Abstract:The cerebral collaterals play an important role in penumbral tissue sustenance after an acute ischaemic stroke. Recent studies have demonstrated the potential role of collaterals in the selection of acute ischaemic stroke patients eligible for reperfusion therapy. However, the understanding of the significance and evidence around the role of collateral status in predicting outcomes in acute ischaemic stroke patients treated with reperfusion therapy is still unclear. Moreover, the use of pre-treatment collatera… Show more
“…Future research should be directed on the combined use of HMCAS with other baseline characteristics or biomarkers. For example, other imaging biomarker considerations, such as arterial collateral status are important in determining the prognosis of AIS patient [ 36 – 39 ]. Although, HMCAS might not be the initial preference in predicting clinical outcome in the tertiary care settings, it may be relatively easy to appreciate in an emergency setting and could reduce the time and complexity of acute stroke workflow [ 5 , 22 ].…”
Section: Discussionmentioning
confidence: 99%
“…Despite the emerging role of HMCAS, its prognostic role in clinical settings, in settings of reperfusion therapy, needs further consideration. Indeed, the clot composition (such as the degree of clot density, relative composition of red blood cells (RBCs) [ 9 ]) in addition to other factors, such as time to reperfusion [ 10 ], baseline stroke severity [ 11 ], collateral status [ 12 , 13 ], etc., are associated with the efficacy of the EVT [ 14 , 15 ]. This study sought to investigate the association of HMCAS with clinical outcomes and its prognostic capacity in anterior circulation AIS patients receiving reperfusion therapy by performing a systematic review and meta-analysis.…”
Pre-intervention CT imaging-based biomarkers, such as hyperdense middle cerebral artery sign (HMCAS) may have a role in acute ischaemic stroke prognostication. However, the clinical utility of HMCAS in settings of reperfusion therapy and the level of prognostic association is still unclear. This systematic review and meta-analysis investigated the association of HMCAS sign with clinical outcomes and its prognostic capacity in acute ischaemic stroke patients treated with reperfusion therapy. Prospective and retrospective studies from the following databases were retrieved from EMBASE, MEDLINE and Cochrane. Association of HMCAS with functional outcome, symptomatic intracerebral haemorrhage (sICH) and mortality were investigated. The random effect model was used to calculate the risk ratio (RR). Subgroup analyses were performed for subgroups of patients receiving thrombolysis (tPA), mechanical thrombectomy (EVT) and/or combined therapy (tPA + EVT). HMCAS significantly increased the rate of poor functional outcome by 1.43-fold in patients (RR 1.43; 95% CI 1.30–1.57;
p
< 0.0001) without any significant differences in sICH rates (RR 0.91; 95% CI 0.68–1.23; p = 0.546) and mortality (RR 1.34; 95% CI 0.72–2.51;
p
= 354) in patients with positive HMCAS as compared to negative HMCAS. In subgroup analyses, significant association between HMCAS and 90 days functional outcome was observed in patients receiving tPA (RR 1.53; 95% CI 1.40–1.67;
p
< 0.0001) or both therapies (RR 1.40; 95% CI 1.08–1.80;
p
= 0.010). This meta-analysis demonstrated that pre-treatment HMCAS increases risk of poor functional outcomes. However, its prognostic sensitivity and specificity in predicting long-term functional outcome, mortality and sICH after reperfusion therapy is poor.
Supplementary Information
The online version contains supplementary material available at 10.1007/s13760-021-01720-3.
“…Future research should be directed on the combined use of HMCAS with other baseline characteristics or biomarkers. For example, other imaging biomarker considerations, such as arterial collateral status are important in determining the prognosis of AIS patient [ 36 – 39 ]. Although, HMCAS might not be the initial preference in predicting clinical outcome in the tertiary care settings, it may be relatively easy to appreciate in an emergency setting and could reduce the time and complexity of acute stroke workflow [ 5 , 22 ].…”
Section: Discussionmentioning
confidence: 99%
“…Despite the emerging role of HMCAS, its prognostic role in clinical settings, in settings of reperfusion therapy, needs further consideration. Indeed, the clot composition (such as the degree of clot density, relative composition of red blood cells (RBCs) [ 9 ]) in addition to other factors, such as time to reperfusion [ 10 ], baseline stroke severity [ 11 ], collateral status [ 12 , 13 ], etc., are associated with the efficacy of the EVT [ 14 , 15 ]. This study sought to investigate the association of HMCAS with clinical outcomes and its prognostic capacity in anterior circulation AIS patients receiving reperfusion therapy by performing a systematic review and meta-analysis.…”
Pre-intervention CT imaging-based biomarkers, such as hyperdense middle cerebral artery sign (HMCAS) may have a role in acute ischaemic stroke prognostication. However, the clinical utility of HMCAS in settings of reperfusion therapy and the level of prognostic association is still unclear. This systematic review and meta-analysis investigated the association of HMCAS sign with clinical outcomes and its prognostic capacity in acute ischaemic stroke patients treated with reperfusion therapy. Prospective and retrospective studies from the following databases were retrieved from EMBASE, MEDLINE and Cochrane. Association of HMCAS with functional outcome, symptomatic intracerebral haemorrhage (sICH) and mortality were investigated. The random effect model was used to calculate the risk ratio (RR). Subgroup analyses were performed for subgroups of patients receiving thrombolysis (tPA), mechanical thrombectomy (EVT) and/or combined therapy (tPA + EVT). HMCAS significantly increased the rate of poor functional outcome by 1.43-fold in patients (RR 1.43; 95% CI 1.30–1.57;
p
< 0.0001) without any significant differences in sICH rates (RR 0.91; 95% CI 0.68–1.23; p = 0.546) and mortality (RR 1.34; 95% CI 0.72–2.51;
p
= 354) in patients with positive HMCAS as compared to negative HMCAS. In subgroup analyses, significant association between HMCAS and 90 days functional outcome was observed in patients receiving tPA (RR 1.53; 95% CI 1.40–1.67;
p
< 0.0001) or both therapies (RR 1.40; 95% CI 1.08–1.80;
p
= 0.010). This meta-analysis demonstrated that pre-treatment HMCAS increases risk of poor functional outcomes. However, its prognostic sensitivity and specificity in predicting long-term functional outcome, mortality and sICH after reperfusion therapy is poor.
Supplementary Information
The online version contains supplementary material available at 10.1007/s13760-021-01720-3.
“…4 NCCT allows clinicians to exclude intracerebral hemorrhage and select patients for intravenous thrombolysis (IVT) with a tissue plasminogen activator (tPA) within 4.5 hours. [4][5][6] Subsequent CTA imaging allows confirmation of large-vessel occlusion, evaluation of the patency of cerebral vasculature, and the assessment of the collateral status, 7 thus is important in guiding patient selection for endovascular thrombectomy (EVT). [8][9][10][11][12] Advanced neuroimaging modalities such as computed tomographic perfusion (CTP) imaging provide additional information regarding baseline tissue perfusion characteristics including the irreversibly infarcted core and the potentially salvageable tissue or ischemic penumbra.…”
Section: Introductionmentioning
confidence: 99%
“…NCCT allows clinicians to exclude intracerebral hemorrhage and select patients for intravenous thrombolysis (IVT) with a tissue plasminogen activator (tPA) within 4.5 hours 4‐6 . Subsequent CTA imaging allows confirmation of large‐vessel occlusion, evaluation of the patency of cerebral vasculature, and the assessment of the collateral status, 7 thus is important in guiding patient selection for endovascular thrombectomy (EVT) 8‐12 …”
Section: Introductionmentioning
confidence: 99%
“…CTP derived perfusion parameters, combined with the information on baseline arterial and venous collateral status determined on CTA, [32][33][34] have the potential to improve imaging-based based decision-making. 7 However, special considerations may apply to prevent the risk of infection in the milieu of Coronavirus Disease (COVID-19). [35][36][37] This study has various limitations.…”
Background: Computed tomography perfusion (CTP) imaging could be useful in guiding reperfusion therapy or patient selection in acute ischemic stroke (AIS) patients. The aim of the current study was to determine the efficacy of the CTP-guided reperfusion therapy in AIS by performing a systematic review and meta-analysis. Methods: Medline/PubMed, Embase, and the Cochrane library were searched using the terms: "CT perfusion", "acute stroke" and "reperfusion therapy". The following studies were included: (a) studies reporting original data; (b) patients aged 18 years or above; (c) patients diagnosed with anterior circulation AIS; and (d) studies with good methodological design. Results: Twenty-two studies were finally included in the metanalysis with a total of 5, 687 patients. CTP-guided reperfusion therapy was associated with increased odds of good functional outcome without significant difference in safety profile. Conclusions: CTP-guided reperfusion therapy improved functional outcomes in AIS, with increased benefits to patients treated with endovascular thrombectomy.
The increasing prevalence of diabetes and stroke is a major global public health concern. Specifically, acute stroke patients, with pre-existing diabetes, pose a clinical challenge. It is established that diabetes is associated with a worse prognosis after acute stroke and the various biological factors that mediate poor recovery profiles in diabetic patients is unknown. The level of association and impact of diabetes, in the setting of reperfusion therapy, is yet to be determined. This article presents a comprehensive overview of the current knowledge of the role of diabetes in stroke, therapeutic strategies for primary and secondary prevention of cardiovascular disease and/or stroke in diabetes, and various therapeutic considerations that may apply during pre-stroke, acute, sub-acute and post-stroke stages. The early diagnosis of diabetes as a comorbidity for stroke, as well as tailored post-stroke management of diabetes, is pivotal to our efforts to limit the burden. Increasing awareness and involvement of neurologists in the management of diabetes and other cardiovascular risk factors is desirable towards improving stroke prevention and efficacy of reperfusion therapy in acute stroke patients with diabetes.
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