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NEUROIMAGING MARKERS IDENTIFYING NOTCH3-MUTATION RELATED INTRACEREBRAL HEMORRHAGE
Abstract
Background and Aims
Hereditary cerebral small vessel disease (CSVD), such as NOTCH3-mutation, is an important differential diagnosis of spontaneous intracerebral hemorrhage (ICH). We aim to identify clinical and imaging characteristics discriminating NOTCH3-mutation related from non-genetic cause of ICH.
Methods
This study was based on a prospectively follow-up CSVD cohort. Next generation sequencing for the common genes of CSVD were performed in patients with ICH and suspicious hereditary cause, such as more severe features of CSVD or younger age of onset. Neuroimaging markers of CSVD, including white matter lesion (WML), lacunes, enlarged perivascular spaces, and cerebral microbleeds (CMB) were compared between patients with and without NOTCH3-mutation.
Results
From 445 patients who had received genetic screening, 47 NOTCH3-mutation and 68 non-genetic patients with ICH were enrolled. Compared with the non-genetic group, patients with NOTCH3-mutation were older, had higher frequency of family history of stroke, thalamus ICH, overwhelming more severe neuroimaging markers of CSVD, especially more CMB in the hippocampus (5.8+/-8.4 vs 0.3+/-0.6) and thalamus (8.4+/-8.2 vs 2.0+/-2.9, both P<0.001). Besides, patients with NOTCH3-mutation and higher risk of recurrent stroke (HR 2.42, 95% CI 1.13–5.20). We further constructed a NOTCH3-ICH score consisting of history of stroke in the siblings, severe deep WML, higher number of hippocampus CMB (>=2) and thalamus CMB (>=7). The sensitivity and specificity were 0.71 and 0.87 for a cut-off score of 2 points, and the area under the receiver operating characteristics was 0.85 (95% CI 0.77–0.93).
Conclusions
Patients with NOTCH3-mutation related ICH had higher burden of CMB in the hippocampus and thalamus. A NOTCH3-ICH score can be used to identifying potential genetic cause of CSVD.
RETROSPECTIVE STUDY OF RADIOLOGICAL PREDICTORS OF GIANT CELL ARTERITIS IN BIOPSY PROVEN CASES OF GIANT CELL ARTERITIS IN BUFFALO, NEW YORK
Abstract
Background and Aims
Giant cell arteritis (GCA) is a clinical and a pathological diagnosis supported by laboratory imaging findings. Biopsy of the STA is positive only in 50% of GCA cases. We aim to identify radiological predictors of GCA.
Methods
A single-center, retrospective chart and image review of suspected cases of GCA. Abnormal findings of the STA on CT Angiogram (CTA) were assessed in both biopsy positive and negative cases. Radiographic findings of blurred vessel wall margins with enhancement, stenosis or occlusion, and calcification of the STA were assessed bilaterally and correlated with the biopsy results.
Results
A total of 615 cases were reviewed. Seventeen biopsy-proven cases were compared with twenty-six biopsy-negative suspected GCA cases. Fisher’s Exact Test showed significant findings (p<.001 and p = .001, respectively) for ipsilateral and contralateral STA changes on CTA head in biopsy-proven cases. Ipsilateral STA changes in imaging have a negative predictive value of 90.9%, a positive predictive value of 88.2 %, specificity of 76.9%, and sensitivity of 71.4%. Regarding the specific radiographic findings, significant findings were found with stenosis or occlusion on ipsilateral STA (p < .001), blurred vessel wall with enhancement in contralateral STA (p<.001), stenosis or occlusion in contralateral STA (p=.03) but nonsignificant for ipsilateral findings of blurred vessel wall margins with enhancement (p=0.168), or calcification (p= .151), and contralateral calcification of STA (p=.395).
Conclusions
CTA head can be an effective tool to predict biopsy positivity in suspected cases of GCA along with clinical and laboratory parameters and it improves the diagnostic yield of STA biopsy.
POOR CORTICAL VENOUS OPACIFICATION ON BASELINE CTA PREDICTS POST-EVT PARENCHYMAL HEMORRHAGE AND WORSE OUTCOMES
Abstract
Background and Aims
Parenchymal hemorrhage (PH) is a major complication in patients with acute ischemic stroke. We studied the association between cortical venous opacification and risk of PH following endovascular treatment (EVT).
Methods
This is a post hoc analysis of patients in the control arm of ESCAPE NA-1 trial who had adequate venous assessment on CT angiography. Any PH and symptomatic intracranial hemorrhage (SICH) were compared between patients with poor venous opacification (cortical vein opacification score (COVES) <3) versus good opacification (COVES≥3). The relationships with unfavorable functional outcome (90d modified Rankin scale 3-6) and mortality were assessed.
Results
Among 545 patients, 55 (10.2%) had PH (6.7% PH1 and 3.5% PH2) and 19 (3.5%) had SICH. Poor venous opacification was observed in 286 patients (51.4% women, median age 71 years, interquartile range 61-81). Poor venous opacification was independently associated with PH in univariable and multivariable logistic regression adjusted for age, NIHSS score, ASPECTS, occlusion site, alteplase, collateral status, and time from onset to randomization, 43/283 (15.2%) in poor venous opacification vs. 12/257 (4.7%) in good opacification group (adjusted OR 3.2 [95% CI, 1.6-6.6]). SICH was not associated with venous opacification, 14/283 (4.9%) vs. 5/257 (1.9%), p=0.06 (unadjusted OR 2.6 [95% CI, 0.9-7.4]) in poor and good opacification groups, respectively. Poor opacification predicted unfavorable functional outcome (adjusted OR 3.4, 95% CI, 2.2-5.4) and mortality (adjusted OR 2.2, 95% CI, 1.2-4.0).
Conclusions
Poor venous opacification on CTA is strongly associated with an increased risk of parenchymal hemorrhage and worse clinical outcomes after EVT.
ASSOCIATION OF THROMBUS DENSITY IN PATIENTS WITH M1 OCCLUSIONS WITH OUTCOME
Abstract
Background and Aims
The association of thrombus density with reperfusion and functional outcome remains conflicted in acute ischemic stroke. We evaluated if hyperdense thrombi were associated with reperfusion and functional outcome after endovascular treatment (EVT).
Methods
Thrombus imaging characteristics were measured in patients with M1 occlusions included in the MR CLEAN Registry. Thrombus density was measured on thin-slice (<2.5 mm) non-contrast computed tomography. Based on median density across the dataset, hyperdense thrombi were defined as thrombi >50 Hounsfield Units (HU). Regression models were used to investigate the association between hyperdense thrombi, successful reperfusion (expanded Treatment In Cerebral Ischemia (eTICI) score 2B-3), and favorable and excellent functional outcome (modified Rankin Scale (mRS) of 0-2 and 0-1, respectively) at 90 days. We adjusted for age, gender, baseline National Institutes of Health Stroke Scale, prestroke mRS, clot burden score, intravenous alteplase treatment (IVT) and carotid tandem lesions. Subgroup analyses were performed in patients treated with or without IVT prior to EVT.
Results
In 434 analyzed patients, hyperdense thrombi were not associated with successful reperfusion (aOR 0.99 [95%CI 0.65-1.51]) or favorable functional outcome (aOR 1.28 [95%CI 0.81-2.01]). Hyperdense thrombi were inversely associated with excellent functional outcome (aOR 0.52 [95%CI 0.32-0.85]). This association was stronger in patients treated with IVT prior to EVT (aOR 0.47 [95%CI 0.26-0.85]) than in EVT only patients (aOR 0.85 [95%CI 0.29-2.52]) (Figure 1).
Conclusions
Hyperdense thrombi were not significantly associated with reperfusion or favorable functional outcome. However, patients with hyperdense thrombi less often achieved excellent functional outcome after EVT.
CT- VERSUS MRI-BASED IMAGING FOR INTRAVENOUS THROMBOLYSIS AND MECHANICAL THROMBECTOMY IN ISCHEMIC STROKE
Abstract
Background and Aims
It is unclear whether a particular stroke imaging modality (CT or MRI) offers an advantage for the acute stroke treatment. The aim of this study was to compare procedure times, efficacy and safety of thrombolysis and/or thrombectomy based on CT versus MRI acute stroke imaging.
Methods
Data of stroke patients who received thrombolysis (IVT) and/or mechanical thrombectomy (MT) were extracted from a nationwide, prospective stroke unit registry and categorized according to initial imaging modality (CT versus MRI).
Results
16799 patients with IVT and 2248 with MT were included. MRI-guided patients (n=2599) were younger, had less comorbidities, less severe strokes and higher rates of strokes with unknown onset. In IVT patients, no differences were observed in neurological improvement (NIHSS ≥ 4, adjusted OR 0.91, CI 0.82-1.02), functional outcome by mRS 0-1 (adjusted OR 0.87, CI 0.71-1.05), sICH (adjusted OR 0.82 CI 0.61-1.08) and mortality (adjusted OR 0.88 CI 0.63-1.22) between the CT and MRI group. Patients with MT selected by MRI showed equal rates of neurological improvement (NIHSS ≥ 8, adjusted OR 1.03, CI 0.78-1.37), mRS 0-2 (adjusted OR 0.87, CI 0.65-1.16), sICH (adjusted OR 0.9, CI 0.51-1.69) and mortality (adjusted OR 0.62, CI 0.35-1.09) as compared to CT. MRI-guided patients showed a significant intra-hospital delay of 20 minutes in both the IVT and the MT group.
Conclusions
CT guided and MRI guided patient selection for IVT/MT seems to perform equal in means of safety and functional outcome. Standardized workflows are needed to shorten delays in MRI guided stroke patients.
THE EFFECT OF NEUROPROTECTANT NA1 ON EARLY INFARCT GROWTH FOLLOWING ENDOVASCULAR THERAPY: THE REPERFUSE-NA1 STUDY
Abstract
Background and Aims
Unfavourable outcome despite successful endovascular therapy (EVT) recanalization may be caused by substantial infarct growth that occurs despite successful reperfusion. The REPERFUSE-NA1 study replicated the preclinical NA1 experiment by investigating the effect of NA1 on early DWI infarct growth in acute ischemic stroke patients receiving EVT.
Methods
The REPERFUSE-NA1 was sub-study of the randomized controlled trial ESCAPE-NA1 (ClinicalTrialGov NCT02930018). Patients received MRI within 5 hours and 24 hours of EVT. The primary outcome was early diffusion weighted (DWI) Infarct growth.
Results
A total of 71 patients was included, of whom 67 had sufficient MR imaging at 5h and 24h post-EVT. For patients who received NA1 compared to placebo, the median age (68.8 v 67.5), baseline NIHSS (15.5 v 16), time from symptom onset to reperfusion (161 v 167 minutes) and mTICI 2b-3 (94.4% v 94.3%) were statistically not different. Median DWI volumes post-EVT (5h) were 13.0 mL (IQR, 5.9-28.1) in NA1 and 13.3 mL (IQR, 3.1-27.0) in placebo. At 24h median DWI volumes increased to 22.6 mL (IQR, 11.2-63.4) in the NA1 group and 22.4 mL (IQR, 7.4-52.3) in the placebo group, equating to a 48.4% DWI volume growth in the NA1 group and a 66.0% growth in the placebo group. Median DWI volume growth was 55.1% for NA1 patients who received alteplase compared to 41.3% for NA1 patients who did not receive alteplase (p=0.65).
Conclusions
The study did not show an effect of NA1 in reducing early DWI growth despite there being substantial DWI infarct growth in both NA1 and control groups.