j.neuarg.2021.07.003, 13:4, (212-220), Online publication date: 1-Oct-2021. García-Tornel Á, Campos D, Rubiera M, Boned S, Olivé-Gadea M, Requena M, Ciolli L, Muchada M, Pagola J, Rodriguez-Luna D, Deck M, Juega J, Rodríguez-Villatoro N, Sanjuan E, Tomasello A, Piñana C, Hernández D, Álvarez-Sabin J, Molina C and Ribó M (2021) Ischemic Core Overestimation on Computed Tomography Perfusion, Stroke, 52:5, (1751-1760), Online publication date: 1-May-2021. Kim-Tenser M, Mlynash M, Lansberg M, Tenser M, Bulic S, Jagadeesan B, Christensen S, Simpkins A, Albers G, Marks M and Heit J (2020) CT perfusion core and ASPECT score prediction of outcomes in DEFUSE 3, International Journal of Stroke, 10.1177/1747493020915141, 16:3, (288-294), Online publication date: 1-Apr-2021. Negrotto M and Al Kasab S (2021) Evidence on Mechanical Thrombectomy in Acute Ischemic Stroke 12 Strokes, 10.1007/978-3-030-56857-3_1, (3-18), . van der Meij A, van Walderveen M, Kruyt N, van Zwet E, Liebler E, Ferrari M and Wermer M (2020) NOn-invasive Vagus nerve stimulation in acute Ischemic Stroke (NOVIS): a study protocol for a randomized clinical trial, Trials, 10.1186/s13063-020-04794-1, 21:1, Online publication date: 1-Dec-2020. Byrne D, Walsh J, Sugrue G, Nicolaou S and Rohr A (2020) CT Imaging of Acute Ischemic Stroke, Canadian Association of Radiologists Journal, 10.1177/0846537120902068, 71:3, (266-280), Online publication date: 1-Aug-2020. Kargiotis O, Psychogios K, Safouris A, Magoufis G, Palaiodimou L, Theodorou A, Bakola E, Stamboulis E, Krogias C and Tsivgoulis G (2020) Transcranial Doppler Monitoring of Acute Reperfusion Therapies in Acute Ischemic Stroke Patients with Underlying Large Vessel Occlusions, Journal of Neurosonology and Neuroimaging, 10.31728/jnn.2020.00084, 12:1, (10-25), Online publication date: 30-Jun-2020. Demeestere J, Wouters A, Christensen S, Lemmens R and Lansberg M (2020) Review of Perfusion Imaging in Acute Ischemic Stroke, Stroke, 51:3, (1017-1024), Online publication date: 1-Mar-2020. Wong M, Flower E and Edlow J (2020) A Primer on Computed Tomography Perfusion Imaging for the Emergency Physician, The Journal of Emergency Medicine, 10.1016/j.jemermed.2019.12.003, 58:2, (260-268), Online publication date: 1-Feb-2020. Debs N, Rasti P, Victor L, Cho T, Frindel C and Rousseau D (2020) Simulated perfusion MRI data to boost training of convolutional neural networks for lesion fate prediction in acute stroke, Computers in Biology and Medicine, 10.1016/j.compbiomed.2019.103579, 116, (103579), Online publication date: 1-Jan-2020. Tang Y (2020) Acute Stroke Imaging Atlas of Emergency Neurovascular Imaging, 10.1007/978-3-030-43654-4_1, (1-20), . (2019) Stroke Radiology Acute Stroke Care, 10.1017/9781108759823.004, (32-57) Saposnik G, Menon B, Kashani N, Wilson A, Yoshimura S, Campbell B, Baxter B, Rabinstein A, Turjman F, Fischer U, Ospel J, Mitchell P, Sylaja P, Cherian M, Kim B, Heo J, Podlasek A, Almekhlafi M, Foss M, Demchuk A, Hill M and Goyal M (2019) Factors Associated With the Decision-Making on Endovascular Thrombectomy for the Management of Acute Ischemic Stroke, Stroke, 50:9, (2441-2447), Online publication date: 1-Sep-2019. Lou M (2019) Can imaging extend the thrombolytic time window after stroke?, Nature Reviews Neurology, 10.1038/s41582-019-0232-y, 15:9, (496-498), Online publication date: 1-Sep-2019. Boulouis G, Baron J and Benhassen W (2019) Letter by Boulouis et al Regarding Article, "Results From DEFUSE 3: Good Collaterals Are Associated With Reduced Ischemic Core Growth but Not Neurologic Outcome", Stroke, 10.1161/STROKEAHA.119.025505, 50:6, Online publication date: 1-Jun-2019. Shaker H, Khan M, Mulderink T, Koehler T, Scurek R, Tubergen T, Packard L, Singer J, Mazaris P, Min J, Wees N, Khan N and Abdelhak T (2019) The Role of CT Perfusion in Defining the Clinically Relevant Core Infarction to Guide Thrombectomy Selection in Patients with Acute Stroke, Journal of Neuroimaging, 10.1111/jon.12599, 29:3, (331-334), Online publication date: 1-May-2019. September 2018Vol 49, Issue 9 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.118.021011PMID: 30355004 Manuscript receivedMay 1, 2018Manuscript acceptedJune 28, 2018Originally publishedAugust 9, 2018Manuscript revisedJune 10, 2018 Keywordsreperfusionthrombectomyclinical trialmagnetic resonance imagingstrokePDF download Advertisement
Referência(s)