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Background and purposeDifferential Subsampling with Cartesian Ordering (DISCO), an ultrafast high-spatial-resolution head MRA, has been introduced. We aimed to determine the diagnostic performance of DISCO-MRA in grading residual aneurysm in comparison with TOF-MRA in patients with treated intracranial aneurysms.Materials and methodsPatients with endovascular treatment and having undergone DISCO-MRA, TOF-MRA, and DSA were included for review. The voxel size and acquisition time were 0.75 × 0.75 × 1 mm3/6 seconds for DISCO-MRA and 0.6 × 0.6 × 1 mm3/6 minutes for TOF-MRA. Residual aneurysms were determined using the Modified Raymond-Roy Classification on TOF-MRA and DISCO-MRA by 2 neuroradiologists independently and were compared against DSA as the reference standard. Statistical analysis was performed using the κ statistic and the χ2 test.ResultsSixty-eight treated intracranial aneurysms were included. The intermodality agreement was κ = 0.82 (95% CI, 0.67-0.97) between DISCO and DSA and 0.44 (95% CI, 0.28-0.61) between TOF and DSA. Modified Raymond-Roy Classification scores matched DSA scores in 60/68 cases (88%; χ2 = 144.4, P < .001 for DISCO and 46/68 cases (68%; χ2 = 65.0, P < .001) for TOF. The diagnostic accuracy for the detection of aneurysm remnants was higher for DISCO (0.96; 95% CI, 0.88-0.99) than for TOF (0.79; 95% CI, 0.68-0.88).ConclusionsIn patients with endovascularly treated intracranial aneurysms, DISCO-MRA provides superior diagnostic performance in comparison with TOF-MRA in delineating residual aneurysms in a fraction of the time.

Background and purposeThe Stroke Treatment Academic Industry Roundtable (STAIR) sponsored an imaging session and workshop during the Stroke Treatment Academic Industry Roundtable XI via webinar on October 1 to 2, 2020, to develop consensus recommendations, particularly regarding optimal imaging at primary stroke centers.MethodsThis forum brought together stroke neurologists, neuroradiologists, neuroimaging research scientists, members of the National Institute of Neurological Disorders and Stroke, industry representatives, and members of the US Food and Drug Administration to discuss imaging priorities in the light of developments in reperfusion therapies, particularly in an extended time window, and reinvigorated interest in brain cytoprotection trials.ResultsThe imaging session summarized and compared the imaging components of recent acute stroke trials and debated the optimal imaging strategy at primary stroke centers. The imaging workshop developed consensus recommendations for optimizing the acquisition, analysis, and interpretation of computed tomography and magnetic resonance acute stroke imaging, and also recommendations on imaging strategies for primary stroke centers.ConclusionsRecent positive acute stroke clinical trials have extended the treatment window for reperfusion therapies using imaging selection. Achieving rapid and high-quality stroke imaging is therefore critical at both primary and comprehensive stroke centers. Recommendations for enhancing stroke imaging research are provided.

Domain-specific endpoints are assessments that correspond to the output of individual neural systems and are useful for capturing treatment effects on specific behaviors. By contrast, global endpoints combine several attributes into a single score and are useful for capturing broad treatment effects in a summary way. While global endpoints have become the de facto mechanism required to define benefit in stroke trials, they also have important limitations, some of which might be addressed by simultaneously measuring domain-specific endpoints. Substantial opportunity remains to identify quantifiable patient benefit that would otherwise not be captured by global endpoints. Potential advantages of incorporating domain-specific endpoints in acute stroke trials are discussed, such as increased granularity of measurement, improved understanding of how therapies affect the brain between acute treatment and day 90, and optimized therapeutic translation. Potential disadvantages are also considered, including time and cost of administering domain-specific endpoints, as well as statistical implications. Domain-specific endpoints and global endpoints are not mutually exclusive, and both capture clinical benefits to patients. Incorporating a broader set of outcome assessments in stroke trials, including both global and domain-specific endpoints, is warranted.

BACKGROUND AND PURPOSE: Automated ASPECTS has the potential of reducing interobserver variability in the determination of early ischemic changes. We aimed to assess the performance of an automated ASPECTS software against the assessment of a neuroradiologist in a comparative analysis with concurrent CTP-based CBV ASPECTS. MATERIALS AND METHODS: Patients with anterior circulation stroke who had baseline NCCT and CTP and underwent successful mechanical thrombectomy were included. NCCT-ASPECTS was assessed by 2 neuroradiologists, and discrepancies were resolved by consensus. CTP-CBV ASPECTS was assessed by a different neuroradiologist. Automated ASPECTS was provided by Brainomix software. ASPECTS was dichotomized (ASPECTS ≥6 or 6 or ≤6 hours). RESULTS: A total of 58 patients were included. The interobserver agreement for NCCT ASPECTS was moderate (κ = 0.48) and marginally improved (κ = 0.64) for dichotomized data. Automated ASPECTS showed excellent agreement with consensus reads (κ = 0.84) and CTP-CBV ASPECTS (κ = 0.84). Intraclass correlation coefficients for ASPECTS across all 3 groups were 0.84 (95% CI, 0.76-0.90, raw scores) and 0.94 (95% CI, 0.91-0.96, dichotomized scores). Automated scores were comparable with consensus reads and CTP-CBV ASPECTS in patients when grouped on the basis of time from symptom onset (>6 or ≤6 hours). There was significant (P

BACKGROUND AND PURPOSE: The Bayesian probabilistic method has shown promising results to offset noise-related variability in perfusion analysis. Using CTP, we aimed to find optimal Bayesian-estimated thresholds based on multiparametric voxel-level models to estimate the ischemic core in patients with acute ischemic stroke. MATERIALS AND METHODS: Patients with anterior circulation acute ischemic stroke who had baseline CTP and achieved successful recanalization were included. In a subset of patients, multiparametric voxel-based models were constructed between Bayesian-processed CTP maps and follow-up MRIs to identify pretreatment CTP parameters that were predictive of infarction using robust logistic regression. Subsequently CTP-estimated ischemic core volumes from our Bayesian model were compared against routine clinical practice oscillation singular value decomposition-relative cerebral blood flow

Background We explored the clinical significance of the residual hematoma cavity 1 year after minimally invasive intracerebral hemorrhage (ICH) evacuation. Methods Patients presenting with spontaneous supratentorial ICH were evaluated for minimally invasive surgical evacuation. Inclusion criteria included age ≥18 years, preoperative hematoma volume (Hv) ≥15 mL, presenting National Institutes of Health Stroke Scale score ≥6, and premorbid modified Rankin Scale (mRS) score ≤3. Patients with longitudinal CT scans at least 3 months after evacuation were included in the study. Remnant cavity volumes (Cv) after evacuation were computed using semi-automatic volumetric segmentation software. Relative cavity volume (rCv) was defined as the ratio of the preoperative Hv to the remnant Cv. Results 108 patients with a total of 484 head CT scans were included in the study. The median postoperative Cv was 2.4 (IQR 0.0-11) mL, or just 6% (0-33%) of the preoperative Hv. The median residual Cv on the final head CT scan a median of 13 months (range 11-27 months) after surgery had increased to 9.4 (IQR 3.1-18) mL, or 25% (10-60%) of the preoperative Hv. rCv on the final head CT scan was negatively associated with measures of operative success including evacuation percentage, postoperative Hv ≤ 15 mL, and decreased time from ictus to evacuation. rCv on the final head CT scan was also associated with a worse 6-month functional outcome (β per mRS point 17.6%, P<0.0001; area under the receiver operating characteristic curve 0.91). Conclusion After minimally invasive ICH evacuation the hematoma lesion decompresses significantly, with a residual Cv just 6% of the original lesion, but then gradually increases in size over time. Early and high percentage ICH evacuation may reduce the remnant Cv over time which, in turn, is associated with improved functional outcomes. [ABSTRACT FROM AUTHOR]

Background Diffusion-weighted imaging (DWI) lesions have been linked to poor outcomes after intracerebral hemorrhage (ICH). We aimed to assess the impact of cerebral digital subtraction angiography (DSA) on the presence of DWI lesions in patients who underwent minimally invasive surgery (MIS) for ICH. Methods Retrospective chart review was performed on ICH patients treated with MIS in a single health system from 2015 to 2021. One hundred and seventy consecutive patients who underwent postoperative MRIS were reviewed. Univariate analyses were conducted to determine associations. Variables with p<0.05 were included in multivariate analyses. Results DWI lesions were present in 88 (52%) patients who underwent MIS for ICH. Of the 83 patients who underwent preoperative DSA, 56 (67%) patients demonstrated DWI lesions. In this DSA cohort, older age, severe leukoaraiosis, larger preoperative hematoma volume, and increased presenting National Institutes of Health Stroke Score (NIHSS) were independently associated with DWI lesion identification (p<0.05). In contrast, of 87 patients who did not undergo DSA, 32 (37%) patients demonstrated DWI lesions on MRI. In the non-DSA cohort, presenting systolic blood pressure, intraventricular hemorrhage, and NIHSS were independently associated with DWI lesions (p<0.05). Higher DWI lesion burden was independently associated with poor modified Rankin Scale (mRS) at 6 months on a univariate (p=0.02) and multivariate level (p=0.02). Conclusions In this cohort of ICH patients who underwent minimally invasive evacuation, preprocedural angiography was associated with the presence of DWI lesions on post-ICH evacuation MRI. Furthermore, the burden of DWI lesions portends a worse prognosis after ICH. [ABSTRACT FROM AUTHOR]

BACKGROUND AND PURPOSE:The safety and efficacy of the PulseRider for the treatment of wide-neck, bifurcation aneurysms at the basilar and carotid terminus locations were studied in a prospective trial, the Adjunctive Neurovascular Support of Wide-Neck Aneurysm Embolization and Reconstruction (ANSWER) trial, reporting on initial 6-month angiographic and clinical results. This report provides insight into the longer term durability and safety with 12-month data. MATERIALS AND METHODS:Aneurysms treated with the PulseRider among enrolled sites were prospectively studied. Updated 12-month data on clinical and imaging end points are included. RESULTS:Thirty-four patients were enrolled (29 women, 5 men) with a mean age of 60.9 years. The mean aneurysm height ranged from 2.4 to 15.9 mm with a mean neck size of 5.2 mm (range, 2.3-11.6 mm). At 1 year, there were no device migrations or symptomatic in-stent stenoses. Raymond-Roy I occlusion was achieved in 53% of cases at the time of treatment and progressed to 61% and 67% at 6 and 12 months, respectively. Adequate occlusion (Raymond-Roy I/II) progressed from 88% at 6 months to 90% at 12 months. No recanalizations were observed. There was 1 delayed ischemic event. Good outcome (mRS 0-2) was achieved in 90% of patients. CONCLUSIONS:The updated 1-year results from the ANSWER trial demonstrate aneurysm stability and an acceptable safety profile for aneurysms treated at the basilar apex and carotid terminus. Prospective data from a larger set of aneurysms treated at other locations are required to assess how treatment with PulseRider compares with alternatives for treating wide-neck bifurcation aneurysms.

BACKGROUND AND PURPOSE: Patients with acute stroke with robust collateral flow have better clinical outcomes and may benefit from endovascular treatment throughout an extended time window. Using a multiparametric approach, we aimed to identify MR perfusion parameters that can represent the extent of collaterals, approximating DSA. MATERIALS AND METHODS: Patients with anterior circulation proximal arterial occlusion who had baseline MR perfusion and DSA were evaluated. The volume of arterial tissue delay (ATD) at thresholds of 2-6 seconds (ATD2-6 seconds) and >6 seconds (ATD>6 seconds) in addition to corresponding values of normalized CBV and CBF was calculated using VOI analysis. The association of MR perfusion parameters and the status of collaterals on DSA were assessed by multivariate analyses. Receiver operating characteristic analysis was performed. RESULTS: Of 108 patients reviewed, 39 met our inclusion criteria. On DSA, 22/39 (56%) patients had good collaterals. Patients with good collaterals had significantly smaller baseline and final infarct volumes, smaller volumes of severe hypoperfusion (ATD>6 seconds), larger volumes of moderate hypoperfusion (ATD2-6 seconds), and higher relative CBF and relative CBV values than patients with insufficient collaterals. Combining the 2 parameters into a Perfusion Collateral Index (volume of ATD2-6 seconds × relative CBV2-6 seconds) yielded the highest accuracy for predicting collateral status: At a threshold of 61.7, this index identified 15/17 (88%) patients with insufficient collaterals and 22/22 (100%) patients with good collaterals, for an overall accuracy of 94.1%. CONCLUSIONS: The Perfusion Collateral Index can predict the baseline collateral status with 94% diagnostic accuracy compared with DSA.