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Background Intracranial hemorrhage is a known complication after endovascular treatment in patients with acute ischemic stroke due to large vessel occlusion, but the association between radiologic hemorrhage severity and outcome is controversial. Purpose To investigate the prevalence and impact on outcome of intracranial hemorrhage and hemorrhage severity after endovascular stroke treatment. Materials and Methods The Efficacy and Safety of Nerinetide for the Treatment of Acute Ischemic Stroke (ESCAPE-NA1) trial enrolled participants with acute large vessel occlusion stroke who underwent endovascular treatment from March 1, 2017, to August 12, 2019. Evidence of any intracranial hemorrhage, hemorrhage multiplicity, and radiologic severity, according to the Heidelberg classification (hemorrhagic infarction type 1 [HI1], hemorrhagic infarction type 2 [HI2], parenchymal hematoma type 1 [PH1], and parenchymal hematoma type 2 [PH2]) was assessed at CT or MRI 24 hours after endovascular treatment. Good functional outcome, defined as a modified Rankin score of 0-2 at 90 days, was compared between participants with intracranial hemorrhage and those without intracranial hemorrhage at follow-up imaging and between hemorrhage subtypes. Poisson regression was performed to obtain adjusted effect size estimates for the presence of any intracranial hemorrhage and hemorrhage subtypes at good functional outcome. Results Of 1097 evaluated participants (mean age, 69 years ± 14 [standard deviation]; 551 men), any degree of intracranial hemorrhage was observed in 372 (34%). Good outcomes were less often achieved among participants with hemorrhage than among those without hemorrhage at follow-up imaging (164 of 372 participants [44%] vs 500 of 720 [69%], respectively; P < .01). After adjusting for baseline variables and infarct volume, intracranial hemorrhage was not associated with decreased chances of good outcome (adjusted risk ratio [RR] = 0.91 [95% CI: 0.82, 1.02], P = .10), but there was a graded relationship of radiologic hemorrhage severity and outcomes, whereby PH1 (RR = 0.77 [95% CI: 0.61, 0.97], P = .03) and PH2 (RR = 0.41 [95% CI: 0.21, 0.81], P = .01) were associated with decreased chances of good outcome. Conclusion Any degree of intracranial hemorrhage after endovascular treatment was seen in one-third of participants. A graded association existed between radiologic hemorrhage severity and outcome. Hemorrhagic infarction was not associated with outcome, whereas parenchymal hematoma was strongly associated with poor outcome, independent of infarct volume. © RSNA, 2021 Clinical trial registration no. NCT01778335 Online supplemental material is available for this article.

Background The effect of infarct pattern on functional outcome in acute ischemic stroke is incompletely understood. Purpose To investigate the association of qualitative and quantitative infarct variables at 24-hour follow-up noncontrast CT and diffusion-weighted MRI with 90-day clinical outcome. Materials and Methods The Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke, or ESCAPE-NA1, randomized controlled trial enrolled patients with large-vessel-occlusion stroke undergoing mechanical thrombectomy from March 1, 2017, to August 12, 2019. In this post hoc analysis of the trial, qualitative infarct variables (predominantly gray [vs gray and white] matter involvement, corticospinal tract involvement, infarct structure [scattered vs territorial]) and total infarct volume were assessed at 24-hour follow-up noncontrast CT or diffusion-weighted MRI. White and gray matter infarct volumes were assessed in patients by using follow-up diffusion-weighted MRI. Infarct variables were compared between patients with and those without good outcome, defined as a modified Rankin Scale score of 0-2 at 90 days. The association of infarct variables with good outcome was determined with use of multivariable logistic regression. Separate regression models were used to report effect size estimates with adjustment for total infarct volume. Results Qualitative infarct variables were assessed in 1026 patients (mean age ± standard deviation, 69 years ± 13; 522 men) and quantitative infarct variables were assessed in a subgroup of 358 of 1026 patients (mean age, 67 years ± 13; 190 women). Patients with gray and white matter involvement (odds ratio [OR] after multivariable adjustment, 0.19; 95% CI: 0.14, 0.25; P < .001), corticospinal tract involvement (OR after multivariable adjustment, 0.06; 95% CI: 0.04, 0.10; P < .001), and territorial infarcts (OR after multivariable adjustment, 0.22; 95% CI: 0.14, 0.32; P < .001) were less likely to achieve good outcome, independent of total infarct volume. Conclusion Infarct confinement to the gray matter, corticospinal tract sparing, and scattered infarct structure at 24-hour noncontrast CT and diffusion-weighted MRI were highly predictive of good 90-day clinical outcome, independent of total infarct volume. Clinical trial registration no. NCT02930018 © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Mossa-Basha in this issue.

Background Recent evidence suggests that presence of an intracranial arterial thrombus with a hyperdense artery sign (HAS) at noncontrast CT (NCCT) is associated with better response to intravenous alteplase. Patients with HAS may benefit more from combined intravenous alteplase and endovascular treatment (EVT). Purpose To investigate whether HAS at NCCT modifies the treatment effect of adding intravenous alteplase on clinical outcome in patients with acute large-vessel occlusion undergoing EVT. Materials and Methods This study is a secondary analysis of a prospective randomized trial (Direct Intra-arterial thrombectomy in order to Revascularize AIS patients with large-vessel occlusion Efficiently in Chinese Tertiary hospitals: A Multicenter randomized clinical Trial [DIRECT-MT]), which compared adding alteplase to EVT versus EVT alone in participants with acute large-vessel occlusion between February 2018 and July 2019. Participants with catheter angiograms and adequate NCCT for HAS evaluation were included. HAS was determined visually by two independent investigators at baseline NCCT. Treatment effect of intravenous alteplase administration according to presence of HAS on the primary clinical outcome (modified Rankin Scale [mRS] score at 90 days) and secondary and safety outcomes were assessed using adjusted multivariable regression models. Results Among 633 included participants (356 men [56%]; median age, 69 years), HAS was observed in 283 participants (45%): 142 of 313 participants (45%) in the EVT-only group and 141 of 320 participants (44%) in the group with added intravenous alteplase. Treatment-by-HAS interaction was observed for the primary outcome (

To describe the use of an imaging selection tool, multiphase computed tomographic (CT) angiography, in patients with acute ischemic stroke (AIS) and to demonstrate its interrater reliability and ability to help determine clinical outcome.The local ethics board approved this study. Data are from the pilot phase of PRoveIT, a prospective observational study analyzing utility of multimodal imaging in the triage of patients with AIS. Patients underwent baseline unenhanced CT, single-phase CT angiography of the head and neck, multiphase CT angiography, and perfusion CT. Multiphase CT angiography generates time-resolved images of pial arteries. Pial arterial filling was scored on a six-point ordinal scale, and interrater reliability was tested. Clinical outcomes included a 50% or greater decrease in National Institutes of Health Stroke Scale (NIHSS) over 24 hours and 90-day modified Rankin Scale (mRS) score of 0-2. The ability to predict clinical outcomes was compared between single-phase CT angiography, multiphase CT angiography, and perfusion CT by using receiver operating curve analysis, Akaike information criterion (AIC), and Bayesian information criterion (BIC).A total of 147 patients were included. Interrater reliability for multiphase CT angiography is excellent (n = 30, κ = 0.81, P.001). At receiver operating characteristic curve analysis, the ability to predict clinical outcome is modest (C statistic = 0.56, 95% confidence interval [CI]: 0.52, 0.63 for ≥50% decrease in NIHSS over 24 hours; C statistic = 0.6, 95% CI: 0.53, 0.68 for 90-day mRS score of 0-2) but better than that of models using single-phase CT angiography and perfusion CT (P.05 overall). With AIC and BIC, models that use multiphase CT angiography are better than models that use single-phase CT angiography and perfusion CT for a decrease of 50% or more in NIHSS over 24 hours (AIC = 166, BIC = 171.7; values were lowest for multiphase CT angiography) and a 90-day mRS score of 0-2 (AIC = 132.1, BIC = 137.4; values were lowest for multiphase CT angiography).Multiphase CT angiography is a reliable tool for imaging selection in patients with AIS.

Angiography; Intracerebral hemorrhage; Prediction Angiografía; Hemorragia intracerebral; Predicción Angiografia; Hemorràgia intracerebral; Predicció Purpose To determine the prevalence of the spot sign and the accuracy of using the spot sign to predict intracerebral hemorrhage (ICH) expansion with standardized multiphase computed tomographic (CT) angiography. Materials and Methods This prospective observational cohort study included 123 consecutive patients with acute ICH (onset 33% or >6 mL) at 24 hours. Associations between the presence of the spot sign and substantial hematoma expansion were assessed by using the Pearson χ2 test. Results The later the phase of CT angiography, the higher the frequency of the spot sign. The spot sign was seen in 29.3% of patients in phase 1, 43.1% of patients in phase 2, and 46.3% of patients in phase 3 (P < .001). The presence of the spot sign in any phase was related to substantial hematoma expansion (P < .001 for all comparisons; Bonferroni adjusted α = .0125), with highest positive predictive value in phase 1 (64.0%) and highest negative predictive value in phase 2 (90.2%). The more arterial the pattern of spot sign presentation, the greater the frequency of substantial hematoma expansion (P = .013). Absolute hematoma growth analysis revealed a hierarchical pattern of spot sign presentations, as follows: A > B > C > D > no spot sign (P = .002). Conclusion Multiphase CT angiography can help differentiate among different forms of spot sign presentation and can help stratify patients at risk for hematoma expansion. The more arterial the spot sign pattern, the greater the frequency and extent of expansion.

International audience; Purpose To study the relationship between functional independence and time to reperfusion in the Solitaire with the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) trial in patients with disabling acute ischemic stroke who underwent endovascular therapy plus intravenous tissue plasminogen activator (tPA) administration versus tPA administration alone and to investigate variables that affect time spent during discrete steps. Materials and Methods Data were analyzed from the SWIFT PRIME trial, a global, multicenter, prospective study in which outcomes were compared in patients treated with intravenous tPA alone or in combination with the Solitaire device (Covidien, Irvine, Calif). Between December 2012 and November 2014, 196 patients were enrolled. The relation between time from (a) symptom onset to reperfusion and (b) imaging to reperfusion and clinical outcome was analyzed, along with patient and health system characteristics that affect discrete steps in patient workflow. Multivariable logistic regression was used to assess relationships between time and outcome; negative binomial regression was used to evaluate effects on workflow. The institutional review board at each site approved the trial. Patients provided written informed consent, or, at select sites, there was an exception from having to acquire explicit informed consent in emergency circumstances. Results In the stent retriever arm of the study, symptom onset to reperfusion time of 150 minutes led to 91% estimated probability of functional independence, which decreased by 10% over the next hour and by 20% with every subsequent hour of delay. Time from arrival at the emergency department to arterial access was 90 minutes (interquartile range, 69-120 minutes), and time to reperfusion was 129 minutes (interquartile range, 108-169 minutes). Patients who initially arrived at a referring facility had longer symptom onset to groin puncture times compared with patients who presented directly to the endovascular-capable center (275 vs 179.5 minutes, P < .001). Conclusion Fast reperfusion leads to improved functional outcome among patients with acute stroke treated with stent retrievers. Detailed attention to workflow with iterative feedback and aggressive time goals may have contributed to efficient workflow environments. (©) RSNA, 2016 Online supplemental material is available for this article.

Overall improvement in the interpretation of images obtained in the emergency department and involvement in decision making will reinforce the participation of radiology in the local stroke team and will increase the added value of radiology to stroke care.

Neuro-Sweet syndrome is a rare neurologic complication of Sweet disease, and awareness of the imaging findings will help one make an early diagnosis and initiate appropriate treatment.

To prospectively determine the parameters derived at admission computed tomographic (CT) perfusion imaging admission that best differentiate ischemic white matter that recovers from that which infarcts, with the latter retrospectively defined at a CT examination performed without contrast material (unenhanced CT) 5-7 days after the event.Ethics committee approval and informed consent were obtained. Thirty patients with stroke underwent unenhanced CT, CT angiography, and CT perfusion studies at admission. Additionally, CT angiography was performed 24 hours after the stroke, and an unenhanced CT study was performed 5-7 days after the stroke. Five patients were excluded; the remaining patients (10 men, 15 women; mean age, 70 years +/- 13 [standard deviation]) were separated into those with recanalization (n = 16) and those without recanalization (n = 9) at 24 hours. For patients with recanalization, the final infarct was outlined on unenhanced CT images obtained 5-7 days after the event and was superimposed on coregistered maps from the CT perfusion study performed at admission. Ischemic white matter tissue (cerebral blood flow [CBF]14 mL/min/100 g) was identified at the admission CT perfusion study, and the penumbra was defined as the difference between the ischemic region and the infarct region.Infarct regions showed a matched decrease in CBF and cerebral blood volume (CBV) at admission, whereas penumbra regions showed a significant (P.05) decrease in CBF but no change in CBV (P.05) from contralateral values. A threshold CBF . CBV value of 8.14 was the most sensitive (95%, 20 of 21 regions) and specific (94%, 32 of 34 regions) parameter for differentiating between regions of ischemic white matter that recovered and regions of ischemic white matter that infarcted.The product of CBF and CBV derived from CT perfusion data provided the best differentiation between regions of ischemic white matter that infarcted and regions of ischemic white matter that recovered 5-7 days after a stroke.

It is clear that imaging will play a major role in further advancing the indications for endovascular treatment; furthermore, imaging can make stroke systems of care more efficient by helping physicians make decisions regarding transfer of patients with an acute ischemic stroke from primary stroke centers to centers capable of performing endovascular procedures.

To use baseline computed tomographic (CT) angiography to analyze imaging and clinical end points in an Interventional Management of Stroke III cohort to identify patients who would benefit from endovascular stroke therapy.The primary clinical end point was 90-day dichotomized modified Rankin Scale (mRS) score. Secondary end points were 90-day mRS score distribution and 24-hour recanalization. Prespecified subgroup was baseline proximal occlusions (internal carotid, M1, or basilar arteries). Exploratory analyses were subsets with any occlusion and specific sites of occlusion (two-sided α = .01).Of 656 subjects, 306 (47%) underwent baseline CT angiography or magnetic resonance angiography. Of 306, 282 (92%) had arterial occlusions. At baseline CT angiography, proximal occlusions (n = 220) demonstrated no difference in primary outcome (41.3% [62 of 150] endovascular vs 38% [27 of 70] intravenous [IV] tissue-plasminogen activator [tPA]; relative risk, 1.07 [99% confidence interval: 0.67, 1.70]; P = .70); however, 24-hour recanalization rate was higher for endovascular treatment (n = 167; 84.3% [97 of 115] endovascular vs 56% [29 of 52] IV tPA; P.001). Exploratory subgroup analysis for any occlusion at baseline CT angiography did not demonstrate significant differences between endovascular and IV tPA arms for primary outcome (44.7% [85 of 190] vs 38% [35 of 92], P = .29), although ordinal shift analysis of full mRS distribution demonstrated a trend toward more favorable outcome (P = .011). Carotid T- or L-type occlusion (terminal internal carotid artery [ICA] with M1 middle cerebral artery and/or A1 anterior cerebral artery involvement) or tandem (extracranial or intracranial) ICA and M1 occlusion subgroup also showed a trend favoring endovascular treatment over IV tPA alone for primary outcome (26% [12 of 46] vs 4% [one of 23], P = .047).Significant differences were identified between treatment arms for 24-hour recanalization in proximal occlusions; carotid T- or L-type and tandem ICA and M1 occlusions showed greater recanalization and a trend toward better outcome with endovascular treatment. Vascular imaging should be mandated in future endovascular trials to identify such occlusions. Online supplemental material is available for this article.

Perfusion imaging in acute ischemic stroke is a promising technique; we have a responsibility to design research studies that increase the understanding of the role of this tool in acute ischemic stroke treatment by enrolling more patients in research studies rather than jumping the gun and using the tool as a clinical aid.

A 66-year-old woman presented with numbness in the anteromedial aspect of her right thigh and difficulty with right leg movement for the past year. She did not have back pain or lower limb pain, nor did she have a history of relevant trauma. At the time of presentation, her arterial hypertension and osteoarthritis were being treated. She had a history of localized laryngeal amyloidosis, which was found at 30 years of age and treated with laser excision and tracheostomy. Physical examination revealed mild spasticity and impaired pain and temperature sensation in the right leg. She underwent magnetic resonance (MR) imaging, myelography, and postmyelography computed tomography (CT) of the thoracic spine.

A 31-year-old otherwise healthy woman presented with frequent unilateral headaches that lasted from a few hours to a few days and occurred as often as three or four times per week. Symptoms started at the time of her first pregnancy 3 years earlier and persisted without any progression in intensity or frequency. Physical examination findings were normal, and there were no neurologic deficits. Magnetic resonance (MR) images of the brain and unenhanced computed tomographic (CT) scans of the head were obtained.

To compare the clinical results of percutaneous sclerotherapy of venous vascular malformations (VVMs) with the authors' proposed magnetic resonance (MR) imaging classification.MR findings and clinical results of percutaneous alcohol sclerotherapy in 59 pediatric patients with VVMs were retrospectively reviewed. Before treatment, lesions were graded with MR imaging on the basis of margins and size, respectively: grade 1, well defined, less than or equal to 5 cm; grade 2A, well defined, greater than 5 cm; grade 2B, ill defined, less than or equal to 5 cm; and grade 3, ill defined, greater than 5 cm. Regression models were used to test trends in therapy across the MR classification grades, including the repeat sclerotherapies, volumes of ethanol and metrizamide administered for each lesion, and number of access sites. Clinical response to sclerotherapy, which was evaluated with consensus by a multidisciplinary team, was graded as poor, good, or excellent. Association between MR imaging grade and clinical assessment was tested with the Fisher exact test.There were 14 grade 1 lesions, nine grade 2A, 15 grade 2B, and 21 grade 3. Twenty-four patients had a poor response to sclerotherapy; 19, good; and 16, excellent. Ten of 14 (71%) grade 1 lesions had an excellent response; none, a poor response. Twelve of 21 (57%) grade 3 lesions had a poor response; none, an excellent result. Grade 2 lesions were relatively equally distributed among the three categories, with the exception of nine of 15 (60%) grade 2B lesions that had a poor response (P.001). There was a trend with increasing lesion grade for increasing numbers of sclerotherapy sessions, volumes of ethanol and metrizamide for each lesion, and numbers of access sites.There is a strong association between this proposed MR imaging classification and the results of percutaneous sclerotherapy.