Collateral Status Research Articles

Cerebral Infarct Growth: Pathophysiology, Pragmatic Assessment, and Clinical Implications.

Cerebral ischemic injury occurs when blood flow drops below a critical level, resulting in an energy failure. The progressive transformation of hypoperfused viable tissue, the ischemic penumbra, into infarction is a mechanism shared by patients with ischemic stroke if timely reperfusion is not achieved. Yet, the pace at which this transformation occurs, known as the infarct growth rate (IGR), exhibits remarkable heterogeneity among patients, brain regions, and over time, reflecting differences in compensatory collateral flow and ischemic tolerance. We review (1) the pathophysiology of infarct growth, (2) the advantages and pitfalls of different approaches of IGR measurement, (3) research gaps for future studies, and (4) the clinical implications of stroke progressor phenotypes. The estimated average IGR in patients with acute large vessel occlusion stroke is 5.4 mL/h although there is wide variability based on ischemic stroke subtype, occlusion location, presence of collaterals, and patient baseline status. The IGR can be calculated using various pragmatic strategies, mostly either quantifying the extension of the infarct at a particular time and dividing this measure by the time that elapsed from symptom onset to imaging assessment or by using collateral blood flow status as a radiological surrogate marker. The IGR defines a spectrum of clinical stroke phenotypes, often dichotomized into fast and slow progressors. An IGR ≥10 mL/h and the perfusion metric hypoperfusion intensity ratio ≥0.5 are commonly used definitions of fast progressors. A nuanced understanding of the IGR and stroke progressor phenotypes could have clinical implications, including informing prognostication, acute decision-making in peripheral-to-comprehensive transfer patients eligible for thrombectomy, and selection for adjuvant neuroprotective agents.

Recruitment of pial collaterals and carotid occlusive disease in large-vessel occlusion ischemic stroke.

Despite the fundamental role of pial collateral vessels in limiting the progression of ischemic tissue injury in acute stroke with large vessel occlusion (LVO), in addition to the fact that collateral vessel abundance varies naturally from person to person for genetic reasons, there is limited knowledge regarding potential factors contributing to inherent interindividual variation in pial collateral supply. As it has been repeatedly hypothesized that chronic carotid occlusive disease may favor pial collateralization, we aimed to investigate the association between quantitatively assessed leptomeningeal collateral supply and pre-existing carotid stenosis in patients with acute stroke due to LVO. Patients with proximal middle cerebral artery (MCA) occlusion with or without additional internal carotid artery (ICA) occlusion were included. The degree of collateral supply was quantitatively assessed based on signal variance in T2*-weighted time series in perfusion-weighted magnetic resonance imaging (PWI). Patients were stratified into two groups according to quantitative collateral status (poor and fair to good collateral supply). The prevalence of high-grade ICA stenosis (≥70%) was evaluated in both groups. A total of 98 patients (mean age 68.8 ± 16.1 years, n = 52 (53.1%) of whom were female individuals) with MCA and/or ICA occlusion were included in the final analysis. Out of these patients, 42 had poor collateral supply, while 56 exhibited fair to good collateral supply. Additionally, 18 patients showed ipsilateral high-grade ICA stenosis. After classifying the entire cohort based on their collateral status (poor vs. fair to good collateral supply), there was no significant difference in the proportion of the patients with ipsilateral high-grade ICA stenosis between the two groups. Specifically, 6 (14.3%) patients had poor collateral supply, and 12 (21.1%) patients had fair to good collateral supply. The odds ratio (OR) was 1.58, with a 95% confidence interval (CI) of 0.490-5.685 and the p-value of 0.440. In the entire patient cohort, signal variance-based collateral supply was significantly correlated with initial stroke severity (r = -0.360, p < 0.001), baseline ischemic core volume (r = -0.362, p < 0.001), and functional outcomes (score on the modified Rankin Scale) at discharge (r = -0.367, p < 0.01). In this study, we performed a quantitative and observer-independent MRI-based collateral assessment in patients with LVO. We found no significant difference in the prevalence of pre-existing high-grade ICA stenosis between patients with fair to good collateral supply and those with poor collateral supply. The potential influence of demographic and clinical variables on pial collateral supply in patients with acute stroke warrants further exploration in future studies. MRI-based collateral supply is significantly related to initial stroke severity, ischemic core volume, and early functional outcomes.

More severe cerebral small vessel disease associated with poor leptomeningeal collaterals in symptomatic intracranial atherosclerotic stenosis.

We investigated the association between cerebral small vessel disease (CSVD) and ipsilateral leptomeningeal collateral (LMC) status in patients with symptomatic intracranial atherosclerotic stenosis (sICAS). In 108 patients with 50-99% symptomatic intracranial internal carotid artery or M1 middle cerebral artery stenosis, 4 CSVD imaging markers (lacunes, cerebral microbleeds, enlarged perivascular spaces [EPVSs], and white matter hyperintensities [WMHs]) were assessed in MRI. Score of 0 or 1 was assigned to each marker and added up as a summary CSVD score (ranging 0-4) to reflect an overall CSVD burden. Ipsilateral LMC status was assessed by determining the laterality of distal vessels in anterior and posterior cerebral artery territories on CT angiography. Moderate-to-severe EPVSs (adjusted odds ratio [aOR] = 4.15; p = 0.031) and WMHs (aOR = 5.90; p = 0.010), and higher summary CSVD score (aOR = 1.66; p = 0.030) were independently associated with poor LMCs. There was significant interaction between stenosis percentage in sICAS and summary CSVD score on poor LMCs (p = 0.022 for interaction), when higher CSVD score was significantly associated with poor LMCs in patients with severe sICAS (aOR = 2.84; p = 0.011) but not in those with moderate sICAS. The findings indicated possibly adverse effect of CSVD on the recruitment or development of LMCs in sICAS patients, especially in patients with severe sICAS.

Factors Influencing the Association of 24-hour National Institutes of Health Stroke Scale & 90-day Modified Rankin Score.

The modified Rankin Scale (mRS) at 90days is the primary outcome in most acute stroke studies, but the long follow-up period has disadvantages. The National Institutes of Health Stroke Scale (NIHSS) at 24 h shows astrong, but imperfect, association with 90-day mRS. This study examines the association between 24-hour NIHSS and 90-day mRS and reasons for discrepancies. Data are from the ESCAPE-NA1 thrombectomy patients. To address the non-normality distribution of the NIHSS and include deceased patients, a7-point ordinal score was generated by grouping 24-hour NIHSS. The association of ordinal 24-hour NIHSS and 90-day mRS was assessed with adjusted ordinal logistic regression. Differences in baseline and treatment/post-treatment variables were compared between patients with discordant and concordant outcomes. One-thousand-seventy-six patients with available 24-hour NIHSS and 90-day mRS were included (median 24-hour NIHSS6[IQR: 2-14], median 90-day mRS2[IQR: 1-4]). Ordinal 24-hour NIHSS was associated with 90-day mRS (adjusted cOR 2.53 [95%CI 2.33-2.74]). Forty-eight (4.5%) patients had discordant outcomes. Of those, 19(1.8%) had 24-hour NIHSS < 6 and 90-day mRS5-6; all of which had ≥ 1 severe adverse event, most commonly pneumonia (6[31.6%]) or recurrent stroke (4[21.1%]). Twenty-nine patients (2.7%) had 24-hour NIHSS > 14 and 90-day mRS 0-2. In these patients, baseline NIHSS and ASPECTS was lower, and collateral status was worse. An ordinal NIHSS score that includes death at 24 h shows astrong association with 90-day mRS, suggesting that it could be used as an alternative outcome. Patients with discrepant outcomes differed from the remaining patients regarding their baseline NIHSS, ASPECTS, collateral status, and post-stroke complications.

High Hypoperfusion Intensity Ratio Is Independently Associated with Very Poor Outcomes in Large Ischemic Core Stroke.

Recent advances have highlighted the efficacy of endovascular thrombectomy (EVT) in patients with large ischemic core stroke, yet asignificant portion still experience very poor outcomes, defined as a90-day modified Rankin Score (mRS) of 5-6. This study aims to investigate the hypoperfusion intensity ratio (HIR) as aprognostic imaging parameter for these outcomes. In amulticenter retrospective cohort study, data from consecutive patients undergoing EVT for acute ischemic stroke with large vessel occlusion (AIS-LVO) at two comprehensive stroke centers were analyzed. The study included patients with an Alberta Stroke Program Early CT Score (ASPECTS) of5 or less and utilized pretreatment perfusion imaging to calculate HIR. The primary outcome was very poor outcomes (90days mRS 5-6). Among 102 patients included, 59 (57.8%) had very poor outcome (90days mRS 5-6). Multivariable logistic regression analysis adjusting for multiple covariates including admission National Institutes of Health Stroke Scale (NIHSS) and EVT revealed that higher admission NIHSS (adjusted odds ratio [aOR] 1.224, 95% CI 1.089-1.374, p = 0.001) and HIR (aOR per 0.1 incremental change, 1.34, 95% CI 1.02-1.82, P = 0.042) were independently associated with very poor outcomes. This study demonstrates that admission NIHSS and HIR are independently associated with very poor outcome (90days mRS 5-6) in patients with large ischemic core strokes. These findings highlight the importance of collateral status and perfusion imaging in predicting outcomes in this patient population, suggesting apotential role for HIR in the triage and management of large core stroke patients.

Evolving Role of Coronary Collaterals in STEMI Outcomes: A Comparative Analysis of Pandemic and Post-Pandemic Phases.

Acute ST-elevation myocardial infarction (STEMI) is a critical condition where coronary collaterals can mitigate myocardial damage. The Coronavirus Disease 2019 (COVID-19) pandemic introduced unique challenges in STEMI management, potentially affecting outcomes. This study evaluates the efficacy of coronary collaterals during the pandemic compared to the post-pandemic period. A review of 1465 STEMI patients treated at a high-volume tertiary care center from April 2020 to December 2022 was conducted. Collaterals were assessed using the Rentrop classification. In-hospital mortality and 1-year major adverse cardiac events (MACE) were analyzed based on collateral status and timeframes. During the pandemic, there was a higher incidence of robust collaterals (28.2% vs 23.2%, P = .04), but they were less protective, with similar in-hospital mortality (14.4% vs 8.1%, P = .07) and 1-year MACE rates (21.9% vs 30.4%, P = .09) across groups. Post-pandemic, robust collaterals showed significant protective effects with reduced in-hospital mortality (3.6% vs 7.4%, P = .04) and 1-year MACE rates (17.1% vs 24.9%, P = .03). These findings highlight a dynamic role of collaterals in STEMI management, with the pandemic impairing their functionality. This underscores the need for adaptive STEMI care strategies, especially during global health crises.

Thrombectomy Outcomes for Anterior Circulation Stroke in the 6-24 h Time Window Solely Based On NCCT and CTA: ASingle Center Study.

Since perfusion imaging may be unavailable in smaller hospitals, alternative imaging selection methods for acute ischemic stroke can improve outcomes and optimize resources. This study assessed the safety and effectiveness of using imaging criteria other than DEFUSE3 and DAWN for thrombectomy beyond 6 h from symptom onset in patients stroke in the anterior circulation. This is aretrospective, single-center analysis of consecutive patients with large vessel occlusion in the anterior circulation undergoing thrombectomy. Patients were categorized into two groups based on the collateral status (moderate collaterals and good collaterals). Among 198 patients, 106 (54%) met the inclusion criteria and were analyzed. Good collateral status was observed in 78 (74%) patients. Patients with good collaterals showed significantly lower mRS scores at discharge and at 90days compared to their counterparts with moderate collateral status (4 (3-4) vs.4 (4-5); p = 0.001 and 2 (0-4) vs.6 (3-6); p < 0.001, respectively). More patients with good collateral status achieved favorable outcomes at 90days compared to those with moderate status (48 (61.5%) vs.5 (17.9%); p < 0.001). Good collaterals were an independent predictor of good clinical outcomes at 90days (OR = 1.31, 95% CI: 1.13-1.53, p < 0.001). Selecting patients for endovascular treatment of acute ischemic stroke using non-contrast CT and CT angiography shows 90-day outcomes similar to the DAWN and DEFUSE-3trials. Using collateral status on CT angiography can predict favorable outcomes after mechanical thrombectomy in resource-limited settings where perfusion imaging is unavailable.

The Los Angeles motor scale (LAMS) and ASPECTS score are independently associated with DSA ASITN collateral score.

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). 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. 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. 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.

The effect of Clot Burden Score on clinical outcomes in acute ischemic stroke patients with atrial fibrillation treated with endovascular thrombectomy.

The Clot Burden Score (CBS) is used to assess thrombus length. The influence of CBS on functional outcome was barely analyzed in patients with acute ischemic stroke (AIS) with atrial fibrillation (AF). To assess the association between CBS and clinical outcomes in large vessel occlusion (LVO)-related patients with AF who have undergone endovascular thrombectomy (EVT). A total of 160 patients with AF were enrolled between January 2021 and April 2023. The CTA-CBS score was used to quantify the thrombus burden. The primary outcome was the modified Rankin scale (mRS) score at 90 days. A multivariate logistic regression model was used to identify prognostic predictors and determine the correlation between CTA-CBS and clinical outcomes. In the multivariable logistic regression, younger age, smaller clots, and better collateral status were the favorable prognosis factors. The odds ratios (OR) were 0.956 (95% confidence interval [CI] = 0.924-0.988, P = 0.008), 1.29 (95% CI = 1.110-1.499, P < 0.001), and 1.706 (95% CI = 1.065-2.731, P = 0.026), respectively. A smaller clot correlated with better outcomes OR of 1.29 (95% CI = 1.110-1.499, P < 0.001) for the entire cohort, 1.395 (95% CI = 1.142-1.702, P < 0.001) for bridging the EVT subgroup, and 1.171 (95% CI = 0.866-1.582, P = 0.305) for direct EVT subgroup. In LVO-related AIS patients with AF treated with EVT, lower CBS is associated with poorer functional outcomes. Notably, CBS acts as a prognostic imaging biomarker in the direct EVT subgroup and does not in bridging the EVT subgroup.

Insights into multilevel tissue-level collateral status using ColorViz maps from dual data sources in acute ischemic cerebrovascular diseases: A STARD-compliant retrospective study.

This study aims to explore the utility of ColorViz mapping from dual data sources for assessing arterial collateral circulation and predicting cerebral tissue-level collateral (TLC) in patients with acute ischemic cerebrovascular diseases. A retrospective study was conducted at a single center on a cohort of 79 patients diagnosed with acute ischemic cerebrovascular diseases between November 2021 and April 2022, who had undergone both multi-phase CT angiography (mCTA) and computed tomography perfusion (CTP). The quality of images and arterial collateral status depicted on ColorViz maps from dual data-sets (mCTA and CTP) were assessed using a "5-point scale" and a "10-point scale," respectively. The status of TLC was evaluated by analyzing multilevel hypoperfusion volume and the hypoperfusion intensity ratio (HIR). The Spearman correlation coefficient was employed to examine the association between arterial collateral status derived from dual data sources and TLC. Receiver operating characteristic curve analysis was used to determine the diagnostic efficacy in detecting large vessel occlusive acute ischemic stroke (LVO-AIS). The ColorViz maps derived from dual data sources facilitated comparable image quality, with over 95% of cases meeting diagnostic criteria, for the evaluation of arterial level collateral circulation. Patients with robust arterial collateral circulation, as determined by dual data sources, were more likely to exhibit favorable TLC status, as evidenced by reductions in hypoperfusion volume (Tmax > 4 seconds, Tmax > 6 seconds, Tmax > 8 seconds, and Tmax > 10 seconds, P < .05) and HIR (Tmax > 6 seconds/4 seconds, Tmax > 8 seconds/4 seconds, Tmax > 10 seconds/4 seconds, and Tmax > 8 seconds/6 seconds, P < .05). The sensitivity and specificity in detecting LVO-AIS was 60.00% and 97.73% for mCTA source maps, while 74.29% and 72.73% for CTP source maps (P > .05 based on De-Long test). In conclusion, this study indicates that ColorViz maps derived from both data sources are equally important in evaluating arterial collateral circulation and enhancing diagnostic efficiency in patients with LVO-AIS, as well as offering insights into the TLC status based on hypoperfusion volume and HIR.

Association between heart failure and cerebral collateral flow in large vessel occlusive ischemic stroke

BackgroundCerebral collateral circulation plays a crucial role in determining the extent of brain ischemia in large vessel occlusive (LVO) stroke. Heart failure (HF) is known to cause cerebral hypoperfusion, yet the relationship between HF and robustness of collateral flow has not been well described. MethodsConsecutive patients with middle cerebral and/or internal carotid LVO who underwent endovascular thrombectomy (EVT) between 2012 and 2020 were included. Single-phase head CTA prior to EVT was used to assess collateral status (poor <50 % filling; good ≥50 %). Classification of HF by left ventricular ejection fraction (LVEF) on echocardiogram was used where HF with reduced ejection fraction (HFrEF) had LVEF ≤40 %, HF with preserved EF (HFpEF) had LVEF ≥50 % with evidence of structural heart disease, and no HF had LVEF≥50 % without structural heart disease. Multivariable logistic regression analyses were performed to evaluate the association between HF and poor collaterals. ResultsWe identified 235 patients, mean age was 69 ± 15 years; initial NIHSS was 18 ± 7. Of these, 107 (45.5 %) had HF and 105 (44.7 %) had poor collaterals. Those with HF were likely to have poor collaterals compared to those without HF (56.1 % vs 35.2 %, P = 0.001). There was a dose-dependent relationship between EF and poor collaterals: adjusted odds of poor collaterals were 1.63 and 2.45 in HFpEF and HFrEF, compared to those without HF (trend P = .018). ConclusionPatients with HFrEF are more likely to have poor cerebral collaterals. Further study is needed to explore the pathomechanisms. Optimization of HF may improve cerebral collaterals and enhance EVT outcomes.

Ischemic core volumes and collateral status have diurnal fluctuations – A retrospective cohort study of 18,137 patients

IntroductionRecent observations suggest that circadian rhythms are implicated in the timing of stroke onset and the speed of infarct progression. We aimed to replicate these observations in a large, multi-center, automated imaging database. MethodsThe RAPID Insights database was queried from 02/01/2016 to 01/31/2022 for patients with perfusion imaging and automated detection of an ischemic stroke due to a presumed large vessel occlusion. Exclusion criteria included: patient age ≤25, mismatch volume of <0 cc, and failure to register a positive value on either relative cerebral blood flow (rCBF) reduction of 38% less than normal or total mismatch volume. Imaging time was subdivided into three epochs: Night: 23:00h-06:59h and Day: 07:00h-14:59h, and Evening: 15:00h-22:59h. Perfusion parameters were defined using standard conventions for core volume, penumbra, and collateral circulation (measured via the Hypoperfusion Intensity Ratio, HIR). Statistical significance was tested using a sinusoidal regression analysis. ResultsA total of 18,137 cases were analyzed. The peak incidence of stroke imaging of patients with LVOs occurred around noon. A sinusoidal pattern was present, with larger ischemic core volumes and higher HIR during the night compared to the day: peak ischemic core volume of 23.4 cc occurred with imaging performed at 3:56 AM (p<0.001) and peak HIR of 0.35 at 3:40 AM (p<0.001). ConclusionWe found that ischemic core volumes were larger and collateral status worse at nighttime compared to daytime in this large national database. These findings support prior data suggesting that poor collateral recruitment with subsequent larger ischemic stroke volumes may occur at night.

Association between ischaemic stroke aetiology and leptomeningeal collateral status: a retrospective cohort study.

There is limited understanding of the pathomechanistic relationship between leptomeningeal collateral formation and ischaemic stroke aetiology. We aimed to assess the association of leptomeningeal collateral status and ischaemic stroke aetiology, using the widely recognised "Trial of Org 10172 in Acute Stroke Treatment" (TOAST) classification categorising strokes into five distinct aetiologies. Retrospective study of consecutively admitted adult ischaemic stroke patients at a Swiss stroke centre. Leptomeningeal collateral status was assessed on admission with single-phase CT-angiographies using a validated 4-point score. Patients were categorised into large-artery atherosclerosis (LAA), cardioembolic (CE), small-vessel disease (SVD) and cryptogenic (CG) according to the TOAST classification. We performed ordinal and binary (poor [collaterals filling ≤50% of the occluded territory] vs good [collaterals filling >50% of the occluded territory] collateralisation) logistic regression to evaluate the impact of TOAST aetiology on collateral status. Among 191 patients, LAA patients had better collateral status compared to non-LAA aetiology (LAA: 2 vs CE: 2 vs SVD: 3 vs CG: 2, pLAAvsnon-LAA= 0.04). In weighted multivariate logistic regression, LAA and SVD independently predicted better collateral status (binary models [adjusted odds ratio; aOR]: LAA: 3.72 [1.21-11.44] and SVD: 4.19 [1.21-14.52]; ordinal models [adjusted common odds ratio; acOR]: LAA: 2.26 [95% CI: 1.23-4.15] and SVD: 1.94 [1.03-3.66]), while CE predicted worse collateral status (binary models [aOR]: CE: 0.17 [0.07-0.41]; ordinal models [acOR]: CE: 0.24 [0.11-0.51]). The aetiology of ischaemic stroke is associated with leptomeningeal collateral status on single-phase CT-angiography, with LAA and SVD predicting better and CE predicting worse collateral status.

3D mobile regression vision transformer for collateral imaging in acute ischemic stroke.

The accurate and timely assessment of the collateral perfusion status is crucial in the diagnosis and treatment of patients with acute ischemic stroke. Previous works have shown that collateral imaging, derived from CT angiography, MR perfusion, and MR angiography, aids in evaluating the collateral status. However, such methods are time-consuming and/or sub-optimal due to the nature of manual processing and heuristics. Recently, deep learning approaches have shown to be promising for generating collateral imaging. These, however, suffer from the computational complexity and cost. In this study, we propose a mobile, lightweight deep regression neural network for collateral imaging in acute ischemic stroke, leveraging dynamic susceptibility contrast MR perfusion (DSC-MRP). Built based upon lightweight convolution and Transformer architectures, the proposed model manages the balance between the model complexity and performance. We evaluated the performance of the proposed model in generating the five-phase collateral maps, including arterial, capillary, early venous, late venous, and delayed phases, using DSC-MRP from 952 patients. In comparison with various deep learning models, the proposed method was superior to the competitors with similar complexity and was comparable to the competitors of high complexity. The results suggest that the proposed model is able to facilitate rapid and precise assessment of the collateral status of patients with acute ischemic stroke, leading to improved patient care and outcome.

Collaterals at angiography guide clinical outcomes after endovascular stroke therapy in HERMES

BackgroundRobust collateral circulation has been linked with better reperfusion and clinical outcomes. It remains unclear how individual assessments of collateral circulation may be translated into clinical practice.MethodsThe pooled Highly Effective...

Development and validation of a novel nomogram model predicting the unfavorable outcome based on NAR and collaterals status for patients with AIS

IntroductionStroke is a leading cause of disability and mortality globally. This study aimed to develop a prognostic nomogram based on neutrophil-to-albumin ratio (NAR) and collateral status in acute ischemic stroke (AIS) patients with anterior large vessel occlusion (LVO). Material & method590 AIS patients with LVO assessed for regional leptomeningeal collateral (rLMC) were retrospectively enrolled, and randomly divided into a training set (n = 414) and a testing set (n = 176). Unfavorable functional outcome was defined as a modified Rankin scale (mRS) score of 3 to 6 at 3 months. We assessed the accuracy and clinical utility of the nomogram using calibration plots, area under the curve (AUC), decision curve analysis (DCA), net reclassification index (NRI), and integrated discrimination improvement (IDI). ResultsBoth NAR and rLMC were independently associated with unfavorable outcome at 3 months (OR=8.96, p=0.0341; OR=0.89, p=0.0002, respectively). The developed nomogram (akaike information criterion (AIC)=398.77), which included NAR, rLMC and other factors, showed good performance (the AUC for the development and validation cohorts was 0.848 and 0.840 respectively) and improved the predictive value compared to a model without NAR and rLMC, according to an overall NRI of 3.27% (p=0.2401), overall IDI of 3.27% (p=0.2414), and a higher AUC (0.848 vs 0.831). ConclusionsNAR can serve as an independent predictor in AIS patients with anterior LVO, and the nomogram incorporating NAR and rLMC is reliable in predicting unfavorable outcome. Further studies with larger sample sizes are needed to validate and extend these findings.

Automated Classification of Collateral Circulation for Ischemic Stroke in Cone-Beam CT Images Using VGG11: A Deep Learning Approach

Background: Ischemic stroke poses significant challenges in diagnosis and treatment, necessitating efficient and accurate methods for assessing collateral circulation, a critical determinant of patient prognosis. Manual classification of collateral circulation in ischemic stroke using traditional imaging techniques is labor-intensive and prone to subjectivity. This study presented the automated classification of collateral circulation patterns in cone-beam CT (CBCT) images, utilizing the VGG11 architecture. Methods: The study utilized a dataset of CBCT images from ischemic stroke patients, accurately labeled with their respective collateral circulation status. To ensure uniformity and comparability, image normalization was executed during the preprocessing phase to standardize pixel values to a consistent scale or range. Then, the VGG11 model is trained using an augmented dataset and classifies collateral circulation patterns. Results: Performance evaluation of the proposed approach demonstrates promising results, with the model achieving an accuracy of 58.32%, a sensitivity of 75.50%, a specificity of 44.10%, a precision of 52.70%, and an F1 score of 62.10% in classifying collateral circulation patterns. Conclusions: This approach automates classification, potentially reducing diagnostic delays and improving patient outcomes. It also lays the groundwork for future research in using deep learning for better stroke diagnosis and management. This study is a significant advancement toward developing practical tools to assist doctors in making informed decisions for ischemic stroke patients.

Studi Kasus Gugatan dalam Rekonvensi tentang Pengangkatan Sita Jaminan pada Perkara Perlawanan dalam Putusan Nomor 452/Pdt.G/2023/PA JT

Reconvention can be filed in all cases except those which regulated in Article 132a HIR. HIR does not regulate material requirements regarding the substantial connection between convention and reconvention claim. Judicial practice tends to do so, as stated in Court Decision Number 452/Pdt.G/2023/PA JT. The Judges determined to reject the reconvention claim based on the consideration that the reconvention’s claim was closely related to the convention one, so the claim in the reconvention was rejected as the convention’s claim decided to be rejected. This research aims to determine the basis of the reconvention claim regarding the removal of collateral confiscation based on the Civil Procedure Law and determine the legal consequence of the court decision which rejected the reconvention claim regarding the collateral confiscation of dispute object. The results showed that the reconvention claim which requested the implementation of the confiscation of collateral is closely related to the convention one. The reconvention filed basically has fulfilled the regulations in Article 132a and Article 132b HIR. The decision to reject this claim was based on the fact that both claims, convention and reconvention, were closely related, this statement is supported by Jurisprudence Number 1527 K/Sip/1973. The legal consequence of rejecting both claims are that the dispute object is not under collateral confiscation status.

Pre-treatment radiological factors associated with poor functional outcome in an Asian cohort of large vessel occlusion acute ischemic stroke patients undergoing mechanical thrombectomy.

Endovascular thrombectomy (EVT) is the current standard of care for large vessel occlusion (LVO) acute ischemic stroke (AIS); however, up to two-thirds of EVT patients have poor functional outcomes despite successful reperfusion. Many radiological markers have been studied as predictive biomarkers for patient outcomes in AIS. This study seeks to determine which clinico-radiological factors are associated with outcomes of interest to aid selection of patients for EVT for LVO AIS. A retrospective study of patients who underwent EVT from 2016 to 2020 was performed. Data on various radiological variables, such as anatomical parameters, clot characteristics, collateral status, and infarct size, were collected alongside traditional demographic and clinical variables. Univariate and multivariate analysis was performed for the primary outcomes of functional independence at 3 months post-stroke (modified Rankin Scale 0-2) and secondary outcomes of in-hospital mortality and symptomatic intracranial hemorrhage. The study cohort comprised 325 consecutive patients with anterior circulation LVO AIS (54.5% male) with a median age of 68 years (interquartile range 57-76). The median NIHSS was 19. Age, hypertension, hyperlipidaemia, National Institutes of Health Stroke Scale (NIHSS), Alberta mCTA score, ASPECTS, clot length, thrombus HU and mTICI score and the angle between ICA and CCA were associated with functional outcomes at 3 months on univariate analysis. On multivariate analysis, age, Alberta mCTA collaterals and NIHSS were significantly associated with functional outcomes, while ASPECTS approached significance. Among the many proposed radiological markers for patients in the hyperacute setting undergoing EVT, the existing well-validated clinico-radiological measures remain strongly associated with functional status.

Quantitative evaluation of CTP derived time-density alterations versus CTP for collateral status prediction with stroke

Background and ObjectivesCollateral status is a pivotal determinant of clinical outcomes in acute ischemic stroke (AIS); however, its evaluation can be challenging. We investigated the predictive value of CT perfusion (CTP) derived time and density alterations versus CTP for collateral status prediction in AIS. MethodsConsecutive patients with anterior circulation occlusion within 24 h were retrospectively included. Time-density curves of the CTP specified ischemic core, penumbra, and the corresponding contralateral unaffected brain were obtained. The collateral status was dichotomised into robust (4–5 scores) and poor (0–3 scores) using multiphase collateral scoring, as described by Menon et al.. Receiver operating characteristic curves and multivariable regression analysis were performed to assess the predictive ability of CTP-designated tissue time and density alterations, CTP for robust collaterals, and favourable outcomes (mRS score of 0–2 at 90 days). ResultsOne-hundred patients (median age, 68 years; interquartile range, 57–80 years; 61 men) were included. A smaller ischemic core, shorter peak time delay, lower peak density decrease, lower cerebral blood volume ratio, and cerebral blood flow ratio in the CTP specified ischemic core were significantly associated with robust collaterals (PFDR ≤ 0.004). The peak time delay demonstrated the highest diagnostic value (AUC, 0.74; P < 0.001) with 66.7 % sensitivity and 73.7 % specificity. Furthermore, the peak time delay of less than 8.5 s was an independent predictor of robust collaterals and favourable clinical outcomes. ConclusionsRobust collateral status was significantly associated with the peak time delay in the ischemic core. It is a promising image marker for predicting collateral status and functional outcomes in AIS.