Difficulty of MRI Based Identification of Lesion Age by Acute Infra-Tentorial Ischemic Stroke

Große-Dresselhaus, Florian; Galinović, Ivana; Villringer, Kersten; Audebert, Heinrich J.; Fiebach, Jochen B.

doi:10.1371/journal.pone.0092868

Cited by 10 publications

(16 citation statements)

References 8 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…There is still debate about when an ischemic lesion may become positive on FLAIR in the course of formation of these lesions. Due to this FLAIR‐to‐DWI mismatch, FLAIR sequences may not adequately identify acute to hyperacute cerebral ischemic events related to also as “tissue‐clock” of FLAIR imaging …”

Section: Definitionsmentioning

confidence: 99%

“…SCE/SCL have not been linked to any sequela for patients so far. Five studies monitored MRI during follow‐up in patients with SCE/SCL . Six (4%) lesions out of a total of 137 were still detectable after 2 weeks up to 22 months.…”

Section: Relevance Of Cerebral Eventsmentioning

confidence: 99%

“…9,17,18 In contrast, the T2-weighted fluid attenuated inverse recovery sequence (FLAIR) has been shown to turn positive only with delay (in larger infarcts up to 20 hours and even longer for smaller infarct sizes), and FLAIR positivity is related to the volume of DWI-hyperintensity. 18,[20][21][22] Therefore, MRI to detect AF-ablation-related events performed on day 1 after the procedure may underestimate the true incidence of lesions if FLAIR positivity is a prerequisite (Fig. 1).…”

Section: Definitionsmentioning

confidence: 99%

See 2 more Smart Citations

Silent Cerebral Events/Lesions Related to Atrial Fibrillation Ablation: A Clinical Review

Deneke

Jaı̈s²,

Scaglione

et al. 2015

Cardiovasc electrophysiol

154

View full text Add to dashboard Cite

Brain magnetic resonance imaging (MRI) has identified a high incidence of cerebral ischemia in asymptomatic patients after atrial fibrillation (AF) ablation (silent). Detection of cerebral ischemic events on MRI is based on acute hyperintense lesions on diffusion-weighted imaging. In the literature, the incidence is related to specifications of MRI and depends on the definition applied. In comparative studies, silent cerebral events (SCE, diffusion-weighted MRI [DWI] positive only) appear to be approximately 3 times more common compared to using a definition of silent cerebral lesions (SCL; without fluid attenuated inverse recovery sequence [FLAIR] positivity). Whereas the FLAIR sequence may turn positive within days after the ischemic event, SCE definition is highly sensitive for early phases of ischemic brain damage. SCE/SCL appear to represent cerebral ischemic infarcts and determine the "embolic fingerprint" of a specific ablation technology and strategy used. The optimum time point for detecting SCE is early after AF ablation (24-72 hours), whereas detection of SCL can only be performed within the first 2-7 days (due to delay of FLAIR positivity). Different technology-, procedure-, and patient-related parameters have been identified to play a role in the multifactorial genesis of SCE/SCL. In recent years, evidence has been gathered that there may be differences of SCE/SCL rates depending upon the ablation technology used, but small patient numbers and a large number of potential confounders hamper all studies. As major findings of recent studies, mode of periprocedural and intraprocedural anticoagulation has been identified as a major predictor for incidences of SCE/SCL. Whereas procedural characteristics related to higher SCE/SCL-rates may be modified, unchangeable patient-related factors should be taken into account for future individualized risk assessment. Novel ablation devices introduced into the market should be tested for their potential embolic fingerprint and refinements of ablation procedures to reduce their embolic potential should be prompted. The knowledge of "best practice" in terms of low SCE/SCL rates has prompted changes in work-flow, which have been implemented into ablation procedures using novel ablation devices. So far, no study has linked SCE/SCL to neuropsychological decline and the low number of AF-ablation-associated events needs to be weighted against the multitude of preexisting asymptomatic MRI-detected brain lesions related to the course of AF itself. Future studies are needed to evaluate if more white matter hyperintensities due to AF may be prevented by AF ablation (producing only a small number of SCE/SCL).

show abstract

Section: Definitionsmentioning

confidence: 99%

Section: Relevance Of Cerebral Eventsmentioning

confidence: 99%

Section: Definitionsmentioning

confidence: 99%

See 1 more Smart Citation

Silent Cerebral Events/Lesions Related to Atrial Fibrillation Ablation: A Clinical Review

Deneke

Jaı̈s²,

Scaglione

et al. 2015

Cardiovasc electrophysiol

154

View full text Add to dashboard Cite

show abstract

“…How far our results are applicable for larger and more severe strokes cannot be estimated. Third, as the DWI-FLAIR mismatch was shown to be limited for infratentorial stroke [19] , we excluded patients with infratentorial stroke. Whether quantitative rSI biomarkers can provide prediction for thrombolytic treatment in patients with infratentorial stroke needs to be investigated.…”

Section: Discussionmentioning

confidence: 99%

Clinical-Radiological Parameters Improve the Prediction of the Thrombolysis Time Window by Both MRI Signal Intensities and DWI-FLAIR Mismatch

Madai

Wood²,

Galinović³

et al. 2016

Cerebrovasc Dis

Self Cite

View full text Add to dashboard Cite

Background: With regard to acute stroke, patients with unknown time from stroke onset are not eligible for thrombolysis. Quantitative diffusion weighted imaging (DWI) and fluid attenuated inversion recovery (FLAIR) MRI relative signal intensity (rSI) biomarkers have been introduced to predict eligibility for thrombolysis, but have shown heterogeneous results in the past. In the present work, we investigated whether the inclusion of easily obtainable clinical-radiological parameters would improve the prediction of the thrombolysis time window by rSIs and compared their performance to the visual DWI-FLAIR mismatch. Methods: In a retrospective study, patients from 2 centers with proven stroke with onset <12 h were included. The DWI lesion was segmented and overlaid on ADC and FLAIR images. rSI mean and SD, were calculated as follows: (mean ROI value/mean value of the unaffected hemisphere). Additionally, the visual DWI-FLAIR mismatch was evaluated. Prediction of the thrombolysis time window was evaluated by the area-under-the-curve (AUC) derived from receiver operating characteristic (ROC) curve analysis. Factors such as the association of age, National Institutes of Health Stroke Scale, MRI field strength, lesion size, vessel occlusion and Wahlund-Score with rSI were investigated and the models were adjusted and stratified accordingly. Results: In 82 patients, the unadjusted rSI measures DWI-mean and -SD showed the highest AUCs (AUC 0.86-0.87). Adjustment for clinical-radiological covariates significantly improved the performance of FLAIR-mean (0.91) and DWI-SD (0.91). The best prediction results based on the AUC were found for the final stratified and adjusted models of DWI-SD (0.94) and FLAIR-mean (0.96) and a multivariable DWI-FLAIR model (0.95). The adjusted visual DWI-FLAIR mismatch did not perform in a significantly worse manner (0.89). ADC-rSIs showed fair performance in all models. Conclusions: Quantitative DWI and FLAIR MRI biomarkers as well as the visual DWI-FLAIR mismatch provide excellent prediction of eligibility for thrombolysis in acute stroke, when easily obtainable clinical-radiological parameters are included in the prediction models.

show abstract

“…28,29 MRI imaging using a FLAIR technique can take up to 20 h to detect neurologic infarction and can take even longer for smaller infarcts. 31 This makes it challenging for FLAIR to be useful in SCL/ SCE detection immediately after AF ablation. In contrast, MRI using DWI can detect even small infarcts within minutes of their development, as this sequence is precise on picking up cellular edema (one of the early manifestations of ischemic cell injury) and shows up as hyperintense lesions on MRI (Figure 1).…”

Section: Silent Cerebral Lesions or Eventsmentioning

confidence: 99%

Innovative Approaches to Assess the Impact and Steps to Decrease the Neurological Consequences of Ablation

Ponamgi¹,

Yasin²,

Padmanabhan³

et al. 2016

JICRM

View full text Add to dashboard Cite

ABSTRACT. Despite continued innovations in catheter design and technique, catheter ablation for atrial fibrillation (AF) is still fraught with a few serious complications-most feared of which is stroke. Although a ''classic'' clinically disabling stroke is less common (about 1%) after AF ablation, many recent studies have identified an increased incidence of asymptomatic ischemic cerebral lesions known as ''silent clinical lesions'' (SCLs) associated with the procedure. As once thought, these new SCLs seen on post-ablation magnetic resonance imaging of the brain were not actually clinically ''silent'' and were shown to have significant clinical and neuropsychiatric effects on these patients in the long term. These SCLs are thought to represent the ''embolic fingerprints'' of the ablation procedure, suggesting involvement and the need for innovation as well as improved safety at multiple levels before, during, and after the procedure. This may require a multimodality approach involving several measures such as having better peri-procedural anticoagulation strategies, using real-time monitoring for markers of neurologic injury, giving meticulous attention to sheath management, using novel energy sources that are less thrombogenic, and finally establishing imaging protocols for timely detection of these lesions post ablation. The current literature is reviewed here to explore such opportunities to improve neurological outcomes of catheter ablation for AF.

show abstract

Difficulty of MRI Based Identification of Lesion Age by Acute Infra-Tentorial Ischemic Stroke

Cited by 10 publications

References 8 publications

Silent Cerebral Events/Lesions Related to Atrial Fibrillation Ablation: A Clinical Review

Silent Cerebral Events/Lesions Related to Atrial Fibrillation Ablation: A Clinical Review

Clinical-Radiological Parameters Improve the Prediction of the Thrombolysis Time Window by Both MRI Signal Intensities and DWI-FLAIR Mismatch

Innovative Approaches to Assess the Impact and Steps to Decrease the Neurological Consequences of Ablation

Contact Info

Product

Resources

About