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Background: Pretreatment computed tomography perfusion parameter relative cerebral blood volume (rCBV) lesion volume has been shown to predict 90-day modified Rankin Scale score in small-core strokes with Alberta Stroke Program Early Computed Tomography Score ≥5, including those with medium-vessel occlusions (mid and distal M2 segment occlusions). Hence, in this study we aim to assess the performance of different rCBV lesion volume thresholds (rCBV <42%, rCBV <38%, and rCBV <34%) with 90-day modified Rankin Scale score including patients with large core (Alberta Stroke Program Early Computed Tomography Score <5) and strictly including only patients with anterior circulation large-vessel occlusion., Methods and Results: In this retrospective evaluation of our prospectively collected database, inclusion criteria were (1) Computed tomographic angiography confirmed anterior circulation large-vessel occlusion from September 1, 2017, to October 1, 2023; and (2) diagnostic computed tomography perfusion. Student t test, Mann-Whitney U test, and χ 2 test were used in the univariate data analysis. Spearman's rank correlation analysis was used to assess correlations. Outcome measure was dichotomized into good functional outcome (90-day modified Rankin Scale score, 0-2) and poor functional outcome (90-day modified Rankin Scale score, 3-6) for logistic regression and receiver operating characteristic analysis. P ≤0.05 was considered significant. In total, 229 patients met our inclusion criteria. The majority of the patients (n=161) in our cohort had M1 occlusion. All the rCBV thresholds were significantly higher in patients with poor 90-day functional outcomes and were independently associated with the outcome. Spearman's rank correlation analysis revealed a slightly stronger correlation of rCBV <42% (ρ=0.27, P <0.001), as compared with rCBV <38% (ρ=0.25, P <0.001) and rCBV <34% (ρ=0.24, P <0.001) with functional outcome. Receiver operating characteristic analysis revealed that rCBV <42% (area under the curve, 0.67 [95% CI, 0.60-0.74]; P <0.001) performed marginally better than rCBV <38% (area under the curve, 0.66 [95% CI, 0.59-0.73]; P <0.001), and rCBV <34% (area under the curve, 0.65 [95% CI, 0.58-0.72]; P <0.001)., Conclusions: All the rCBV thresholds were independently associated with poor 90-day functional outcome; however, the rCBV <42% marginally outperformed rCBV <38% and rCBV <34% lesion volumes.

Objectives: The variation in quality and quantity of collateral status (CS) is in part responsible for a wide variability in extent of neural damage following acute ischemic stroke from large vessel occlusion (AIS-LVO). Single-phase CTA based clot burden score (CBS) is a promising marker in estimating CS. The aim of this study is to assess the relationship of pretreatment CTA based CBS with the reference standard Digital subtraction angiography (DSA) based American Society of Interventional and Therapeutic Neuroradiology (ASITN) CS., Methods: In this retrospective study, inclusion criteria were as follows: (1) Anterior circulation LVO confirmed on CTA from January 9, 2017 to January 10, 2023; (2) diagnostic CTA; and (3) underwent mechanical thrombectomy with documented DSA CS. Spearman's rank correlation analysis, multivariate logistic regression and ROC analysis was performed to assess the correlation of CTA CBS with DSA CS. P ≤ .05 was considered significant., Results: 292 consecutive patients (median age = 68 years; 56.2% female) met our inclusion criteria. CTA CBS and DSA CS showed significant positive correlation (ρ = 0.51, P < .001). On multivariate logistic regression analysis CBS was found to be independently associated with DSA CS (adjusted OR = 1.83, P < .001, 95% CI: 1.54-2.19), after adjusting for age, sex, race, hyperlipidemia, hypertension, diabetes, prior stroke or transient ischemic attack, atrial fibrillation, premorbid mRS, admission NIH stroke scale, and ASPECTS. ROC analysis of CBS in predicting good DSA CS showed AUC of 0.76 (P < .001; 95% CI: 0.68-0.82). CBS threshold of > 6 has 84.6% sensitivity and 42.3% specificity in predicting good DSA CS., Conclusion: CTA CBS is independently associated with DSA CS and serves as a valuable supplementary tool for CS estimation. Further research is necessary to enhance our understanding of the role of CTA CBS in clinical decision-making for patients with AIS-LVO., Advances in Knowledge: CBS by indirectly estimating CS has shown to predict outcomes in AIS-LVO patients. No studies report association of CBS with reference standard DSA. In this study we further establish CBS as an independent marker of CS., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Institute of Radiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background and Purpose: Mechanical thrombectomy (MT) is the treatment standard for large vessel occlusion (LVO) stroke. Under current guidelines, only patients with smaller ischemic core volumes (ICV) are eligible for MT. Thus, it is of interest to quickly estimate ICV in stroke patients. The Los Angeles Motor Scale (LAMS) is a validated tool used to assess stroke severity directly in the field. This study aims to determine whether LAMS score is also associated with ICV, as defined by the CBF <30% volume on CT perfusion imaging., Methods: We performed a retrospective, multicenter cohort study of consecutive patients presenting with LVO stroke from 9/1/2017 to 10/1/2023. The inclusion criteria were patients with (1) stroke caused by large vessel occlusion confirmed on CTA and (2) diagnostically adequate, multimodal pretreatment CT imaging. Demographic, clinical, and imaging data was collected through manual chart review. Both univariate and multivariate analyses were applied to assess associations. A p -value <.05 was considered significant., Results: A total of 283 patients (median age: 69, IQR: 61-78) were included in the study. On multivariate logistic regression analysis, we found that lower admission LAMS score (adjusted OR: 0.511, 95% CI: 0.313-0.834, p = .007) was independently associated with a CBF <30% volume of less than 50cc., Conclusions: Admission LAMS is an independent predictor of a CBF <30% volume of less than 50cc. This demonstrates that LAMS can be used to estimate ICV, which will aid in the early triaging of LVO patients to thrombectomy-capable centers., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors do not have any conflict of interest to disclose except for Dr Vivek Yedavalli, who serves as a consultant for MRIOnline (Cincinnati, OH, USA), RAPID (iSchemaView, Menlo Park, CA, USA), and editorial board of Frontiers in Radiology.

Background: Endovascular thrombectomy (EVT) has shown promise in randomized controlled trials (RCTs) for large ischemic core stroke patients, yet variability in core definition and onset-to-imaging time creates heterogeneity in outcomes. This study aims to clarify the prevalence and implications of core-perfusion mismatch (MM) versus no mismatch (No MM) in such patients, utilizing established imaging criteria., Methods: A retrospective cohort study was conducted including patients from 7/29/2019 to 1/29/2023, with data extracted from a continuously maintained database. Patients were eligible if they met criteria including multimodal CT imaging performed within 24 h from last known well (LKW), AIS-LVO diagnosis, and ischemic core size defined by specific rCBF thresholds. Mismatch was assessed based on different operational definitions from the EXTEND and DEFUSE 3 trials., Results: Fifty-two patients were included, with various time windows from LKW. Using EXTEND criteria, a significant portion of early window patients exhibited MM; however, fewer patients met MM criteria in the late window. Defining MM using DEFUSE 3 criteria yielded similar patterns, but with overall lower MM prevalence in the late window. When employing rCBF <38% as a surrogate for ischemic core, a higher percentage of patients were classified as MM across both time windows compared to rCBF <30%., Conclusion: The prevalence of MM in large ischemic core patients varies significantly depending on the imaging criteria and time from LKW. Notably, MM was more prevalent in the early time window across all criteria used. Additional RCTs are needed to determine if this definition of MM identifies patients who will benefit most from EVT., Competing Interests: Declarations. Conflict of interest: V. Yedavalli, H.A. Salim, D.A. Lakhani, J. Mei, A. Balar, B. Musmar, N. Adeeb, M. Hoseinyazdi, L. Luna, F. Deng, N.Z. Hyson, A.A. Dmytriw, A. Guenego, H. Lu, V.C. Urrutia, K. Nael, E.B. Marsh, R. Llinas, A.E. Hillis, M. Wintermark, T.D. Faizy, J.J. Heit and G.W. Albers declare that they have no competing interests. Ethical standards: This study was approved through the institutional review board (JHU-IRB00269637) and follows the STROBE checklist guidelines as an observational study., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background and Purpose: Ischemic strokes due to isolated posterior cerebral artery (PCA) occlusions represent 5% of all strokes but have significant impacts on patients' quality of life, primarily due to visual deficits and thalamic involvement. Current guidelines for acute PCA occlusion management are sparse, and the prognostic value of perfusion imaging parameters remains underexplored., Methods: We conducted a retrospective analysis of 32 patients with isolated PCA occlusions treated at Johns Hopkins Medical Institutions between January 2017 and March 2023. Patients underwent pretreatment perfusion imaging, with perfusion parameters analyzed using RAPID software. The primary outcome was short-term clinical outcome as measured by the National Institutes of Health Stroke Scale (NIHSS) at discharge., Results: The median age of the cohort was 70 years, with 34% female and 66% male. Significant correlations were found between NIHSS at discharge and various perfusion parameters, including time-to-maximum (Tmax) >6 seconds (ρ = .55, p = .004), Tmax >8 seconds (ρ = .59, p = .002), Tmax >10 seconds (ρ = .6, p = .001), mismatch volume (ρ = .51, p = .008), and cerebral blood volume (CBV) < 34% (ρ = .59, p = .002)., Conclusions: Tmax and CBV volumes significantly correlated with discharge NIHSS with marginal superiority of Tmax >10 seconds and CBV <42% volumes. These findings suggest that CT and MR perfusion imaging can play a crucial role in the acute management of PCA strokes, though larger, standardized studies are needed to validate these results and refine imaging thresholds specific to posterior circulation infarcts., (© 2024 American Society of Neuroimaging.)

Background: Mechanical thrombectomy (MT) is the treatment standard in eligible patients with acute ischemic stroke (AIS) secondary to large vessel occlusions (LVO). Studies have shown that good collateral status is a strong predictor of MT efficacy, thus making collateral status important to quickly assess. The Los Angeles Motor Scale is a clinically validated tool for identifying LVO in the field. The aim of this study is to investigate whether admission LAMS score is also associated with the American Society of Interventional and Therapeutic Neuroradiology (ASITN) collateral score on digital subtraction angiography (DSA)., Methods: We conducted a retrospective multicenter cohort study of consecutive patients presenting with AIS caused by LVO from 9/1/2017 to 10/1/2023 with diagnostically adequate DSA imaging. Demographic, clinical, and imaging data was collected through manual chart review. Both univariate and multivariate analysis were applied to assess associations. A p -value <0.05 was considered significant., Results: A total of 308 patients (median age: 68, IQR: 57.5-77) were included in the study. On multivariate logistic regression analysis, we found that lower admission LAMS score (adjusted OR: 0.82, 95% CI: 0.68-0.98, p  < 0.05) and higher ASPECTS score (adjusted OR: 1.21, 95% CI: 1.02-1.42, p  < 0.05) were independently associated with good DSA ASITN collateral score of 3-4., Conclusions: Admission LAMS and ASPECTS score are both independently associated with DSA ASITN collateral score. This demonstrates the capability of LAMS to act as a surrogate marker of CS in the field.

Background: Recent large core trials have highlighted the effectiveness of mechanical thrombectomy (MT) in acute ischemic stroke with large vessel occlusion. Variable perfusion-imaging thresholds and poor Alberta Stroke Program Early Computed Tomography Score reliability underline the need for more standardized, quantitative ischemia measures for MT patient selection. We aimed to identify the computed tomography perfusion parameter most strongly associated with poor outcomes in patients with acute ischemic stroke-large vessel occlusion with significant ischemic cores., Methods: In this study from 2 comprehensive stroke centers from 2 comprehensive stroke centers within the Johns Hopkins Medical Enterprise (Johns Hopkins Hospita-East Baltimore and Bayview Medical Campus) from July 29, 2019 to January 29, 2023 in a continuously maintained database, we included patients with acute ischemic stroke-large vessel occlusion with ischemic core volumes defined as relative cerebral blood flow <30% and ≥50 mL on computed tomography perfusion or Alberta Stroke Program Early Computed Tomography Score <6. We used receiver operating characteristics to find the optimal cutoff for parameters like cerebral blood volume (CBV) <34%, 38%, 42%, and relative cerebral blood flow >20%, 30%, 34%, 38%, and time-to-maximum >4, 6, 8, and 10 seconds. The primary outcome was unfavorable outcomes (90-day modified Rankin Scale score 4-6). Multivariable models were adjusted for age, sex, diabetes, baseline National Institutes of Health Stroke Scale, intravenous thrombolysis, and MT., Results: We identified 59 patients with large ischemic cores. A receiver operating characteristic curve analysis showed that CBV<42% ≥68 mL is associated with unfavorable outcomes (90-day modified Rankin Scale score 4-6) with an area under the curve of 0.90 (95% CI, 0.82-0.99) in the total and MT-only cohorts. Dichotomizing at this CBV threshold, patients in the ≥68 mL group exhibited significantly higher relative cerebral blood flow, time-to-maximum >8 and 10 seconds volumes, higher CBV volumes, higher HIR, and lower CBV index. The multivariable model incorporating CBV<42% ≥68 mL predicted poor outcomes robustly in both cohorts (area under the curve for MT-only subgroup was 0.87 [95% CI, 0.75-1.00])., Conclusions: CBV<42% ≥68 mL most effectively forecasts poor outcomes in patients with large-core stroke, confirming its value alongside other parameters like time-to-maximum in managing acute ischemic stroke-large vessel occlusion., Competing Interests: Dr Yedavalli reports compensation from IschemaView (RAPID AI) for consultant services and compensation from MRIOnline for consultant services. Dr Guenego reports compensation from Acandis for consultant services; compensation from Rapid Medical Ltd for consultant services; and compensation from phenox, Inc, for consultant services. Dr Heit reports compensation from iSchemaView for consultant services; compensation from Medtronic for consultant services; and compensation from MicroVention Inc for consultant services. Dr Albers reports compensation from iSchemaView for consultant services; compensation from Genentech for consultant services; and stock holdings in iSchemaView. Dr Urrutia reports grants from Genentech and employment by Johns Hopkins University School of Medicine. Dr Nael reports compensation from BRAINOMIX LIMITED for consultant services and compensation from Olea Medical for consultant services. Dr Hillis reports compensation from American Heart Association for other services; compensation from Elsevier Publishing for other services; employment by Johns Hopkins University School of Medicine; compensation from National Institute on Deafness and Other Communication Disorders for other services; and grants from National Institute on Deafness and Other Communication Disorders. The other authors report no conflicts.

Background: Collateral status (CS) is an important biomarker of functional outcomes in patients with acute ischemic stroke secondary to large vessel occlusion (AIS-LVO). Pretreatment CT perfusion (CTP) parameters serve as reliable surrogates of collateral status (CS). In this study, we aim to assess the relationship between the relative cerebral blood flow less than 38% (rCBF <38%), with the reference standard American Society of Interventional and Therapeutic Neuroradiology (ASITN) collateral score (CS) on DSA., Methods: In this prospectively collected, retrospectively reviewed analysis, inclusion criteria were as follows: (a) CT angiography (CTA) confirmed anterior circulation large vessel occlusion from 9/1/2017 to 10/01/2023; (b) diagnostic CT perfusion; and (c) underwent mechanical thrombectomy with documented ASITN CS. The ratios of the CTP-derived CBF values were calculated by dividing the values of the ischemic lesion by the corresponding values of the contralateral normal region (which were defined as rCBF). Spearman's rank correlation and logistic regression analysis were performed to determine the relationship of rCBF <38% lesion volume with DSA ASITN CS. p ≤ .05 was considered significant., Results: In total, 223 patients [mean age: 67.77 ± 15.76 years, 56.1% ( n = 125) female] met our inclusion criteria. Significant negative correlation was noted between rCBF <38% volume and DSA CS (ρ = -0.37, p < .001). On multivariate logistic regression analysis, rCBF <38% volume was found to be independently associated with worse ASITN CS (unadjusted OR: 3.03, 95% CI: 1.60-5.69, p < .001, and adjusted OR: 2.73, 95% CI: 1.34-5.50, p < .01)., Conclusion: Greater volume of tissue with rCBF <38% is independently associated with better DSA CS. rCBF <38% is a useful adjunct tool in collateralization-based prognostication. Future studies are needed to expand our understanding of the role of rCBF <38% within the decision-making in patients with AIS-LVO., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: VSY, JJH, and GWA are consultants for RAPID.AI, and GWA holds RAPID.AI equity.

Background: Prolonged venous transit (PVT), defined as presence of time-to-maximum ≥ 10 s within the superior sagittal sinus (SSS) and/or torcula, is a novel, qualitatively assessed computed tomography perfusion surrogate parameter of venous outflow with potential utility in pretreatment acute ischemic stroke imaging for neuroprognostication. We aim to characterize the correlation between PVT and neurological functional outcomes in thrombectomy-treated patients., Methods: A prospectively-collected database of large vessel occlusion acute ischemic stroke patients treated with thrombectomy was retrospectively analyzed. Spearman's rank correlation coefficient and point-biserial correlations were performed between PVT status (i.e., no region, either SSS or torcula, or both), 90-day modified Rankin score (mRS), mortality (mRS 6), and poor functional outcome (mRS 4-6 vs 0-3)., Results: Of 128 patients, correlation between PVT and 90-day mRS ( ρ = 0.35, p < 0.0001), mortality (r = 0.26, p = 0.002), and poor functional outcome (r = 0.27, p = 0.002) were significant., Conclusion: There is a modest, significant correlation between PVT and severity of neurological functional outcome. Consequently, PVT is an easily-ascertained, qualitative metric that may be useful as an adjunct for anticipating a patient's clinical course. Future analyses will determine the significance of incorporating PVT in clinical decision-making., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Drs. Vivek Yedavalli, Jeremy Heit, and Gregory Albers are consultants for iSchemaView (Menlo Park, CA), not related to submitted work.

Background and Aim: The Los Angeles Motor Scale (LAMS) is an objective tool that has been used to rapidly assess and predict the presence of large vessel occlusion (LVO) in the pre-hospital setting successfully in several studies. However, studies assessing the relationship between LAMS score and CT perfusion collateral status (CS) markers such as cerebral blood volume (CBV) index, and hypoperfusion intensity ratio (HIR) are sparse. Our study therefore aims to assess the association of admission LAMS score with established CTP CS markers CBV Index and HIR in AIS-LVO cases., Materials and Methods: In this prospectively collected, retrospectively reviewed analysis, inclusion criteria were as follows: a) CT angiography (CTA) confirmed anterior circulation LVO from 9/1/2017 to 10/01/2023, and b) diagnostic CT perfusion (CTP). Logistic regression analysis was performed to assess the relationship between admission LAMS with CTP CS markers HIR and CBV Index. p ≤ 0.05 was considered significant., Results: In total, 285 consecutive patients (median age = 69 years; 56 % female) met our inclusion criteria. Multivariable logistic regression analysis adjusting for sex, age, ASPECTS, tPA, premorbid mRS, admission NIH stroke scale, prior history of TIA, stroke, atrial fibrillation, diabetes mellitus, hyperlipidemia, coronary artery disease and hypertension, admission LAMS was found to be independently associated with CBV Index (adjusted OR:0.82, p < 0.01), and HIR (adjusted OR:0.59, p < 0.05)., Conclusion: LAMS is independently associated with CTP CS markers, CBV index and HIR. This finding suggests that LAMS may also provide an indirect estimate of CS., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background and Purpose: Distal medium vessel occlusions (DMVOs) are a significant contributor to acute ischemic stroke (AIS), with collateral status (CS) playing a pivotal role in modulating ischemic damage progression. We aimed to explore baseline characteristics associated with CS in AIS-DMVO., Methods: This retrospective analysis of a prospectively collected database enrolled 130 AIS-DMVO patients from two comprehensive stroke centers. Baseline characteristics, including patient demographics, admission National Institutes of Health Stroke Scale (NIHSS) score, admission Los Angeles Motor Scale (LAMS) score, and co-morbidities, including hypertension, hyperlipidemia, diabetes, coronary artery disease, atrial fibrillation, and history of transient ischemic attack or stroke, were collected. The analysis was dichotomized to good CS, reflected by hypoperfusion index ratio (HIR) <.3, versus poor CS, reflected by HIR ≥.3., Results: Good CS was observed in 34% of the patients. As to the occluded location, 43.8% occurred in proximal M2, 16.9% in mid M2, 35.4% in more distal middle cerebral artery, and 3.8% in distal anterior cerebral artery. In multivariate logistic analysis, a lower NIHSS score and a lower LAMS score were both independently associated with a good CS (odds ratio [OR]: 0.88, 95% confidence interval [CI]: 0.82-0.95, p < .001 and OR: 0.77, 95% CI: 0.62-0.96, p = .018, respectively). Patients with poor CS were more likely to manifest as moderate to severe stroke (29.1% vs. 4.5%, p < .001), while patients with good CS had a significantly higher chance of having a minor stroke clinically (40.9% vs. 12.8%, p < .001)., Conclusions: CS remains an important determinant in the severity of AIS-DMVO. Collateral enhancement strategies may be a worthwhile pursuit in AIS-DMVO patients with more severe initial stroke presentation, which can be swiftly identified by the concise LAMS and serves as a proxy for underlying poor CS., (© 2024 American Society of Neuroimaging.)

Background: Cervical spine computed tomography (CSCT) scans are frequently performed in older emergency department (ED) trauma patients based on the 65-year-old high-risk criterion of the Canadian Cervical Spine Rule (CCR). We sought to determine the positivity rate of CSCT scans in symptomatic and asymptomatic patients to assess the current applicability of age in the CCR., Methods: We reviewed CSCT ED reports from two institutional hospitals from 2018 to 2023. The primary variable was age; however, we also recorded fracture types and sites and type of treatments. Patients were separated into symptomatic and asymptomatic cohorts. We used a Fisher's exact test to compare variables between the asymptomatic and symptomatic groups and chi-square tests for comparison between age groups., Results: Of 9455 CSCTs performed in patients ≥ 65 years, 192 (2.0%) fractures were identified (113 females); 28 (0.30%) were in asymptomatic patients. The rates of fractures (1.6%) and asymptomatic fractures (0.18%) were lowest in the 65- to 70-year age group. There were no distinguishing features as to the level or part of the vertebra fractured or surgical treatment rate between asymptomatic and symptomatic patients., Conclusions: Cervical spine fractures in posttrauma patients ≥ 65 years are uncommon, with the lowest incidence in those 65 to 70 years old. Excluding asymptomatic individuals aged 65-70 from routine CSCT presents a minimal risk of missed fractures (0.18%). This prompts consideration for refining age-based screening and integrating shared decision making into the clinical protocol for this demographic, reflecting the low incidence of fractures and the changing health profile of the aging population., (© 2024 Society for Academic Emergency Medicine.)

Background: Distal medium vessel occlusions (DMVOs) contribute substantially to the incidence of acute ischemic strokes (AIS) and pose distinct challenges in clinical management and prognosis. Neuroimaging techniques, such as Fluid Attenuation Inversion Recovery (FLAIR) imaging and cerebral blood volume (CBV) index derived from perfusion imaging, have significantly improved our ability to assess the impact of strokes and predict their outcomes. The primary objective of this study was to investigate relationship between follow-up infarct volume (FIV) as assessed by FLAIR imaging in patients with DMVOs., Methods: This prospectively collected, retrospective reviewed cohort study included patients from two comprehensive stroke centers within the Johns Hopkins Medical Enterprise, spanning August 2018-October 2022. The cohort consisted of adults with AIS attributable to DMVO. Detailed imaging analyses were conducted, encompassing non-contrast CT, CT angiography (CTA), CT perfusion (CTP), and FLAIR imaging. Univariable and multivariable linear regression models were employed to assess the association between different factors and FIV., Results: The study included 79 patients with DMVO stroke with a median age of 69 years (IQR, 62-77 years), and 57% (n = 45) were female. There was a negative correlation between the CBV index and FIV in a univariable linear regression analysis (Beta =  - 16; 95% CI,  - 23 to  - 8.3; p < 0.001) and a multivariable linear regression model (Beta =  - 9.1 per 0.1 change; 95% CI,  - 15 to  - 2.7; p = 0.006). Diabetes was independently associated with larger FIV (Beta = 46; 95% CI, 16 to 75; p = 0.003). Additionally, a higher baseline ASPECTS was associated with lower FIV (Beta =  - 30; 95% CI,  - 41 to  - 20; p < 0.001)., Conclusion: Our findings underscore the CBV index as an independent association with FIV in DMVOs, which highlights the critical role of collateral circulation in determining stroke outcomes in this patient population. In addition, our study confirms a negative association of ASPECTS with FLAIR FIV and identifies diabetes as independent factor associated with larger FIV. These insights pave the way for further large-scale, prospective studies to corroborate these findings, thereby refining the strategies for stroke prognostication and management., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background/purpose: Distal medium vessel occlusions (DMVOs) account for a large percentage of vessel occlusions resulting in acute ischemic stroke (AIS) with disabling symptoms. We aim to assess whether pretreatment quantitative CTP collateral status (CS) parameters can serve as imaging biomarkers for good clinical outcomes prediction in successfully recanalized middle cerebral artery (MCA) DMVOs., Methods: We performed a retrospective analysis of consecutive patients with AIS secondary to primary MCA-DMVOs who were successfully recanalized by mechanical thrombectomy (MT) defined as modified thrombolysis in cerebral infarction (mTICI) 2b, 2c, or 3. We evaluated the association between the CBV index and HIR independently with good clinical outcomes (modified Rankin score 0-2) using Spearman rank correlation, logistic regression, and ROC analyses., Results: From 22 August 2018 to 18 October 2022 8/22/2018 to 10/18/2022, 60 consecutive patients met our inclusion criteria (mean age 71.2 ± 13.9 years old [mean ± SD], 35 female). The CBV index (r = -0.693, p < 0.001) and HIR (0.687, p < 0.001) strongly correlated with 90-day mRS. A CBV index ≥ 0.7 (odds ratio, OR, 2.27, range 6.94-21.23 [OR] 2.27 [6.94-21.23], p = 0.001)) and lower likelihood of prior stroke (0.13 [0.33-0.86]), p = 0.024)) were independently associated with good outcomes. The ROC analysis demonstrated good performance of the CBV index in predicting good 90-day mRS (AUC 0.73, p = 0.003) with a threshold of 0.7 for optimal sensitivity (71% [52.0-85.8%]) and specificity (76% [54.9-90.6%]). The HIR also demonstrated adequate performance in predicting good 90-day mRS (AUC 0.77, p = 0.001) with a threshold of 0.3 for optimal sensitivity (64.5% [45.4-80.8%]) and specificity (76.0% [54.9-90.6%])., Conclusion: A CBV index ≥ 0.7 may be independently associated with good clinical outcomes in our cohort of AIS caused by MCA-DMVOs that were successfully treated with MT. Furthermore, a HIR < 0.3 is also associated with good clinical outcomes. This is the first study of which we are aware to identify a CBV index threshold for MCA-DMVOs., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background and Purpose: We aimed to predict the functional outcome of acute ischemic stroke patients with anterior circulation large vessel occlusions (LVOs), irrespective of how they were treated or the severity of the stroke at admission, by only using imaging parameters in machine learning models., Methods: Consecutive adult patients with anterior circulation LVOs who were scanned with CT angiography (CTA) and CT perfusion were queried in this single-center, retrospective study. The favorable outcome was defined as a modified Rankin score (mRS) of 0-2 at 90 days. Predictor variables included only imaging parameters. CatBoost, XGBoost, and Random Forest were employed. Algorithms were evaluated using the area under the receiver operating characteristic curve (AUROC), the area under the precision-recall curve (AUPRC), accuracy, Brier score, recall, and precision. SHapley Additive exPlanations were implemented., Results: A total of 180 patients (102 female) were included, with a median age of 69.5. Ninety-two patients had an mRS between 0 and 2. The best algorithm in terms of AUROC was XGBoost (0.91). Furthermore, the XGBoost model exhibited a precision of 0.72, a recall of 0.81, an AUPRC of 0.83, an accuracy of 0.78, and a Brier score of 0.17. Multiphase CTA collateral score was the most significant feature in predicting the outcome., Conclusions: Using only imaging parameters, our model had an AUROC of 0.91 which was superior to most previous studies, indicating that imaging parameters may be as accurate as conventional predictors. The multiphase CTA collateral score was the most predictive variable, highlighting the importance of collaterals., (© 2024 American Society of Neuroimaging.)

Pretreatment CT Perfusion (CTP) parameter rCBV < 42% lesion volume has recently been shown to predict 90-day mRS. In this study, we aim to assess the relationship between rCBV < 42% and a radiographic follow-up infarct volume delineated on FLAIR images. In this retrospective evaluation of our prospectively collected database, we included acute stroke patients triaged by multimodal CT imaging, including CT angiography and perfusion imaging, with confirmed anterior circulation large vessel occlusion between 9 January 2017 and 10 January 2023. Follow-up FLAIR imaging was used to determine the final infarct volume. Student t, Mann-Whitney-U, and Chi-Square tests were used to assess differences. Spearman's rank correlation and linear regression analysis were used to assess associations between rCBV < 42% and follow-up infarct volume on FLAIR. In total, 158 patients (median age: 68 years, 52.5% female) met our inclusion criteria. rCBV < 42% (ρ = 0.56, p < 0.001) significantly correlated with follow-up-FLAIR infarct volume. On multivariable linear regression analysis, rCBV < 42% lesion volume (beta = 0.60, p < 0.001), ASPECTS (beta = -0.214, p < 0.01), mTICI (beta = -0.277, p < 0.001), and diabetes (beta = 0.16, p < 0.05) were independently associated with follow-up infarct volume. The rCBV < 42% lesion volume is independently associated with FLAIR follow-up infarct volume.

Although pretreatment radiographic biomarkers are well established for hemorrhagic transformation (HT) following successful mechanical thrombectomy (MT) in large vessel occlusion (LVO) strokes, they are yet to be explored for medium vessel occlusion (MeVO) acute ischemic strokes. We aim to investigate pretreatment imaging biomarkers representative of collateral status, namely the hypoperfusion intensity ratio (HIR) and cerebral blood volume (CBV) index, and their association with HT in successfully recanalized MeVOs. A prospectively collected registry of acute ischemic stroke patients with MeVOs successfully recanalized with MT between 2019 and 2023 was retrospectively reviewed. A multivariate logistic regression for HT of any subtype was derived by combining significant univariate predictors into a forward stepwise regression with minimization of Akaike information criterion. Of 60 MeVO patients successfully recanalized with MT, HT occurred in 28.3% of patients. Independent factors for HT included: diabetes mellitus history (p = 0.0005), CBV index (p = 0.0071), and proximal versus distal occlusion location (p = 0.0062). A multivariate model with these factors had strong diagnostic performance for predicting HT (area under curve [AUC] 0.93, p < 0.001). Lower CBV indexes, distal occlusion location, and diabetes history are significantly associated with HT in MeVOs successfully recanalized with MT. Of note, HIR was not found to be significantly associated with HT., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: Poor venous outflow (VO) profiles are associated with unfavorable outcomes in patients with acute ischemic stroke caused by large vessel occlusion (AIS-LVO), despite achieving successful reperfusion. The objective of this study is to assess the association between mortality and prolonged venous transit (PVT), a novel visual qualitative VO marker on CT perfusion (CTP) time to maximum (Tmax) maps., Methods: We performed a retrospective analysis of prospectively collected data from consecutive adult patients with AIS-LVO with successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/2c/3). PVT+ was defined as Tmax ≥10 s timing on CTP Tmax maps in at least one of the following: superior sagittal sinus (proximal venous drainage) and/or torcula (deep venous drainage). PVT- was defined as lacking this in both regions. The primary outcome was mortality at 90 days. In a 1:1 propensity score-matched cohort, regressions were performed to determine the effect of PVT on 90-day mortality., Results: In 127 patients of median (IQR) age 71 (64-81) years, mortality occurred in a significantly greater proportion of PVT+ patients than PVT- patients (32.5% vs 12.6%, P=0.01). This significant difference persisted after matching (P=0.03). PVT+ was associated with a significantly increased likelihood of 90-day mortality (OR 1.22 (95% CI 1.02 to 1.46), P=0.03) in the matched cohort., Conclusions: PVT+ was significantly associated with 90-day mortality despite successful reperfusion therapy in patients with AIS-LVO. PVT is a simple VO profile marker with potential as an adjunctive metric during acute evaluation of AIS-LVO patients. Future studies will expand our understanding of using PVT in the evaluation of patients with AIS-LVO., Competing Interests: Competing interests: VSY, JJH and GWA are consultants for iSchemaView (Menlo Park, California, USA) not related to the submitted work., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The pretreatment CT perfusion (CTP) marker the relative cerebral blood volume (rCBV) < 42% lesion volume has recently been shown to predict 90-day functional outcomes; however, studies assessing correlations of the rCBV < 42% lesion volume with other outcomes remain sparse. Here, we aim to assess the relationship between the rCBV < 42% lesion volume and the reference standard digital subtraction angiography (DSA)-derived American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN) collateral score, hereby referred as the DSA CS. Methods: In this retrospective evaluation of our prospectively collected database, we included acute stroke patients triaged by multimodal CT imaging, including CT angiography and perfusion imaging, with confirmed anterior circulation large vessel occlusion between 1 September 2017 and 1 October 2023. Group differences were assessed using the Student's t test, Mann-Whitney U test and Chi-Square test. Spearman's rank correlation and logistic regression analyses were used to assess associations between rCBV < 42% and DSA CS. Results: In total, 222 patients (median age: 69 years, 56.3% female) met our inclusion criteria. In the multivariable logistic regression analysis, taking into account age, sex, race, hypertension, hyperlipidemia, diabetes, atrial fibrillation, prior stroke or transient ischemic attack, the admission National Institute of Health stroke scale, the premorbid modified Rankin score, the Alberta stroke program early CT score (ASPECTS), and segment occlusion, the rCBV < 42% lesion volume (adjusted OR: 0.98, p < 0.05) was independently associated with the DSA CS. Conclusion: The rCBV < 42% lesion volume is independently associated with the DSA CS.

Background and Purpose: In large vessel occlusion (LVO) stroke patients, relative cerebral blood flow (rCBF)<30% volume thresholds are commonly used in treatment decisions. In the early time window, nearly infarcted but salvageable tissue volumes may lead to pretreatment overestimates of infarct volume, and thus potentially exclude patients who may otherwise benefit from intervention. Our multisite analysis aims to explore the strength of relationships between widely used pretreatment CT parameters and clinical outcomes for early window stroke patients., Methods: Patients from two sites in a prospective registry were analyzed. Patients with LVOs, presenting within 3 hours of last known well, and who were successfully reperfused were included. Primary short-term neurological outcome was percent National Institutes of Health Stroke Scale (NIHSS) change from admission to discharge. Secondary long-term outcome was 90-day modified Rankin score. Spearman's correlations were performed. Significance was attributed to p-value ≤.05., Results: Among 73 patients, median age was 66 (interquartile range 54-76) years. Among all pretreatment imaging parameters, rCBF<30%, rCBF<34%, and rCBF<38% volumes were significantly, inversely correlated with percentage NIHSS change (p<.048). No other parameters significantly correlated with outcomes., Conclusions: Our multisite analysis shows that favorable short-term neurological recovery was significantly correlated with rCBF volumes in the early time window. However, modest strength of correlations provides supportive evidence that the applicability of general ischemic core estimate thresholds in this subpopulation is limited. Our results support future larger-scale efforts to liberalize or reevaluate current rCBF parameter thresholds guiding treatment decisions for early time window stroke patients., (© 2023 American Society of Neuroimaging.)

Objective: For patients presenting with acute ischemic stroke (AIS) caused by large vessel occlusions (LVO), mechanical thrombectomy (MT) is the treatment standard of care in eligible patients. Modified Thrombolysis in Cerebral Infarction (mTICI) grades of 2b, 2c, and 3 are all considered successful reperfusion; however, recent studies have shown achieving mTICI 2c/3 leads to better outcomes than mTICI 2b. This study aims to investigate whether any baseline preprocedural or periprocedural parameters are predictive of achieving mTICI 2c/3 in successfully recanalized LVO patients., Methods: We conducted a retrospective multicenter cohort study of consecutive patients presenting with AIS caused by a LVO from 1 January 2017 to 1 January 2023. Baseline and procedural data were collected through chart review. Univariate and multivariate analysis were applied to determine significant predictors of mTICI 2c/3., Results: A total of 216 patients were included in the study, with 159 (73.6%) achieving mTICI 2c/3 recanalization and 57 (26.4%) achieving mTICI 2b recanalization. We found that a higher groin puncture to first pass time (OR = 0.976, 95%CI: 0.960-0.992, p = 0.004), a higher first pass to recanalization time (OR = 0.985, 95%CI: 0.972-0.998, p = 0.029), a higher admission NIHSS (OR = 0.949, 95%CI: 0.904-0.995, p = 0.031), and a lower age (OR = 1.032, 95%CI: 1.01-1.055, p = 0.005) were associated with a decreased probability of achieving mTICI 2c/3., Interpretation: A lower groin puncture to first pass time, a lower first pass to recanalization time, a lower admission NIHSS, and a higher age were independent predictors of mTICI 2c/3 recanalization., (© 2023 The Authors. Annals of Clinical and Translational Neurology published by Wiley Periodicals LLC on behalf of American Neurological Association.)

Background and Purpose: Acute ischemic stroke due to large vessel occlusion (AIS-LVO) is a major cause of functional dependence. Collateral status (CS) is an important determinant of functional outcomes. Pretreatment CT perfusion (CTP) parameters serve as reliable surrogates of CS. Penumbra Salvage Index (PSI) is another parameter predictive of functional outcomes in AIS-LVO. The aim of this study is to assess the relationship of pretreatment CTP parameters with PSI., Methods: In this prospectively collected, retrospectively reviewed multicenter analysis, inclusion criteria were as follows: (1) CT angiography confirmed middle cerebral artery (MCA) M1-segment and proximal M2-segment occlusion from 9/1/2017 to 9/22/2022; (2) diagnostic CTP; and (3) available diagnostic Magnetic resonance Imaging (MRI) diffusion-weighted images. Pearson correlation analysis was performed to assess the association between cerebral blood volume (CBV) index and hypoperfusion intensity ratio (HIR) with PSI. p value ≤.05 was considered statistically significant., Results: In total, 131 patients (n = 86, M1 and n = 45, proximal M2 occlusion) met our inclusion criteria. CBV index showed a modest positive correlation with PSI (r = 0.34, p<.001) in patients with proximal MCA occlusion. Similar trends were noted in subgroup analysis of patients with M1 occlusion, and proximal M2 occlusion. Whereas, HIR did not have a strong trend or correlation with PSI., Conclusion: CBV index correlates with PSI, whereas HIR does not. Future studies are needed to expand our understanding of the adjunct role of CBV index with other similar pretreatment CTP-based markers in clinical evaluation and decision-making in patients with MCA occlusion., (© 2023 American Society of Neuroimaging.)

Objective: To evaluate the frequency and significance of brain imaging findings in methanol poisoning patients and to propose a criterion for prioritizing brain imaging., Methods: We retrospectively reviewed the data of 306 patients (286 men and 34 women, mean age 32.10 ± 9.9 years) with confirmed methanol poisoning who were admitted to two hospitals in Iran during the COVID-19 pandemic. We analyzed their demographic, clinical, laboratory, and brain imaging data., Results: The main brain computed tomography (CT) scan findings were hypodensity in the putamen (11.1%), cerebellar nuclei (8.2%), diffuse cerebral edema (7.5%), and intracranial hemorrhage (ICH; 1.6%). These findings were associated with blood pH, Glasgow Coma Scale (GCS), renal failure, bicarbonate, oxygen, carbon dioxide, potassium, and glucose levels ( p  < 0.05). Poor prognosis was related to blindness, opium addiction, chronic alcohol use, hyperglycemia, and abnormal CT scans ( p  < 0.001 for all). The most predictive brain imaging findings for poor prognosis were hypodensity in the cerebellar nuclei, diffuse cerebral edema, and ICH., Conclusion: Brain imaging can provide valuable information for the diagnosis and management of methanol poisoning patients. We suggest that patients with severe acidosis, low GCS, low pH, low oxygen saturation, and high glucose levels should undergo brain CT scan as a priority., Competing Interests: The authors declare no conflict of interest., (© 2023 The Authors. Health Science Reports published by Wiley Periodicals LLC.)

Background: Pretreatment CT Perfusion (CTP) parameters serve as reliable surrogates of collateral status (CS). In this study, we aim to assess the relationship between the novel compensation index (CI, Tmax > 4 s/Tmax > 6 s) and already established CTP collateral markers, namely cerebral blood volume (CBV) index and Hypoperfusion Intensity Ratio (HIR), with the reference standard American Society of Interventional and Therapeutic Neuroradiology (ASITN) collateral score (CS) on DSA., Methods: In this retrospective study, inclusion criteria were the following: (a) CT angiography confirmed anterior circulation large vessel occlusion from 9 January 2017 to 10 January 2023; (b) diagnostic CT perfusion; and (c) underwent mechanical thrombectomy with documented DSA-CS. Student t -test, Mann-Whitney-U-test and Chi-square test were used to assess differences. Spearman's rank correlation and logistic regression analysis were used to assess associations. p ≤ 0.05 was considered significant., Results: In total, 223 patients (mean age: 67.8 ± 15.8, 56% female) met our inclusion criteria. The CI (ρ = 0.37, p < 0.001) and HIR (ρ = -0.29, p < 0.001) significantly correlated with DSA-CS. Whereas the CBV Index (ρ = 0.1, p > 0.05) did not correlate with DSA-CS. On multivariate logistic regression analysis taking into account age, sex, ASPECTS, tPA, premorbid mRS, NIH stroke scale, prior history of TIA, stroke, atrial fibrillation, diabetes mellitus, hyperlipidemia, heart disease and hypertension, only CI was not found to be independently associated with DSA-CS (adjusted OR = 1.387, 95% CI: 1.09-1.77, p < 0.01)., Conclusion: CI demonstrates a stronger correlation with DSA-CS compared to both the HIR and CBV Index where it may show promise as an additional quantitative pretreatment CS biomarker.

Objective: To assess pretreatment and interventional parameters as predictors of favorable Activity Measure for Post-Acute Care (AM-PAC) scores for optimal discharge planning., Design: In this prospectively collected, retrospectively reviewed multicenter study from 9/1/2017 to 9/22/2022, patients were dichotomized into favorable and unfavorable AM-PAC. Multivariate logistic regression and receiver operator characteristics analyses were performed for the identified significant variables. A P value of ≤.05 was significant., Setting: Hospitalized care., Participants: In total, 229 patients (mean ±SD 70.65 ±15.2 [55.9% women]) met our inclusion criteria. Inclusion criteria were (a) computed tomography (CT) angiography confirmed LVO from 9/1/2017 to 9/22/2022; (b) diagnostic CT perfusion; and (c) available AM-PAC scores., Interventions: None., Main Outcome Measures: Favorable AM-PAC, defined as a daily activity score ≥19 and basic mobility score of ≥17., Results: Patients with favorable AM-PAC were younger (61.3 vs 70.7, P <.001), had lower admission glucose (mean, 124 vs 136, P =.042), lower blood urea nitrogen (mean, 15.59 vs 19.11, P <.001), and lower admission National Institutes of Health Stroke Scale (NIHSS) (mean, 10.58 vs 16.15, P <.001). No differences in sex were noted. Multivariate regression analyses revealed age, admission NIHSS, relative cerebral blood flow (rCBF) <30% volume, and modified thrombolysis in cerebral infarction (mTICI) score to be independent predictors of favorable AM-PAC ( P <.047 for all predictors). The combined model revealed an area under the curve (AUC) of 0.83 (IQR 0.75-0.86)., Conclusion: Excellent recanalization, smaller core volumes, younger age, and lower stroke severity independently predict favorable outcomes as measured by AM-PAC., (Crown Copyright © 2023 Published by Elsevier Inc. on behalf of American Congress of Rehabilitation Medicine.)

Background: Correlative interactions between electrical charges and cancer cells involve important unknown factors in cancer diagnosis and treatment. We previously reported the intrinsic suppressive effects of pure positive electrostatic charges (PEC) on the proliferation and metabolism of invasive cancer cells without any effect on normal cells in cell lines and animal models. The proposed mechanism was the suppression of pro-caspases 3 and 9 with an increase in Bax/Bcl2 ratio in exposed malignant cells and perturbation induced in the KRAS pathway of malignant cells by electrostatic charges due to the phosphate molecule electrostatic charge as the trigger of the pathway. This study aimed to examine PECs as a complementary treatment for patients with different types of solid metastatic tumors, who showed resistance to chemotherapy and radiotherapy., Methods: In this study, solid metastatic tumors of the end-stage patients ( n  = 41) with various types of cancers were locally exposed to PEC for at least one course of 12 days. The patient's signs and symptoms, the changes in their tumor size, and serum markers were followed up from 30 days before positive electrostatic charge treating (PECT) until 6 months after the study., Results: Entirely, 36 patients completed the related follow-ups. Significant reduction in tumor sizes and cancer-associated enzymes as well as improvement in cancer-related signs and symptoms and patients' lifestyles, without any side effects on other tissues or metabolisms of the body, were observed in more than 80% of the candidates., Conclusion: PECT induced significant cancer remission in combination with other therapies. Therefore, this non-ionizing radiation would be a beneficial complementary therapy, with no observable side effects of ionizing radiotherapy, such as post-radiation inflammation., Competing Interests: A US patent has been granted based on this work by MA and AsZ (Patent No.: US 10,806,945 B2). The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Zandi, Shojaeian, Abbasvandi, Faranoush, Anbiaee, Hoseinpour, Gilani, Saghafi, Zandi, Hoseinyazdi, Davari, Miraghaie, Tayebi, Taheri, Ardestani, Sheikhi Mobarakeh, Nikshoar, Enjavi, Kordehlachin, Mousavi-kiasary, Mamdouh, Akbari, Yunesian and Abdolahad.)

Background: Cervical annular fissures (AFs) have not been studied specifically as to their prevalence, imaging features, and persistence over time. We sought to determine the prevalence and natural history of cervical AFs. We hypothesized that these are static lesions that are not prevalent in the population., Methods: This was a cross-sectional retrospective study of cervical MRI examinations performed between 2011-2021. We retrospectively reviewed the studies of 115 consecutive patients (63 female, 52 male) who had 2 or more MRI studies of the cervical spine to identify (1) imaging features of cervical AFs on various pulse sequences, (2) the concurrence of disc bulges/herniations, (3) changes in those imaging findings over time (mean follow-up 39.3 months) and (4) rate at which cervical AFs were mentioned in radiology reports. 620 initial and follow-up studies were reviewed., Results: 50/115 (43.5%) patients had cervical AFs; 21 patients had a single AF and 29 patients had multi-level AFs (total 109 AFs). The most common levels affected were C4-C5 (28%, n = 31) and C5-C6 (27%, n = 30). All cervical AFs were hyperintense on T2WI and, over time, 95% (n = 104/109) of the AFs remained hyperintense; 22% (n = 25) showed less hyperintensity, 10% (n = 11) more hyperintensity, and 60% (n = 66) the same hyperintensity. 5 AFs (4%) resolved completely. Only 2 (8%) of 25 cervical AFs enhanced with gadolinium. The rate of concomitant disc bulges and herniations was 71% (n = 78) and 22% (n = 24) respectively. The presence of cervical AFs did not increase the risk of progression to bulges or herniations. None of the cervical AFs were mentioned in the radiology reports., Conclusions: Cervical AFs occurred in 43.5% of patients but were rarely reported. They usually remained bright on T2W but their brightness could vary over time. Cervical AFs were often associated with disc bulges/herniations and enhanced less frequently (8%) than lumbar disk AFs., Competing Interests: The authors declare no conflict of interest. Unrelated, Dr. Yousem reports royalties from Elsevier, personal fees from Medicolegal consultant, speaking and consulting fees from MRIOnline.com, outside the submitted work., (© 2023 The Author(s).)

Background: The Los Angeles Motor Scale (LAMS) is a rapid pre-hospital scale used to predict stroke severity which has also been shown to accurately predict large vessel occlusions (LVOs). However, to date there is no study exploring whether LAMS correlates with the computed tomography perfusion (CTP) parameters in LVOs., Methods: Patients with LVO between September 2019 and October 2021 were retrospectively reviewed and included if the CTP data and admission neurologic exams were available. The LAMS was documented based on emergency personnel exams or scored retrospectively using an admission neurologic exam. The CTP data was processed by RAPID (IschemaView, Menlo Park, CA, USA) with an ischemic core volume (relative cerebral blood flow [rCBF] < 30%), time-to-maximum (Tmax) volume (Tmax > 6 s delay), hypoperfusion index (HI), and cerebral blood volume (CBV) index. Spearman's correlations were performed between the LAMS and CTP parameters., Results: A total of 85 patients were included, of which there were 9 intracranial internal carotid artery (ICA), 53 proximal M1 branch middle cerebral artery M1, and 23 proximal M2 branch occlusions. Overall, 26 patients had LAMS 0-3, and 59 had LAMS 4-5. In total, LAMS positively correlated with CBF < 30% (Correlation Coefficient (CC): 0.32, p < 0.01), Tmax > 6 s (CC:0.23, p < 0.04), HI (CC:0.27, p < 0.01), and negatively correlated with the CBV index (CC:-0.24, p < 0.05). The relationships between LAMS and CBF were < 30% and the HI was more pronounced in M1 occlusions (CC:0.42, p < 0.01; 0.34, p < 0.01 respectively) and proximal M2 occlusions (CC:0.53, p < 0.01; 0.48, p < 0.03 respectively). The LAMS also correlated with a Tmax > 6 s in M1 occlusions (CC:0.42, p < 0.01), and negatively correlated with the CBV index in M2 occlusions (CC:-0.69, p < 0.01). There were no significant correlations between the LAMS and intracranial ICA occlusions., Conclusions: The results of our preliminary study indicate that the LAMS is positively correlated with the estimated ischemic core, perfusion deficit, and HI, and negatively correlated with the CBV index in patients with anterior circulation LVO, with stronger relationships in the M1 and M2 occlusions. This is the first study showing that the LAMS may be correlated with the collateral status and estimated ischemic core in patients with LVO., Competing Interests: Vivek Yedavalli, is a consultant for RAPID (IschemaView, Menlo Park, CA, USA) and MRIOnline (Cincinnati, OH, USA). Victor C. Urrutia, has research grant funding from Genetech, Inc.

Several baseline hematologic and metabolic laboratory parameters have been linked to acute ischemic stroke (AIS) clinical outcomes in patients who successfully recanalized. However, no study has directly investigated these relationships within the severe stroke subgroup. The goal of this study is to identify potential predictive clinical, lab, and radiographic biomarkers in patients who present with severe AIS due to large vessel occlusion and have been successfully treated with mechanical thrombectomy. This single-center, retrospective study included patients who experienced AIS secondary to large vessel occlusion with an initial NIHSS score ≥ 21 and were recanalized successfully with mechanical thrombectomy. Retrospectively, demographic, clinical, and radiologic data from electronic medical records were extracted, and laboratory baseline parameters were obtained from emergency department records. The clinical outcome was defined as the modified Rankin Scale (mRS) score at 90 days, which was dichotomized into favorable functional outcome (mRS 0-3) or unfavorable functional outcome (mRS 4-6). Multivariate logistic regression was used to build predictive models. A total of 53 patients were included. There were 26 patients in the favorable outcome group and 27 in the unfavorable outcome group. Age and platelet count (PC) were found to be predictors of unfavorable outcomes in the multivariate logistic regression analysis. The areas under the receiver operating characteristic (ROC) curve of models 1 (age only model), 2 (PC only model), and 3 (age and PC model) were 0.71, 0.68, and 0.79, respectively. This is the first study to reveal that elevated PC is an independent predictor of unfavorable outcomes in this specialized group.

At present, clinicians are expected to manage a large volume of complex clinical, laboratory, and imaging data, necessitating sophisticated analytic approaches. Machine learning-based models can use this vast amount of data to create forecasting models. We aimed to predict short- and medium-term functional outcomes in acute ischemic stroke (AIS) patients with proximal middle cerebral artery (MCA) occlusions using machine learning models with clinical, laboratory, and quantitative imaging data as inputs. Included were consecutive AIS patients with MCA M1 and proximal M2 occlusions. The XGBoost, LightGBM, CatBoost, and Random Forest were used to predict the outcome. Minimum redundancy maximum relevancy was used for selecting features. The primary outcomes were the National Institutes of Health Stroke Scale (NIHSS) shift and the modified Rankin Score (mRS) at 90 days. The algorithm with the highest area under the receiver operating characteristic curve (AUROC) for predicting the favorable and unfavorable outcome groups at 90 days was LightGBM. Random Forest had the highest AUROC when predicting the favorable and unfavorable groups based on the NIHSS shift. Using clinical, laboratory, and imaging parameters in conjunction with machine learning, we accurately predicted the functional outcome of AIS patients with proximal MCA occlusions.

Stroke mimics constitute a significant proportion of patients with suspected acute ischemic stroke. These conditions may resemble acute ischemic stroke and demonstrate abnormalities on perfusion imaging sequences. The most common stroke mimics include seizure/epilepsy, migraine with aura, brain tumors, functional disorders, infectious encephalopathies, Wernicke's encephalopathy, and metabolic abnormalities. Brain perfusion imaging techniques, particularly computed tomography perfusion and magnetic resonance perfusion, are being widely used in routine clinical practice for treatment selection in patients presenting with large vessel occlusion. At the same time, the utilization of these imaging modalities enables the opportunity to better diagnose patients with stroke mimics in a time-sensitive setting, leading to appropriate management, decision-making, and resource allocation. In this review, we describe patterns of perfusion abnormalities that could discriminate patients with stroke mimics from those with acute ischemic stroke and provide specific case examples to illustrate these perfusion abnormalities. In addition, we discuss the challenges associated with interpretation of perfusion images in stroke-related pathologies. In general, perfusion imaging can provide additional information in some cases-when used in combination with conventional magnetic resonance imaging and computed tomography-and might help in detecting stroke mimics among patients who present with acute onset focal neurological symptoms., (© 2022 American Society of Neuroimaging.)

Mechanical thrombectomy (MT) is an important therapeutic option in the management of acute ischemic stroke (AIS) caused by large vessel occlusions (LVO). While achieving a modified thrombolysis in cerebral infarction (mTICI), grades of 2b, 2c, and 3 are all considered successful recanalization; recent literature suggests that mTICI grades of 2c/3 are associated with superior outcomes than 2b. The aim of this preliminary study is to determine whether any baseline or procedural parameters can predict whether successfully recanalized patients achieve an mTICI grade of 2c/3 over 2b. Consecutive patients from 9/2019 to 10/2021 who were successfully recanalized following MT for confirmed LVO were included in the study. Baseline and procedural data were collected through manual chart review and analyzed to ascertain whether any variables of interest could predict mTICI 2c/3. A total of 47 patients were included in the preliminary study cohort, with 35 (74.5%) achieving an mTICI score of 2c/3 and 12 (25.5%) achieving an mTICI score of 2b. We found that a lower groin puncture to recanalization time was a strong, independent predictor of TICI 2c/3 ( p = 0.015). These findings emphasize the importance of minimizing procedure time in achieving superior reperfusion but must be corroborated in larger scale studies.

A new biosensor for detecting cancer involved sentinel lymph nodes has been developed via the electrochemical tracing of fatty acid oxidation as a distinct metabolism of malignant cells invading lymph nodes (LNs). The system included integrated platinum needle electrodes that were decorated by carbon nanotubes (as hydrophobic agents) through laser-assisted nanowelding. It was applied to record the dielectric spectroscopy data from LN contents via electrochemical impedance spectroscopy. The system was applied for dielectric spectroscopy of LN contents  via  electrochemical impedance approach. The reduced lipid content of involved LNs, due to fat metabolism by invasive cancer cells, would decrease the charge transfer resistance ( R CT ) of the LNs with respect to their normal counterparts. Multi-walled carbon nanotubes (MWCNTs) with superhydrophobic properties were used to enhance the interaction of Pt needle electrodes with the lipidic contents of lymph nodes. This is the first time that a fatty acid metabolism-based sensing approach has been introduced to detect involved LNs. Moreover, a novel electrode decorating method was applied to enhance the interfacial contact of this lipid detection probe (LDP). In order to avoid doubt about the biocompatibility of ferrocyanide, [Fe(CN) 6 ] 4- and ferricyanide, [Fe(CN) 6 ] 3- , a biocompatible injectable metal ion-based material, ferric carboxymaltose, was selected and applied as the electrolyte for the first time. Rabbit LNs were tested using the LDP in the animal model phase. The system was then used in vitro on 122 dissected human LNs in the operating room. Calibration of the results showed an excellent match between the dielectric response of the LDP (known as charge transfer resistance ( R CT )) and the final pathological diagnoses. The LDP may have a promising future after further clinical investigations for intra-operative distinction between normal and cancerous LNs.

Background: This study was performed with the intention of comparing the clinical, laboratory, and chest computed tomography (CT) findings between severe and non-severe patients as well as between different age groups composed of pediatric patients with confirmed COVID-19., Method: This study was carried out on a total of 53 confirmed COVID-19 pediatric patients who were hospitalized in Namazi and Ali Asghar Hospitals, Shiraz, Iran. The patients were divided into two severe (n = 27) and non-severe (n = 28) groups as well as into other three groups in terms of their age: aged less than two years, aged 3-12 years and 13-17 years. It should be noted that CT scans, laboratory, and clinical features were taken from all patients at the admission time. Abnormal chest CT in COVID-19 pneumonia was found to show one of the following findings: ground-glass opacities (GGO), bilateral involvement, peripheral and diffuse distribution., Result: Fever (79.2%) and dry cough (75.5%) were the most common clinical symptoms. Severe COVID-19 patients showed lymphocytosis, while the non-severe ones did not (P = 0.03). C-reactive protein (CRP) was shown to be significantly lower in patients aged less than two years than those aged 3-12 and 13-17 years (P = 0.01). It was shown also that O 2 saturation experienced a significant increase as did patients' age (P = 0.01). Severe patients had significantly higher CT abnormalities than non-severe patients (48.0% compared to 17.9%, respectively) (P = 0.02)., Conclusion: Lymphocytosis and abnormal CT findings are among the factors most associated with COVID-19 severity. It was, moreover, showed that the severity of COVID-19, O 2 saturation, and respiratory distress were improved as the age of confirmed COVID-19 pediatric patients increased.

The development of medical assisting tools based on artificial intelligence advances is essential in the global fight against COVID-19 outbreak and the future of medical systems. In this study, we introduce ai-corona, a radiologist-assistant deep learning framework for COVID-19 infection diagnosis using chest CT scans. Our framework incorporates an EfficientNetB3-based feature extractor. We employed three datasets; the CC-CCII set, the MasihDaneshvari Hospital (MDH) cohort, and the MosMedData cohort. Overall, these datasets constitute 7184 scans from 5693 subjects and include the COVID-19, non-COVID abnormal (NCA), common pneumonia (CP), non-pneumonia, and Normal classes. We evaluate ai-corona on test sets from the CC-CCII set, MDH cohort, and the entirety of the MosMedData cohort, for which it gained AUC scores of 0.997, 0.989, and 0.954, respectively. Our results indicates ai-corona outperforms all the alternative models. Lastly, our framework's diagnosis capabilities were evaluated as assistant to several experts. Accordingly, We observed an increase in both speed and accuracy of expert diagnosis when incorporating ai-corona's assistance., Competing Interests: The authors have declared that no competing interests exist.

COVID-19 is the shocking viral pandemics of this year which affected the health, economy, communications, and all aspects of social activities all over the world. Early diagnosis of this viral disease is very important since it can prevent lots of mortalities and care consumption. The functional similarities between COVID-19 and COVID-2 in inducing acute respiratory syndrome lightened our mind to find a diagnostic mechanism based on early traces of mitochondrial ROS overproduction as lung cells' dysfunctions induced by the virus. We designed a simple electrochemical sensor to selectively detect the intensity of ROS in the sputum sample (with a volume of less than 500 μl). Comparing the results of the sensor with clinical diagnostics of more than 140 normal and involved cases resulted in a response calibration with accuracy and sensitivity both 97%. Testing the sensor in more than 4 hospitals shed promising lights in ROS based real-time tracing of COVID-19 from the sputum sample., (Copyright © 2020 Elsevier B.V. All rights reserved.)