. 2017 Mar;48(3):664-670.

doi: 10.1161/STROKEAHA.116.014343. Epub 2017 Jan 30.

Multiparametric Magnetic Resonance Imaging for Prediction of Parenchymal Hemorrhage in Acute Ischemic Stroke After Reperfusion Therapy

Kambiz Nael¹, James R Knitter², Reza Jahan², Jeffery Gornbein², Zahra Ajani², Lei Feng², Brett C Meyer², Lee H Schwamm², Albert J Yoo², Randolph S Marshall², Philip M Meyers², Dileep R Yavagal², Max Wintermark², David S Liebeskind², Judy Guzy², Sidney Starkman², Jeffrey L Saver², Chelsea S Kidwell²

Affiliations

¹ From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.). kambiznael@gmail.com.
² From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.).

PMID: 28138001
PMCID: PMC5325250
DOI: 10.1161/STROKEAHA.116.014343

Multiparametric Magnetic Resonance Imaging for Prediction of Parenchymal Hemorrhage in Acute Ischemic Stroke After Reperfusion Therapy

Kambiz Nael et al. Stroke. 2017 Mar.

. 2017 Mar;48(3):664-670.

doi: 10.1161/STROKEAHA.116.014343. Epub 2017 Jan 30.

Authors

Affiliations

¹ From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.). kambiznael@gmail.com.
² From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (K.N.); the Departments of Neurology and Radiology, University of Arizona, Tucson (J.R.K., C.S.K.); the Departments of Radiology and Neurosurgery (R.J.), Biomathematics (J. Gornbein), Neurology (D.S.L., J.L.S.), and Emergency Medicine and Neurology (J. Guzy, S.S.), University of California, Los Angeles; the Departments of Neurology (Z.A.) and Radiology (L.F.), Kaiser Permanente, Los Angeles, CA; the Departments of Neurosciences and the Stroke Center University of California, San Diego (B.C.M.); the Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston (L.H.S.); Texas Stroke Institute, Dallas (A.J.Y.); the Departments of Neurology (R.S.M.) and Neurological Surgery and Radiology (P.M.M.), Columbia University College of Physicians and Surgeons, New York, NY; the Departments of Neurology and Neurosurgery, University of Miami, Jackson Memorial Hospital, FL (D.R.Y.); and the Departments of Radiology and Neurology Stanford University, CA (M.W.).

PMID: 28138001
PMCID: PMC5325250
DOI: 10.1161/STROKEAHA.116.014343

Abstract

Background and purpose: Patients with acute ischemic stroke are at increased risk of developing parenchymal hemorrhage (PH), particularly in the setting of reperfusion therapies. We have developed a predictive model to examine the risk of PH using combined magnetic resonance perfusion and diffusion parameters, including cerebral blood volume (CBV), apparent diffusion coefficient, and microvascular permeability (K2).

Methods: Voxel-based values of CBV, K2, and apparent diffusion coefficient from the ischemic core were obtained using pretreatment magnetic resonance imaging data from patients enrolled in the MR RESCUE clinical trial (Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy). The associations between PH and extreme values of imaging parameters were assessed in univariate and multivariate analyses. Receiver-operating characteristic curve analysis was performed to determine the optimal parameter(s) and threshold for predicting PH.

Results: In 83 patients included in this analysis, 20 developed PH. Univariate analysis showed significantly lower 10th percentile CBV and 10th percentile apparent diffusion coefficient values and significantly higher 90th percentile K2 values within the infarction core of patients with PH. Using classification tree analysis, the 10th percentile CBV at threshold of 0.47 and 90th percentile K2 at threshold of 0.28 resulted in overall predictive accuracy of 88.7%, sensitivity of 90.0%, and specificity of 87.3%, which was superior to any individual or combination of other classifiers.

Conclusions: Our results suggest that combined 10th percentile CBV and 90th percentile K2 is an independent predictor of PH in patients with acute ischemic stroke with diagnostic accuracy superior to individual classifiers alone. This approach may allow risk stratification for patients undergoing reperfusion therapies.

Clinical trial registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00389467.

Keywords: biomarkers; embolectomy; hemorrhage; permeability; stroke.

PubMed Disclaimer

Figures

**Figure 1.**
A 45-y-old man presented with left sided weakness and baseline National Institutes of Health Stroke Scale score of 19. Magnetic resonance imaging (MRI) was obtained 5.5 hours from symptoms’ onset presentation. Axial apparent diffusion coefficient (ADC; A), cerebral blood volume (CBV; B), and microvascular permeability (K2; C) from the pretreatment MRI are shown. Volume of interest (VOI) from the diffusion-weighted image hyperintense region was automatically generated, and after image coregistration, voxel values from VOI were used to calculate 10th percentile ADC (384×10⁻⁶ mm²/s), 10th percentile CBV (0.40), and 90th percentile K2 (0.32). Subsequent MRI 8 d later shows development of parenchymal hemorrhage in the region of infarction (D).

**Figure 2.**
Scatter plots for 10th percentile cerebral blood volume (CBV), 10th percentile apparent diffusion coefficient (ADC), and 90th percentile microvascular permeability (K2). There are moderate negative correlations between 90th percentile K2 with 10th percentile CBV and 10th percentile ADC and a moderate positive correlation between 10th percentile CBV and 10th percentile ADC.

**Figure 3.**
Classification tree model using combined 10th percentile cerebral blood volume (CBV) and 90th percentile microvascular permeability (K2). If 10th percentile CBV ≥0.47 and 90th percentile K2 <0.28, the model predicts no parenchymal hemorrhage (PH) in 55 out of 63 patients. If 10th percentile CBV <0.47 and 90th percentile K2 ≥0.28, the model predicts PH in 18 out of 20 patients.

See this image and copyright information in PMC

References

1. Hacke W, Donnan G, Fieschi C, Kaste M, von Kummer R, Broderick JP, et al. ATLANTIS Trials Investigators; ECASS Trials Investigators; NINDS rt-PA Study Group Investigators. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004;363:768–774. doi: 10.1016/S0140-6736(04)15692-4. - PubMed
1. Selim M, Fink JN, Kumar S, Caplan LR, Horkan C, Chen Y, et al. Predictors of hemorrhagic transformation after intravenous recombinant tissue plasminogen activator: prognostic value of the initial apparent diffusion coefficient and diffusion-weighted lesion volume. Stroke. 2002;33:2047–2052. - PubMed
1. Tong DC, Adami A, Moseley ME, Marks MP. Relationship between apparent diffusion coefficient and subsequent hemorrhagic transformation following acute ischemic stroke. Stroke. 2000;31:2378–2384. - PubMed
1. Bang OY, Saver JL, Alger JR, Shah SH, Buck BH, Starkman S, et al. UCLA MRI Permeability Investigators. Patterns and predictors of blood-brain barrier permeability derangements in acute ischemic stroke. Stroke. 2009;40:454–461. doi: 10.1161/STROKEAHA.108.522847. - PubMed
1. Bang OY, Buck BH, Saver JL, Alger JR, Yoon SR, Starkman S, et al. Prediction of hemorrhagic transformation after recanalization therapy using T2*-permeability magnetic resonance imaging. Ann Neurol. 2007;62:170–176. doi: 10.1002/ana.21174. - PubMed

Publication types

Actions

MeSH terms

Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions

Associated data

Actions
- Search in PubMed
- Search in ClinicalTrials.gov

Grants and funding

P50 NS044378/NS/NINDS NIH HHS/United States

LinkOut - more resources

Full Text Sources
Medical
- ClinicalTrials.gov

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

Multiparametric Magnetic Resonance Imaging for Prediction of Parenchymal Hemorrhage in Acute Ischemic Stroke After Reperfusion Therapy

Affiliations

Multiparametric Magnetic Resonance Imaging for Prediction of Parenchymal Hemorrhage in Acute Ischemic Stroke After Reperfusion Therapy

Authors

Affiliations

Abstract

Figures

References

Publication types

MeSH terms

Associated data

Grants and funding

LinkOut - more resources

Full Text Sources

Medical