Association of initial imaging modality and futile recanalization after thrombectomy

Meinel, Thomas; Kaesmacher, Johannes; Mosimann, Pascal J.; Seiffge, David J; Jung, Simon; Mordasini, Pasquale; Arnold, Marcel; Goeldlin, Martina; Hajdu, Steven D.; Olivé‐Gadea, Marta; Maegerlein, Christian; Costalat, Vincent; Piérot, Laurent; Schaafsma, Joanna D.; Fischer, Urs; Gralla, Jan

doi:10.1212/wnl.0000000000010614

Cited by 46 publications

(59 citation statements)

References 27 publications

(42 reference statements)

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“…Furthermore, the organization of the rescue service is uniformly regulated in BW. In addition, it has already been shown in other studies that the functional outcome and mortality in patients selected by MRI were more favorable than in patients selected by CT. 39 Our outcomes are not measured at a predefined time point but at hospital discharge, which limits the comparison of data compared to those from randomized controlled trials with standardized assessment of outcomes at 3 months.…”

Section: Discussionmentioning

confidence: 99%

MRI as a first-line imaging modality in acute ischemic stroke: a sustainable concept

Althaus

Dreyhaupt

Hyrenbach

et al. 2021

Ther Adv Neurol Disord

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Background: Computed tomography (CT) scans are the first-line imaging technique in acute stroke patients based on the argument of rapid feasibility. Using magnetic resonance imaging (MRI) as the first-line imaging technique is the exception to the rule, although it provides much more diagnostic information and avoids exposure to radiation. We evaluated whether an MRI-based acute stroke concept is fast, suitable, and useful to improve recanalization rates and patient outcomes. Methods: We performed a retrospective observational cohort study comparing patients treated at a comprehensive stroke center (Ulm/Germany) applying an MRI-based acute stroke concept with patients recorded in a large comprehensive stroke registry in Baden-Württemberg (Germany). We analyzed the quality indicators of acute stroke treatment, patient’s outcome, and the rate of transient ischemic attack (TIA) at discharge. Results: A total of 2182 patients from Ulm and 82,760 patients from the Baden-Württemberg (BW) stroke registry (including 29,575 patients of comprehensive stroke centers (BWc)) were included. Intravenous thrombolysis rate was higher in Ulm than in BW or the BWc stroke centers (Ulm 27.4% versus BW 20.9% versus BWc 26.1; p < 0.01), while a door-to-needle time <30 min could be achieved more frequently (Ulm 73.6% versus BW 44.1% versus BWc 47.1%; p < 0.01). Thrombectomy rate in patients with a proximal vascular occlusion was higher (Ulm 69.2% versus BW 50.7% versus BWc 59.3; p < 0.01). The number of TIA diagnoses was lower (Ulm 16.2% versus BW 24.6% versus BWc 19.9%; p < 0.01). More patients showed a shift to a favorable outcome (Ulm 21.1% versus BW 16.9% versus BWc 15.3; p < 0.01). Complication rates were similar. Conclusions: The MRI-based acute stroke concept is suitable, fast and seems to be beneficial. The time-dependent quality indicators were better both in comparison to all stroke units and to the comprehensive stroke units in the area. Based on the MRI concept, high rates of recanalization procedures and fewer TIA diagnoses could be observed. In addition, there was a clear trend towards an improved clinical outcome. A clinical trial comparing the effects of CT and MRI as the primary imaging technique in otherwise identical stroke unit settings is warranted.

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Section: Discussionmentioning

confidence: 99%

MRI as a first-line imaging modality in acute ischemic stroke: a sustainable concept

Althaus

Dreyhaupt

Hyrenbach

et al. 2021

Ther Adv Neurol Disord

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“…Patients selection for MT depends on a fast identification of a LVO and on the evaluation of early ischemic changes, and computed-tomography (CT) and magnetic-resonance-imaging (MRI) are recommended for patient evaluation ( 26 ). However, MRI is superior to CT for detection of acute ischemia ( 27 ), is associated with better outcomes after thrombectomy treatment ( 28 ), whereas CT has been associated with an increased risk of futile reperfusion ( 29 ). While MRI duration is often reported to be longer in patient's screening for MT ( 30 ), MRI did not delay MT ( 30 ) nor impact patient's functional outcome in recent studies ( 30 ).…”

Section: Discussionmentioning

confidence: 99%

Impact of Clot Shape on Successful M1 Endovascular Reperfusion

et al. 2021

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Objectives: The susceptibility-vessel-sign (SVS) allows thrombus visualization, length estimation and composition, and it may impact reperfusion during mechanical thrombectomy (MT). SVS can also describe thrombus shape in the occluded artery: in the straight M1-segment (S-shaped), or in an angulated/traversing a bifurcation segment (A-shaped). We determined whether SVS clot shape influenced reperfusion and outcomes after MT for proximal middle-cerebral-artery (M1) occlusions.Methods: Between May 2015 and March 2018, consecutive patients who underwent MT at one comprehensive stroke center and who had a baseline MRI with a T2* sequence were included. Clinical, procedural and radiographic data, including clot shape on SVS [angulated/bifurcation (A-SVS) vs. straight (S-SVS)] and length were assessed. Primary outcome was successful reperfusion (TICI 2b-3). Secondary outcome were MT complication rates, MT reperfusion time, and clinical outcome at 90-days. Predictors of outcome were assessed with univariate and multivariate analyses.Results: A total of 62 patients were included. 56% (35/62) had an A-SVS. Clots were significantly longer in the A-SVS group (19 mm vs. 8 mm p = 0.0002). Groups were otherwise well-matched with regard to baseline characteristics. There was a significantly lower rate of successful reperfusion in the A-SVS cohort (83%) compared to the S-SVS cohort (96%) in multivariable analysis [OR 0.04 (95% CI, 0.002–0.58), p = 0.02]. There was no significant difference in long term clinical outcome between groups.Conclusion: Clot shape as determined on T2* imaging, in patients presenting with M1 occlusion appears to be a predictor of successful reperfusion after MT. Angulated and bifurcating clots are associated with poorer rates of successful reperfusion.

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“…[5][6][7][8][9] The selection of patients using MRI compared with CT doubles the likelihood of functional independence and results in fewer futile thrombectomies. 10,11 Machine learning, which involves a computer mathematical model learning to perform speci c tasks from existing data, is predicted to play an increasing role in clinical care. 12 It has already been applied to acute stroke computed tomography (CT) imaging interpretation including for hemorrhage identi cation, large vessel occlusion identi cation and ischemic core volume estimation.…”

Section: Introductionmentioning

confidence: 99%

Development and Clinical Application of a Deep Learning Model to Identify Acute Infarct on Magnetic Resonance Imaging

Bridge

Bizzo

Hillis

et al. 2021

Preprint

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BackgroundStroke is a leading cause of death and disability. The ability to quickly identify the presence of acute infarct and quantify the volume on magnetic resonance imaging (MRI) has important treatment implications. MethodsWe developed a machine learning model that used the apparent diffusion coefficient and diffusion weighted imaging series. It was trained on 6,657 MRI studies. All studies were labelled positive or negative for infarct (classification annotation) with 377 having the region of interest outlined (segmentation annotation). The different annotation types facilitated training on more studies while not requiring the extensive time to manually segment every study. We initially validated the model on studies sequestered from the training set. We then tested the model on studies from three clinical scenarios: consecutive stroke team activations for 6-months at the hospital that provided training data, consecutive stroke team activations for 6-months at a hospital that did not provide training data, and an international site. The model results were compared to radiologist ground truth interpretations.ResultsThe model performed better when trained on classification and segmentation annotations (area under the receiver operating curve [AUROC] 0.995 [95% CI, 0.992-0.998] and median Dice coefficient for segmentation overlap of 0.797 [IQR, 0.642-0.861]) compared to segmentation annotations alone (AUROC 0.982 [95% CI, 0.972-0.990] and Dice coefficient 0.776 [IQR, 0.584-0.857]). The model accurately identified infarcts for training hospital stroke team activations (AUROC 0.964 [95% CI, 0.943-0.982], 381 studies), non-training hospital stroke team activations (AUROC 0.981 [95% CI, 0.966-0.993], 247 studies), and at the international site (AUROC 0.998 [95% CI, 0.993-1.000], 171 studies). The model accurately segmented infarcts with Pearson correlation comparing model output and ground truth volumes between 0.968-0.986 for the three scenarios.ConclusionsAcute infarct can be accurately detected and segmented on MRI in real-world clinical scenarios using a machine learning model.

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Association of initial imaging modality and futile recanalization after thrombectomy

Cited by 46 publications

References 27 publications

MRI as a first-line imaging modality in acute ischemic stroke: a sustainable concept

MRI as a first-line imaging modality in acute ischemic stroke: a sustainable concept

Impact of Clot Shape on Successful M1 Endovascular Reperfusion

Development and Clinical Application of a Deep Learning Model to Identify Acute Infarct on Magnetic Resonance Imaging

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