title: Reperfusion of very low cerebral blood volume lesion predicts parenchymal hematoma after endovascular therapy.
abstract: OBJECTIVE
  Ischemic stroke patients with regional very low cerebral blood volume (VLCBV) on baseline imaging have increased risk of parenchymal hemorrhage (PH) after intravenous alteplase-induced reperfusion. We developed a method for automated detection of VLCBV and examined whether patients with reperfused-VLCBV are at increased risk of PH after endovascular reperfusion therapy.
  
  
  METHODS
  Receiver operating characteristic analysis was performed to optimize a relative CBV threshold associated with PH in patients from the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution 2 (DEFUSE 2) study. Regional reperfused-VLCBV was defined as regions with low relative CBV on baseline imaging that demonstrated normal perfusion (Tmax <6 s) on coregistered early follow-up magnetic resonance imaging. The association between VLCBV, regional reperfused-VLCBV and PH was assessed in univariate and multivariate analyses.
  
  
  RESULTS
  In 91 patients, the greatest area under the curve for predicting PH occurred at an relative CBV threshold of <0.42 (area under the curve, 0.77). At this threshold, VLCBV lesion volume ≥3.55 mL optimally predicted PH with 94% sensitivity and 63% specificity. Reperfused-VLCBV lesion volume was more specific (0.74) and equally sensitive (0.94). In total, 18 patients developed PH, of whom 17 presented with VLCBV (39% versus 2%; P=0.001), all of them had regional reperfusion (47% versus 0%; P=0.01), and 71% received intravenous alteplase. VLCBV lesion (odds ratio, 33) and bridging with intravenous alteplase (odds ratio, 3.8) were independently associated with PH. In a separate model, reperfused-VLCBV remained the single independent predictor of PH (odds ratio, 53).
  
  
  CONCLUSIONS
  These results suggest that VLCBV can be used for risk stratification of patients scheduled to undergo endovascular therapy in trials and routine clinical practice.
authors.affiliation: From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.).
authors.forename: Nishant K
authors.initials: NK
authors.lastname: Mishra
authors.affiliation: From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.).
authors.forename: Søren
authors.initials: S
authors.lastname: Christensen
authors.affiliation: From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.).
authors.forename: Anke
authors.initials: A
authors.lastname: Wouters
authors.affiliation: From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.).
authors.forename: Bruce C V
authors.initials: BC
authors.lastname: Campbell
authors.affiliation: From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.).
authors.forename: Matus
authors.initials: M
authors.lastname: Straka
authors.affiliation: From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.).
authors.forename: Michael
authors.initials: M
authors.lastname: Mlynash
authors.affiliation: From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.).
authors.forename: Stephanie
authors.initials: S
authors.lastname: Kemp
authors.affiliation: From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.).
authors.forename: Carlo W
authors.initials: CW
authors.lastname: Cereda
authors.affiliation: From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.).
authors.forename: Roland
authors.initials: R
authors.lastname: Bammer
authors.affiliation: From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.).
authors.forename: Michael P
authors.initials: MP
authors.lastname: Marks
authors.affiliation: From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.).
authors.forename: Gregory W
authors.initials: GW
authors.lastname: Albers
authors.affiliation: From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.). lansberg@stanford.edu.
authors.forename: Maarten G
authors.initials: MG
authors.lastname: Lansberg
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000601:surgery; D002543:Cerebral Hemorrhage / Q000503:physiopathology / Q000601:surgery*; D002560:Cerebrovascular Circulation; D057510:Endovascular Procedures / Q000009:adverse effects*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D020896:Hypovolemia / Q000628:therapy*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D015424:Reperfusion / Q000379:methods*; D018570:Risk Assessment; D020521:Stroke / Q000601:surgery; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: cerebral; hemorrhage; magnetic resonance imaging; perfusion imaging; stroke
references.citation: J Neurointerv Surg. 2015 Jan;7(1):16-21
references.pmid: 24401478
references.citation: Ann Neurol. 2013 Apr;73(4):510-9
references.pmid: 23444008
references.citation: Stroke. 2000 Oct;31(10):2378-84
references.pmid: 11022067
references.citation: Stroke. 2001 Jun;32(6):1330-5
references.pmid: 11387495
references.citation: World Neurosurg. 2014 Sep-Oct;82(3-4):e453-8
references.pmid: 23376392
references.citation: Stroke. 2003 Aug;34(8):e109-37
references.pmid: 12869717
references.citation: Lancet. 1998 Oct 17;352(9136):1245-51
references.pmid: 9788453
references.citation: Stroke. 2005 Apr;36(4):746-50
references.pmid: 15746457
references.citation: AJNR Am J Neuroradiol. 2005 Jun-Jul;26(6):1479-86
references.pmid: 15956519
references.citation: Ann Neurol. 2008 Jan;63(1):52-60
references.pmid: 17880020
references.citation: Stroke. 2008 Apr;39(4):1205-12
references.pmid: 18309168
references.citation: Stroke. 2010 Jan;41(1):82-8
references.pmid: 19959537
references.citation: Stroke. 2010 Mar;41(3):e135-42
references.pmid: 20075362
references.citation: J Magn Reson Imaging. 2010 Nov;32(5):1024-37
references.pmid: 21031505
references.citation: Lancet Neurol. 2012 Oct;11(10):860-7
references.pmid: 22954705
references.citation: N Engl J Med. 2013 Mar 7;368(10):893-903
references.pmid: 23390923
references.citation: Stroke. 2013 Aug;44(8):2318-20
references.pmid: 23723309
references.citation: Stroke. 2013 Nov;44(11):3039-43
references.pmid: 24003043
references.citation: AJNR Am J Neuroradiol. 2014 Mar;35(3):524-8
references.pmid: 24029392
references.citation: Stroke. 1999 Nov;30(11):2280-4
references.pmid: 10548658