Association of follow-up infarct volume with functional outcome in acute ischemic stroke: a pooled analysis of seven randomized trials

Boers, Anna M. M.; Jansen, Ivo G. H.; Beenen, Ludo F. M.; Devlin, Thomas; Román, Luís San; Heo, Ji Hoe; Ribó, Marc; Brown, Scott; Almekhlafi, Mohammed; Liebeskind, David S; Teitelbaum, Jeanne; Lingsma, Hester F.; Zwam, Wim H. van; Cuadras, Patricia; Rochemont, Richard du Mesnil de; Beaumont, Marine; Brown, Martin M.; Yoo, Albert J.; Oostenbrugge, Robert J. van; Menon, Bijoy K; Donnan, Geoffrey A; Mas, Jean Louis; Roos, Yvo B.W.E.M.; Oppenheim, Catherine; Lugt, Aad van der; Dowling, Richard; Hill, Michael D.; Dávalos, Antoni; Moulin, Thierry; Agrinier, Nelly; Demchuk, Andrew M.; Lopes, Demetrius K.; Rodríguez, Lucía Aja; Dippel, Diederik W.J.; Campbell, Bruce; Mitchell, Peter; Al-Ajlan, Fahad S.; Jovin, Tudor G; Madigan, Jeremy; Albers, Gregory W.; Soize, Sébastien; Guillemin, Françis; Reddy, Vivek; Bracard, Serge; Blasco, Jordi; Muir, Keith W.; Nogueira, Raul G; White, Phil; Goyal, Mayank; Davis, Stephen M.; Marquering, Henk A.; Majoie, Charles B. L. M.

doi:10.1136/neurintsurg-2017-013724

Cited by 104 publications

(106 citation statements)

References 24 publications

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“…Also, we did not assess the accuracy of the final infarct volume compared with ENI in the prediction of 3-month functional outcome because we focused on the analysis of pre-therapeutic factors affecting ENI. As the final infarct volume is a strong predictor of the final outcome,25 a future study comparing the ROCs of final infarct volume with ENI at 2 and 24 hours will be meaningful. Finally, we did not evaluate whether combining ENI with other variables available at 24 hours (eg, hemorrhagic transformation, infarct volume) could potentiate the final outcome prediction.…”

Section: Discussionmentioning

confidence: 99%

Can early neurological improvement after mechanical thrombectomy be used as a surrogate for final stroke outcome?

Soize

Fabre

Gawlitza

et al. 2018

J NeuroIntervent Surg

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Background and purposeWe aimed to identify the best definition of early neurological improvement (ENI) at 2 and 24 hours after mechanical thrombectomy (MT) and determine its ability to predict a good functional outcome at 3 months.MethodsThis retrospective analysis was based on a prospectively collected registry of patients treated by MT for ischemic stroke from May 2010 to March 2017. We included patients treated with stent-retrievers with National Institute of Health Stroke Scale (NIHSS) score before treatment and at 2 and/or 24 hours after treatment and modified Rankin Score (mRS) at 3 months. Receiver operating characteristic curve analysis was performed to estimate optimal thresholds for ENI at 2 and 24 hours. The relationship between optimal ENI definitions and good outcome at 3 months (mRS 0–2) was assessed by logistic regression.ResultsThe analysis included 246 patients. At 2 hours, the optimal threshold to predict a good outcome at 3 months was improvementin the NIHSS score of >1 point (AUC 0.83,95% CI 0.77 to 0.87), with sensitivity and specificity 78.3% (62.2–85.7%) and 84.6% (77.2–90.3%), respectively, and OR 12.67 (95% CI 4.69 to 31.10, p<0.0001). At 24 hours, the optimal threshold was an improvementin the NIHSS score of >4 points (AUC 0.93, 95% CI 0.89 to 0.96), with sensitivity and specificity 93.8% (87.7–97.5%) and 83.2% (75.7–89.2%), respectively, and OR 391.32 (95% CI 44.43 to 3448.35, p<0.0001).ConclusionsENI 24 hours after thrombectomy appears to be a straightforward surrogate of long-term endpoints and may have value in future research.

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Section: Discussionmentioning

confidence: 99%

Can early neurological improvement after mechanical thrombectomy be used as a surrogate for final stroke outcome?

Soize

Fabre

Gawlitza

et al. 2018

J NeuroIntervent Surg

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“…This is highly significant because a 50 ml final infarct volume after thrombectomy results in favorable functional outcomes at 3 months even in patients who present with severe neurological deficits. 12 The reliable identification of LVO patients likely to have ischemic cores of this size or smaller despite delays of many hours could expand the use of thrombectomy, and more widely apply the lessons from the recent successful DAWN 9 and DEFUSE 3 10 thrombectomy trials.…”

Section: Discussionmentioning

confidence: 99%

“…It is predicated on our observation of ischemic core stability for many hours in patients with LVOs. 11 To identify effective biomarkers, we used the observation from the HERMES collaboration 12 that patients with final infarcts of <50ml after thrombectomy had an ~80% probability of living independently at 3 months irrespective of initial symptom severity. We searched for presentation biomarkers that identify LVO patients that would have ischemic cores of <50ml one day after stroke onset.…”

Section: Introductionmentioning

confidence: 99%

Identifying Severe Stroke Patients Likely to Benefit From Thrombectomy Despite Delays of up to a Day

González

Silva

et al. 2019

Preprint

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Background and Purpose: Severe ischemic strokes caused by large vessel occlusion (LVO) are treatable up to 24 hours after onset. But not all patients will benefit either because the infarct enlarges too rapidly or because the patient is not at center that is capable of treatment. The purpose was to find biomarkers that reliably identify patients who are likely to benefit from intervention despite long delays .Methods: Thirty-eight acute ischemic stroke patients with LVO who did not undergo thrombolysis or thrombectomy had serial imaging with MRI at presentation and then at ~12 hours, ~1 day, & ~2 days after onset. Presenting clinical and neuroimaging predictors of a therapeutically auspicious ischemic core size (<50 ml) one day after stroke onset were identified.Results: Ischemic core initial growth rate (IGR) was the only independent predictor of functional outcome at 3 months (P=0.002), and a receiver operator characteristics (ROC) analysis revealed that an IGR of <5.4 ml/hr had a 95% sensitivity with a low (5.6%) false positive rate for identifying patients who would have an ischemic core of <50 ml at one day post ictus. Selection using an initial DWI lesion volume <37 ml was similarly powerful with a 90% sensitivity and a low false positive rate. Other imaging markers derived from CT scans were less effective, but may be more practical. Published reports of over 600 LVO ischemic stroke patients disclosed that about half met the highly favorable IGR criteria of <5.4 ml/hr at presentation. Conclusions:Ischemic core initial growth rates of <5.4ml/hr and initial ischemic cores of <37 ml are excellent biomarkers for selecting LVO patients that are likely to benefit from intervention despite long delays due to transfer to thrombectomy-capable stroke centers. Published accounts suggest that about half of all LVO stroke patients meet these criteria.

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“…Endovascular therapy (EVT) has become the standard of care in patients with disabling anterior circulation ischemic stroke due to proximal intracranial thrombi . Cerebral infarct volume observed on follow‐up noncontrast computed tomography (NCCT) scans is an important radiologic outcome measure of the effectiveness of EVT . Recent studies have been shown that clinical outcome after EVT could be correlated with a reduction in post‐treatment infarct volume .…”

Section: Introductionmentioning

confidence: 99%

“…2 Recent studies have been shown that clinical outcome after EVT could be correlated with a reduction in post-treatment infarct volume. 2 It is therefore possible that post-treatment infarct volume estimation would become a robust surrogate outcome measure in future clinical trials in AIS patients. Measurement of posttreatment infarct volume, however, relies on manual segmentation in practice, which is a tedious, time-consuming, and observer dependent method.…”

Section: Introductionmentioning

confidence: 99%

Semi‐automated infarct segmentation from follow‐up noncontrast CT scans in patients with acute ischemic stroke

2019

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Purpose Cerebral infarct volume observed in follow‐up noncontrast computed tomography (NCCT) scans of acute ischemic stroke (AIS) patients is as an important radiologic outcome measure of the effectiveness of endovascular therapy (EVT). In this paper, our aim is to propose a semiautomated segmentation approach that can accurately measure ischemic infarct volume from NCCT images of AIS patients. Methods A novel cascaded random forest (RF) learning is first employed to classify each voxel into normal or ischemic voxel, leading to an infarct probability map. Four types of features: intensity, statistical information in local region, symmetric difference compared to the contralateral side, and spatial probability of infarct occurrence generated by the STAPLE method, are extracted. These features are input into RF to train a first‐stage classifier. The coarse segmentation results generated by the first‐stage classifier are then used to train a fine second‐stage classifier with fivefold cross validation. The RF estimated infarct probability map obtained in the second‐stage testing as well as user input high‐level knowledge are then incorporated into a convex optimization function to obtain final segmentation. One hundred AIS patients were collected in this study, of which 70 patient images were used for evaluation while the remaining 30 patient images were used for RF training. Results Quantitative results show that the proposed approach is capable of yielding a dice coefficient (DC) of 79.42%, significantly outperforming some state‐of‐the‐art automated segmentation methods, such as the RF‐based methods and convolutional neural network (CNN)‐based segmentation method, U‐net. The infarct volume obtained by the proposed method is strongly correlated with the manually segmented volume. In addition, interobserver variability analysis initialized by two observers suggests low user dependency. Conclusions Our proposed semiautomated segmentation method can accurately segment infarct from NCCT of AIS patients.

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Association of follow-up infarct volume with functional outcome in acute ischemic stroke: a pooled analysis of seven randomized trials

Abstract: In patients with an acute ischemic stroke due to a proximal intracranial occlusion of the anterior circulation, FIV is a strong independent predictor of functional outcome and can be assessed before 48 hours, oneither CT or MRI.

Cited by 104 publications

References 24 publications

Can early neurological improvement after mechanical thrombectomy be used as a surrogate for final stroke outcome?

Can early neurological improvement after mechanical thrombectomy be used as a surrogate for final stroke outcome?

Identifying Severe Stroke Patients Likely to Benefit From Thrombectomy Despite Delays of up to a Day

Semi‐automated infarct segmentation from follow‐up noncontrast CT scans in patients with acute ischemic stroke

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