Praneeta R. Konduri

All Publications

• Temporal Net Water Uptake Evolution and its Association with Functional Outcome in Acute Ischemic Stroke. AJNR. American journal of neuroradiology Olszewski, W., Cavalcante, F., van Poppel, L., Beenen, L., Emmer, B. J., van den Wijngaard, I., Lemmens, R., Roos, Y., Marquering, H., Majoie, C., Konduri, P. 2026

  Abstract

  Subacute lesion growth after acute ischemic stroke is associated with worse functional outcomes. The ischemic lesion severity can be assessed with Net Water Uptake (NWU), a CT-based marker of edema. Pre-treatment NWU has been associated with worse functional outcomes; however, it remains unclear how the temporal changes in NWU influence functional outcomes. In this study, we aimed to determine how associations between NWU and functional outcome vary across imaging times up to 1 week after stroke.We included patients from the MRCLEAN NO-IV trial with anterior circulation large vessel occlusion who were treated with endovascular treatment and had baseline, 24-hour, and 1-week follow-up non-contrast CT scans. Functional outcome at 90 days was evaluated using the modified Rankin Scale (mRS), analyzed both as functional independence (mRS 0-2) and across the full ordinal distribution (mRS 0-6). In the primary analysis, associations between NWU measured at different imaging timepoints and functional independence were examined using univariable and multivariable logistic regression models. To evaluate temporal changes in NWU, ΔNWU was calculated at different time intervals (baseline-24 hours, 24 hours-1 week, and baseline-1 week), and its association with outcomes was analyzed using analogous regression models.Out of 539 MRCLEAN NO-IV patients, 115 were included in this study. The median time from stroke onset to randomization was 92(70-140) minutes. The median NWU evolved from 4.3%(IQR:2.1-6.8%) at baseline to 9.0%(IQR:3.0-13%) at 24 hours and 15%(IQR:11-19%) at 1 week. The median patient-level change (ΔNWU) from baseline to 1 week was 10%(IQR: 5.3-16%). NWU measured at 1 week, but not at baseline or 24 hours, was significantly associated with functional dependence, with an aOR of 0.66(95%CI=0.47-0.90) per 5-percantage-point increase in NWU. Furthermore, a higher increase in NWU from baseline to 1 week imaging was significantly associated with functional dependence, with an aOR of 0.66(95%CI=0.47-0.86) per 5-percentage-point increase in ΔNWU1wk-BL.In our population, NWU measured at 1 week is associated with 90-day clinical outcomes, suggesting that lesion evolution continues in the first week after stroke onset and may therefore represent a target for secondary treatments to improve clinical outcomes.

  View details for DOI 10.3174/ajnr.A9330

  View details for PubMedID 41935978

• Deep learning-based non-contrast CT imaging markers enhance post-transfer DWI core volume prediction. AJNR. American journal of neuroradiology van Voorst, H., Konduri, P., Ter Schiphorst, A., Vandewalle, L., Liu, Y., Jiang, B., Heylen, E., Mlynash, M., Christensen, S., Dehkharghani, S., Albers, G. W., Zaharchuk, G., Lansberg, M. G., Heit, J. J. 2026

  Abstract

  BACKGROUND: Deep learning enables the extraction of ischemic lesion size and hypodensity imaging markers from noncontrast CT (DLNCCT) in patients with acute ischemic stroke, but it remains unclear whether those markers can predict post-transfer core volume.METHODS: We performed a post-hoc analysis of prospectively enrolled patients transferred from a primary to a comprehensive center (PSC/CSC) for endovascular treatment (EVT). Using a validated deep-learning NCCT segmentation method, we quantified total lesion volume (per 10mL), modified net water uptake (mNWU %), and severely hypodense volume (≤26 HU per 10mL) and compared these markers with core-lab-rated ASPECTS (per point decrease) and CTP-based evaluation for their association with (adjusted regression coefficient [95%CI]) and predictive performance in addition to baseline variables (R2±SE) for post-transfer CSC-admission DWI core volume.RESULTS: We included 420 patients (239[57%] males) with a median age of 72 years (IQR:61;80). We observed 11.2mL (95%CI:8.3;14.1] larger post-transfer core volumes per point decrease in ASPECTS, 10.0mL (95%CI:6.8;13.3) and 20.0mL (95%CI:12.7;27.2) larger post-transfer core volumes per 10 mL increase in total and severely hypodense DLNCCT volume, respectively. mNWU was not associated with post-transfer core volume (p=0.63). In addition to clinical baseline and CTA variables, post-transfer core volume prediction with ASPECTS (R2:0.49±0.02) and DLNCCT (R2:0.50±0.02) did not differ significantly (p=0.58). Compared with using CTP imaging markers (R2:0.56±0.02), adding ASPECTS (R2:0.63±0.02, p<0.01) and DLNCCT (R2:0.65±0.01, p<0.01) improved performance for post-transfer core volume prediction.CONCLUSION: Total and severely hypodense DLNCCT volumes are independent predictors for post-transfer core volume. These DLNCCT markers improved CTP-based post-transfer core volume prediction.

  View details for DOI 10.3174/ajnr.A9311

  View details for PubMedID 41916751

• Macrovascular angiographic and tissue-level perfusion collateral scoring to predict inter-hospital infarct growth rate Konduri, P. R., van Voorst, H., de Wilde, D., Seners, P., Vandewalle, L., ter Schiphorst, A., Wouters, A., Christensen, S., Yuen, N., Kemp, S., Zaharchuk, G., Mlynash, M., Albers, G., Heit, J., Lansberg, M. LIPPINCOTT WILLIAMS & WILKINS. 2026

  View details for DOI 10.1161/str.57.suppl_1.DP136

  View details for Web of Science ID 001690953100039

• Aggregate Multi-tiered Normalization to Enhance Detection of Impairment in Dynamic BOLD-CVR for Assessment of Hemodynamic Impairment Zhu, Y., Wang, X., Dogra, S., Voorst, H., Heylen, E., Konduri, P. R., Schiphorst, A., Heit, J., Lansberg, M., Albers, G., Dehkharghani, S. LIPPINCOTT WILLIAMS & WILKINS. 2026

  View details for DOI 10.1161/str.57.suppl_1.WP265

  View details for Web of Science ID 001690949600028

• Automated Quantification of Infarct Growth in Endovascular Thrombectomy Using Deep Learning Talati, I., Voorst, H., Yu, Y., Liu, Y., Konduri, P. R., Albers, G., Zaharchuk, G., Heit, J. LIPPINCOTT WILLIAMS & WILKINS. 2026

  View details for DOI 10.1161/str.57.suppl_1.WP259

  View details for Web of Science ID 001690949600020

• Deep generative models for vessel segmentation in CT angiography of the brain. Computers in biology and medicine van Voorst, H., Su, J., Konduri, P. R., Majoie, C. B., Roos, Y. B., Emmer, B. J., Marquering, H. A., de Vos, B. D., Caan, M. W., Isgum, I., MR CLEAN Registry collaborators 2026; 202: 111432

  Abstract

  Automated vessel segmentation in brain CT angiography (CTA) remains challenging despite the potential benefits of its applications. Expert acquisition of reference vessel segmentations is a laborious task. We propose an unsupervised generative deep learning approach that can be trained for vessel segmentation in brain CTA using a large dataset (n=908) of unlabelled brain CTAs and non-contrast enhanced CTs (NCCTs). Our semi-supervised approach uses a conditional generative adversarial network (GAN) for CTA to NCCT translation by generating a contrast map that allows for automatic extraction of vessel segmentations. Furthermore, we propose a 3D Frangi filter-based loss function to enhance tubular structures in the contrast map to improve vessel segmentations. We used a hold-out test set of 9 CTA volumes with manually annotated reference segmentations. We compared our semi-supervised approach with a state-of-the-art supervised nnUnet, trained and evaluated with test set using 9-fold nested cross-validation. Evaluation metrics included voxel-wise Dice similarity coefficient (DSC), true positive rate (TPR), and false positive rate (FPR). The DSC was 4 % lower for the semi-supervised approach (DSC: 0.74) compared to the supervised nnUnet (DSC: 0.78). Both the TPR and FPR were higher for the semi-supervised approach (TPR: 0.75, FPR/1000 voxels:2.05) compared to the supervised nnUnet (TPR:0.71, FPR/1000 voxels:0.87). Hence, the quantitative results showed that our semi-supervised method approaches a supervised state-of-the-art segmentation network. The results demonstrate that a semi-supervised generative deep learning approach for the segmentation of intracranial vessels is feasible without laborious manual segmentations.

  View details for DOI 10.1016/j.compbiomed.2025.111432

  View details for PubMedID 41494368

• Subacute edema progression after acute ischemic stroke: impact of intravenous alteplase administration and reperfusion degree FRONTIERS IN NEUROLOGY Olszewski, W., Cavalcante, F., van Poppel, L., Beenen, L., Emmer, B. J., van den Wijngaard, I., Lemmens, R., Roos, Y., Marquering, H., Konduri, P., Majoie, C., MRCLEAN NO IV Trial Investigators Multictr Randomized Clin Trial 2025; 16

  View details for DOI 10.3389/fneur.2025.1698480

  View details for Web of Science ID 001632373000001

• Subacute edema progression after acute ischemic stroke: impact of intravenous alteplase administration and reperfusion degree. Frontiers in neurology Olszewski, W., Cavalcante, F., van Poppel, L., Beenen, L., Emmer, B. J., van den Wijngaard, I., Lemmens, R., Roos, Y., Marquering, H., Konduri, P., Majoie, C. 2025; 16: 1698480

  Abstract

  Alteplase is known to increase the risk of blood-brain barrier integrity disruption, potentiating hemorrhage and edema. Evolving edema reduces chances of good functional outcomes. There is a paucity of studies that investigate the role of alteplase administration in subacute edema progression. Here we aim to associate alteplase administration in combination with the degree of reperfusion on edema, measured by net water uptake.We included 115 patients from the MRCLEAN NO-IV trial with baseline, 24-h and 1-week follow-up non-contrast CT scans. The cohort consisted of patients who received intravenous thrombolysis (IVT)+ endovascular treatment (EVT) vs. EVT alone. Net water uptake (NWU) was calculated as a ratio of mean lesion density compared to its homologous, contralateral region-of-interest. Unadjusted linear regression analysis was performed to assess the association between NWU progression and alteplase administration, successful reperfusion [expanded Thrombolysis in Cerebral Infarction (eTICI)2B/3], and excellent reperfusion (eTICI2C/3). Adjusted regression analysis was performed to correct for potential confounders.IVT administration was not statistically significantly associated with NWU progression. Regardless of treatment arm, there was substantial increase in NWU during the first 24 h and 1 week post-stroke. In adjusted analysis, successful reperfusion was significantly associated with reduced NWU progression at 24 h (β = -4.6; 95% CI: -8.4, -0.80) and 1 week (β = -6.5; 95% CI: -11, -2.3).Alteplase administration prior to EVT did not impact the subacute edema progression in our cohort, whereas successful reperfusion was strongly associated with reduced edema progression, particularly at later timepoints. These results suggest that alteplase administration according to current guidelines is unlikely to contribute to accelerated edema progression and emphasize that achieving high-grade reperfusion is crucial for reducing secondary injury.

  View details for DOI 10.3389/fneur.2025.1698480

  View details for PubMedID 41376769

  View details for PubMedCentralID PMC12685625

• White matter lesion effect modification of aspirin and unfractionated heparin during endovascular stroke treatment. Insights into imaging van Poppel, L. M., de Vries, L., Mojtahedi, M., van Voorst, H., Konduri, P. R., van de Graaf, R. A., van der Steen, W., Martou, L., Bentley, P., Marquering, H. A., Emmer, B. J., Majoie, C. B. 2025; 16 (1): 224

  Abstract

  Periprocedural aspirin or unfractionated heparin during endovascular treatment in acute ischemic stroke increases symptomatic intracranial hemorrhage (sICH) risk without improving functional outcome. White matter lesions (WMLs) are associated with higher sICH risk and poor functional outcome following stroke. We aimed to assess whether WML volume modifies the effect of aspirin or heparin.In this post-hoc analysis of the MR CLEAN-MED trial, WML volume was automatically determined using deep learning-based segmentation on baseline non-contrast CT scans. Outcomes included good functional outcome (modified Rankin Scale 0-2 at 90 days), any ICH, asymptomatic ICH (aICH), and sICH. Patients received either aspirin or not, and either heparin or not. Multivariable logistic regression evaluated treatment effect and effect modification.Of 628 patients, 614 with baseline CT were included. Median WML volume was 0.59 mL without significant differences between treatment arms. WML volume significantly modified the effect of aspirin on sICH (p = 0.01), but not on functional outcome (p = 0.95), any ICH (p = 0.52), or aICH (p = 0.30). Aspirin was associated with increased sICH risk, which decreased with increasing WML volume (aOR 0.96 [95% CI: 0.93-0.99] per 1 mL). For patients with large WML volumes, aspirin showed no significant effect on sICH risk. The effect of heparin on functional outcome, any ICH, aICH, and sICH was not modified by WML volume (p = 0.53, p = 0.26, p = 0.08, p = 0.63, respectively).WML volume significantly modified the effect of aspirin on sICH risk, with aspirin-associated risk decreasing as WML volume increased. WML volume did not modify the effect of aspirin or heparin on other outcomes.WML volume on non-contrast CT modifies the effect of aspirin during endovascular thrombectomy on sICH risk, yet no WML-based patient subgroup showed save benefits from periprocedural aspirin or heparin treatment.Periprocedural aspirin and unfractionated heparin during endovascular treatment cause a higher hemorrhage risk. WML volume is associated with worse functional outcome and WML volume significantly modifies the effect of aspirin on symptomatic hemorrhage risk, with aspirin-associated risk decreasing with increasing WML volume. No WML-volume-based patient subgroup was identified where aspirin or heparin treatment demonstrated safe clinical benefit.

  View details for DOI 10.1186/s13244-025-02095-2

  View details for PubMedID 41123765

  View details for PubMedCentralID PMC12546164

• Hypodensity Beyond the Ischemic Core: Penumbral Changes Detected With Relative Noncontrast Computed Tomography. Stroke Vandewalle, L., Konduri, P. R., Christensen, S., Seners, P., Wouters, A., Yuen, N., Mlynash, M., Kemp, S., Heit, J. J., Albers, G. W., Demeestere, J., Lansberg, M. G., Lemmens, R. 2025

  Abstract

  BACKGROUND: In acute ischemic stroke, infarcted tissue gradually becomes detectable on noncontrast computed tomography (NCCT) as a hypodensity representing vasogenic edema. We studied whether subtle NCCT density changes are also present in penumbral tissue.METHODS: This observational cohort study included patients with stroke with anterior circulation occlusions from the CRISP2 study (CT Perfusion to Predict Response to Recanalization in Ischemic Stroke Project 2) who were transferred from a primary to a comprehensive stroke center for consideration of endovascular thrombectomy. Patients received baseline NCCT and computed tomography perfusion at the referring hospital and magnetic resonance imaging at the receiving hospital. We created baseline relative NCCT images, which compare voxel density to the corresponding area in the contralateral hemisphere. We analyzed the relative density of rNCCT in the core and penumbra (based on computed tomography perfusion in referring hospitals). We also assessed the correlation between relative density and the degree of hypoperfusion in the penumbra, defined as the time-to-maximum of the tissue residue function. We studied the association between penumbral changes and functional outcomes on the full distribution of the modified Rankin Scale score at 90 days.RESULTS: From the 314 patients, 162 met inclusion criteria with a median (interquartile range) age of 73 (61-83) years, penumbra volume of 78 (52-113) mL, and core volume of 0.6 (0-13.0) mL; 54% were men. The relative density was reduced by a median of 1.8% (P<0.0001) in the penumbra and 3.3% in the core (P<0.0001). Relative hypodensity in the penumbra was more profound with increasing hypoperfusion: 1.5% in regions with time-to-maximum of 6- to 8-s region, 1.8% in time-to-maximum of 8- to 10-s v, and 2.2% in time-to-maximum >10-s region (P<0.0001). We identified a trend toward worse outcomes with more hypodense penumbra (odds ratio, 1.193 [95% CI, 0.996-1.430]).CONCLUSIONS: In patients with anterior circulation acute ischemic stroke, we identified relative hypodensity in penumbral tissue on NCCT with potential clinical relevance on 90-day functional outcomes. The hypodensity was more pronounced with increasing hypoperfusion severity.

  View details for DOI 10.1161/STROKEAHA.124.050317

  View details for PubMedID 40557487

• Sex differences in clot, vessel and tissue characteristics in patients with a large vessel occlusion treated with endovascular thrombectomy EUROPEAN STROKE JOURNAL van der Meij, A., Holswilder, G., Bernsen, M. E., van Os, H. J. A., Hofmeijer, J., Spaander, F. H. M., Martens, J. M., van den Wijngaard, I. R., Lingsma, H. F., Konduri, P. R., Majoie, C., Schonewille, W. J., Dippel, D. W. J., Kruyt, N. D., Nederkoorn, P. J., van Walderveen, M. A. A., Wermer, M. J. H., MR CLEAN Registry investigators 2024; 9 (3): 600-612

  Abstract

  To improve our understanding of the relatively poor outcome after endovascular treatment (EVT) in women we assessed possible sex differences in baseline neuroimaging characteristics of acute ischemic stroke patients with large anterior vessel occlusion (LVO).We included all consecutive patients from the MR CLEAN Registry who underwent EVT between 2014 and 2017. On baseline non-contrast CT and CT angiography, we assessed clot location and clot burden score (CBS), vessel characteristics (presence of atherosclerosis, tortuosity, size, and collateral status), and tissue characteristics with the Alberta Stroke Program Early Computed Tomography Score (ASPECTS). Radiological outcome was assessed with the extended thrombolysis in cerebral infarction score (eTICI) and functional outcome with the modified Rankin Scale score (mRS) at 90 days. Sex-differences were assessed with multivariable regression analyses with adjustments for possible confounders.3180 patients were included (median age 72 years, 48% women). Clots in women were less often located in the intracranial internal carotid artery (ICA) (25%vs 28%, odds ratio (OR) 0.85;95% confidence interval: 0.73-1.00). CBS was similar between sexes (median 6, IQR 4-8). Intracranial (aOR 0.73;95% CI:0.62-0.87) and extracranial (aOR 0.64;95% CI:0.43-0.95) atherosclerosis was less prevalent in women. Vessel tortuosity was more frequent in women in the cervical ICA (aOR 1.89;95% CI:1.39-2.57) and women more often had severe elongation of the aortic arch (aOR 1.38;95% CI:1.00-1.91). ICA radius was smaller in women (2.3vs 2.5 mm, mean difference 0.22;95% CI:0.09-0.35) while M1 radius was essentially equal (1.6vs 1.7 mm, mean difference 0.09;95% CI:-0.02-0.21). Women had better collateral status (⩾50% filling in 62%vs 53% in men, aOR 1.48;95% CI:1.29-1.70). Finally, ASPECT scores were equal between women and men (median 9 in both sexes, IQR 8-10vs 9-10). Reperfusion rates were similar between women and men (acOR 0.94;95% CI:0.83-1.07). However, women less often reached functional independence than men (34%vs 46%, aOR 0.68;95% CI:0.53-0.86).On baseline imaging of this Dutch Registry, men and women with LVO mainly differ in vessel characteristics such as atherosclerotic burden, extracranial vessel tortuosity, and collateral status. These sex differences do not result in different reperfusion rates and are, therefore, not likely to explain the worse functional outcome in women after EVT.

  View details for DOI 10.1177/23969873241231125

  View details for Web of Science ID 001177975700001

  View details for PubMedID 38420950

  View details for PubMedCentralID PMC11418468

• Generation of a Virtual Cohort of Patients for in Silico Trials of Acute Ischemic Stroke Treatments APPLIED SCIENCES-BASEL Bridio, S., Luraghi, G., Ramella, A., Matas, J., Dubini, G., Luisi, C. A., Neidlin, M., Konduri, P., Terreros, N., Marquering, H. A., Majoie, C. M., Migliavacca, F. 2023; 13 (18)

  View details for DOI 10.3390/app131810074

  View details for Web of Science ID 001071333200001

• Role of intravenous alteplase on late lesion growth and clinical outcome after stroke treatment JOURNAL OF CEREBRAL BLOOD FLOW AND METABOLISM Konduri, P., Cavalcante, F., van Voorst, H., Rinkel, L., Kappelhof, M., van Kranendonk, K., Treurniet, K., Emmer, B., Coutinho, J., Wolff, L., Hofmeijer, J., Uyttenboogaart, M., van Zwam, W., Roos, Y., Majoie, C., Marquering, H., MR CLEAN NO IV Trial Investigators 2023: 271678X231167755

  Abstract

  Several acute ischemic stroke mechanisms that cause lesion growth continue after treatment which is detrimental to long-term clinical outcome. The potential role of intravenous alteplase treatment (IVT), a standard in stroke care, in cessing the physiological processes causing post-treatment lesion development is understudied. We analyzed patients from the MR CLEAN-NO IV trial with good quality 24-hour and 1-week follow-up Non-Contrast CT scans. We delineated hypo- and hyper-dense regions on the scans as lesion. We performed univariable logistic and linear regression to estimate the influence of IVT on the presence (growth > 0 ml) and extent of late lesion growth. The association between late lesion growth and mRS was assessed using ordinal logistic regression. Interaction analysis was performed to evaluate the influence of IVT on this association. Of the 63/116 were randomized to included patients, IVT. Median growth was 8.4(-0.88-26) ml. IVT was not significantly associated with the presence (OR: 1.24 (0.57-2.74, p = 0.59) or extent (β = 5.1(-8.8-19), p = 0.47) of growth. Late lesion growth was associated with worse clinical outcome (aOR: 0.85(0.76-0.95), p < 0.01; per 10 ml). IVT did not influence this association (p = 0.18). We did not find evidence that IVT influences late lesion growth or the relationship between growth and worse clinical outcome. Therapies to reduce lesion development are necessary.

  View details for DOI 10.1177/0271678X231167755

  View details for Web of Science ID 000963793400001

  View details for PubMedID 37017421

• Prognostic Value of Thrombus Volume and Interaction With First-Line Endovascular Treatment Device Choice STROKE van Voorst, H., Bruggeman, A. A. E., Andriessen, J. W., Hoving, J. R., Konduri, P., Yang, W., Kappelhof, M., Terreros, N., Roos, Y. H., van Zwam, W., van der Lugt, A., van der Hoorn, A., Boiten, J., Roosendaal, S., Jenniskens, S., Caan, M. A., Marquering, H. J., Emmer, B., Majoie, C. M. 2023; 54 (4): 1056-1065

  Abstract

  A larger thrombus in patients with acute ischemic stroke might result in more complex endovascular treatment procedures, resulting in poorer patient outcomes. Current evidence on thrombus volume and length related to procedural and functional outcomes remains contradicting. This study aimed to assess the prognostic value of thrombus volume and thrombus length and whether this relationship differs between first-line stent retrievers and aspiration devices for endovascular treatment.In this multicenter retrospective cohort study, 670 of 3279 patients from the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) for endovascularly treated large vessel occlusions were included. Thrombus volume (0.1 mL) and length (0.1 mm) based on manual segmentations and measurements were related to reperfusion grade (expanded Treatment in Cerebral Infarction score) after endovascular treatment, the number of retrieval attempts, symptomatic intracranial hemorrhage, and a shift for functional outcome at 90 days measured with the reverted ordinal modified Rankin Scale (odds ratio >1 implies a favorable outcome). Univariable and multivariable linear and logistic regression were used to report common odds ratios (cORs)/adjusted cOR and regression coefficients (B/aB) with 95% CIs. Furthermore, a multiplicative interaction term was used to analyze the relationship between first-line device choice, stent retrievers versus aspiration device, thrombus volume, and outcomes.Thrombus volume was associated with functional outcome (adjusted cOR, 0.83 [95% CI, 0.71-0.97]) and number of retrieval attempts (aB, 0.16 [95% CI, 0.16-0.28]) but not with the other outcome measures. Thrombus length was only associated with functional independence (adjusted cOR, 0.45 [95% CI, 0.24-0.85]). Patients with more voluminous thrombi had worse functional outcomes if endovascular treatment was based on first-line stent retrievers (interaction cOR, 0.67 [95% CI, 0.50-0.89]; P=0.005; adjusted cOR, 0.74 [95% CI, 0.55-1.0]; P=0.04).In this study, patients with a more voluminous thrombus required more endovascular thrombus retrieval attempts and had a worse functional outcome. Patients with a lengthier thrombus were less likely to achieve functional independence at 90 days. For more voluminous thrombi, first-line stent retrieval compared with first-line aspiration might be associated with worse functional outcome.

  View details for DOI 10.1161/STROKEAHA.122.041606

  View details for Web of Science ID 000968172400040

  View details for PubMedID 36912141

• Infarct Evolution in Patients with Anterior Circulation Large-Vessel Occlusion Randomized to IV Alteplase and Endovascular Treatment versus Endovascular Treatment Alone AMERICAN JOURNAL OF NEURORADIOLOGY Hoving, J. W., van Voorst, H., Kappelhof, M., Tolhuisen, M., Treurniet, K. M., LeCouffe, N. E., Rinkel, L. A., Koopman, M. S., Cavalcante, F., Konduri, P. R., van den Wijngaard, I. R., Ghariq, E., Meijer, F., Coutinho, J. M., Marquering, H. A., Roos, Y. M., Emmer, B. J., Majoie, C. M. 2023: 434-440

  Abstract

  Infarct evolution after endovascular treatment varies widely among patients with stroke and may be affected by baseline characteristics and procedural outcomes. Moreover, IV alteplase and endovascular treatment may influence the relationship of these factors to infarct evolution. We aimed to assess whether the infarct evolution between baseline and follow-up imaging was different for patients who received IVT and EVT versus EVT alone.We included patients from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN)-NO IV trial with baseline CTP and follow-up imaging. Follow-up infarct volume was segmented on 24-hour or 1-week follow-up DWI or NCCT. Infarct evolution was defined as the follow-up lesion volume: CTP core volume. Substantial infarct growth was defined as an increase in follow-up infarct volume of >10 mL. We assessed whether infarct evolution was different for patients with IV alteplase and endovascular treatment versus endovascular treatment alone and evaluated the association of baseline characteristics and procedural outcomes with infarct evolution using multivariable regression.From 228 patients with CTP results available, 145 patients had follow-up imaging and were included in our analysis. For patients with IV alteplase and endovascular treatment versus endovascular treatment alone, the baseline median CTP core volume was 17 (interquartile range = 4-35) mL versus 11 (interquartile range = 6-24) mL. The median follow-up infarct volume was 13 (interquartile range, 4-48) mL versus 17 (interquartile range = 4-50) mL. Collateral status and occlusion location were negatively associated with substantial infarct growth in patients with and without IV alteplase before endovascular treatment.No statistically significant difference in infarct evolution was found in directly admitted patients who received IV alteplase and endovascular treatment within 4.5 hours of symptom onset versus patients who underwent endovascular treatment alone. Collateral status and occlusion location may be useful predictors of infarct evolution prognosis in patients eligible for IV alteplase who underwent endovascular treatment.

  View details for DOI 10.3174/ajnr.A7826

  View details for Web of Science ID 000957854600001

  View details for PubMedID 36958803

  View details for PubMedCentralID PMC10084906

• Infarct volume after ischemic stroke as a mediator of the effect of endovascular thrombectomy on early postprocedural neurologic deficit JOURNAL OF STROKE & CEREBROVASCULAR DISEASES Samuels, N., Compagne, K. C. J., van der Ende, N. A. M., Chalos, V., Konduri, P. R., van Doormaal, P., van Zwam, W. H., Majoie, C. M., Marquering, H. A., Roozenbeek, B., Lingsma, H. F., Dippel, D. W. J., van der Lugt, A., MR CLEAN Investigators 2023; 32 (2): 106906

  Abstract

  The beneficial effect of endovascular thrombectomy (EVT) on clinical outcome is assumed to be caused by reduced follow-up infarct volume (FIV), which could serve as an early imaging endpoint. However, the effect of EVT on the modified Rankin Scale (mRS) was poorly explained by FIV. NIHSS at 5-7 days could be a more specific measure of the effect of reperfusion therapy, as opposed to the mRS at 3 months. Therefore, we aimed to assess to what extent the effect of EVT on NIHSS is explained by FIV.We used data from the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands; n = 500) trial to evaluate the mediating role of FIV within 1 week in the relationship between EVT and baseline adjusted NIHSS at 5-7 days.Larger FIVs were associated with higher NIHSS after treatment (adjusted beta-coefficient (aβ) 0.47;95%CI 0.39-0.55). EVT was associated with smaller FIVs (β -0.35;95%CI-0.64 to -0.06) and lower NIHSS (β -0.63;95%CI-0.90 to -0.35). After adjustment for FIV, the effect of EVT on NIHSS decreased (aβ -0.47;95%CI-0.72 to -0.23), indicating that effect of EVT on neurologic deficit is partially mediated by FIV. Reduction of FIV explained 34% (95%CI;5%-93%) of the effect of EVT on the NIHSS at 5-7 days.Larger FIV was significantly associated with larger neurological deficits after treatment. Reduced infarct volume after EVT explains one third of treatment benefit in terms of neurological deficit. This suggests that FIV is of interest as an imaging biomarker of stroke treatment effect.

  View details for DOI 10.1016/j.jstrokecerebrovasdis.2022.106906

  View details for Web of Science ID 000999664600013

  View details for PubMedID 36473395

• Prognostic Value of Combined Radiomic Features from Follow-Up DWI and T2-FLAIR in Acute Ischemic Stroke JOURNAL OF CARDIOVASCULAR DEVELOPMENT AND DISEASE Gerbasi, A., Konduri, P., Tolhuisen, M., Cavalcante, F., Rinkel, L., Kappelhof, M., Wolff, L., Coutinho, J. M., Emmer, B. J., Costalat, V., Arquizan, C., Hofmeijer, J., Uyttenboogaart, M., van Zwam, W., Roos, Y., Quaglini, S., Bellazzi, R., Majoie, C., Marquering, H., MR CLEAN-NO IV Trial Investigators 2022; 9 (12)

  Abstract

  The biological pathways involved in lesion formation after an acute ischemic stroke (AIS) are poorly understood. Despite successful reperfusion treatment, up to two thirds of patients with large vessel occlusion remain functionally dependent. Imaging characteristics extracted from DWI and T2-FLAIR follow-up MR sequences could aid in providing a better understanding of the lesion constituents. We built a fully automated pipeline based on a tree ensemble machine learning model to predict poor long-term functional outcome in patients from the MR CLEAN-NO IV trial. Several feature sets were compared, considering only imaging, only clinical, or both types of features. Nested cross-validation with grid search and a feature selection procedure based on SHapley Additive exPlanations (SHAP) was used to train and validate the models. Considering features from both imaging modalities in combination with clinical characteristics led to the best prognostic model (AUC = 0.85, 95%CI [0.81, 0.89]). Moreover, SHAP values showed that imaging features from both sequences have a relevant impact on the final classification, with texture heterogeneity being the most predictive imaging biomarker. This study suggests the prognostic value of both DWI and T2-FLAIR follow-up sequences for AIS patients. If combined with clinical characteristics, they could lead to better understanding of lesion pathophysiology and improved long-term functional outcome prediction.

  View details for DOI 10.3390/jcdd9120468

  View details for Web of Science ID 000901196700001

  View details for PubMedID 36547465

  View details for PubMedCentralID PMC9786822

• In silico thrombectomy trials for acute ischemic stroke COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE Miller, C., Konduri, P., Bridio, S., Luraghi, G., Terreros, N., Boodt, N., Samuels, N., Matas, J., Migliavacca, F., Lingsma, H., van der Lugt, A., Roos, Y., Dippel, D., Marquering, H., Majoie, C., Hoekstra, A. 2023; 228: 107244

  Abstract

  In silico trials aim to speed up the introduction of new devices in clinical practice by testing device design and performance in different patient scenarios and improving patient stratification for optimizing clinical trials. In this paper, we demonstrate an in silico trial framework for thrombectomy treatment of acute ischemic stroke and apply this framework to compare treatment outcomes in different subpopulations and with different thrombectomy stent-retriever devices. We employ a novel surrogate thrombectomy model to evaluate the thrombectomy success in the in silico trial.The surrogate thrombectomy model, built using data from a fine-grained finite-element model, is a device-specific binary classifier (logistic regression), to estimate the probability of successful recanalization, the outcome of interest. We incorporate this surrogate model within our previously developed in silico trial framework and demonstrate its use with three examples of in silico clinical trials. The first trial is a validation trial for the surrogate thrombectomy model. We then present two exploratory trials: one evaluating the performance of a commercially available device based on the fibrin composition in the occluding thrombus and one comparing the performance of two commercially available stent retrievers.The Validation Trial showed the surrogate thrombectomy model was able to reproduce a similar recanalization rate as the real-life MR CLEAN trial (p=0.6). Results from the first exploratory trial showed that the chance of successful thrombectomy increases with higher blood cell concentrations in the thrombi, which is in line with observations from clinical data. The second exploratory trial showed improved recanalization success with a newer stent retriever device; however, these results require further investigation as the surrogate model for the newer stent retriever device has not yet been validated.In this novel study, we have shown that in silico trials have the potential to help inform medical device developers on the performance of a new device and may also be used to select populations of interest for a clinical trial. This would reduce the time and costs involved in device development and traditional clinical trials.

  View details for DOI 10.1016/j.cmpb.2022.107244

  View details for Web of Science ID 000892622500006

  View details for PubMedID 36434958

• Risk factors of late lesion growth after acute ischemic stroke treatment FRONTIERS IN NEUROLOGY Konduri, P., Bucker, A., Boers, A., Dutra, B., Samuels, N., Treurniet, K., Berkhemer, O., Yoo, A., van Zwam, W., van Oostenbrugge, R., van der Lugt, A., Dippel, D., Roos, Y., Bot, J., Majoie, C., Marquering, H., MR CLEAN Trial Investigators 2022; 13: 977608

  Abstract

  Even days after treatment of acute ischemic stroke due to a large vessel occlusion, the infarct lesion continues to grow. This late, subacute growth is associated with unfavorable functional outcome. In this study, we aim to identify patient characteristics that are risk factors of late, subacute lesion growth.Patients from the MR CLEAN trial cohort with good quality 24 h and 1-week follow up non-contrast CT scans were included. Late Lesion growth was defined as the difference between the ischemic lesion volume assessed after 1-week and 24-h. To identify risk factors, patient characteristics associated with lesion growth (categorized in quartiles) in univariable ordinal analysis (p < 0.1) were included in a multivariable ordinal regression model.In the 226 patients that were included, the median lesion growth was 22 (IQR 10-45) ml. In the multivariable model, lower collateral capacity [aOR: 0.62 (95% CI: 0.44-0.87); p = 0.01], longer time to treatment [aOR: 1.04 (1-1.08); p = 0.04], unsuccessful recanalization [aOR: 0.57 (95% CI: 0.34-0.97); p = 0.04], and larger midline shift [aOR: 1.18 (95% CI: 1.02-1.36); p = 0.02] were associated with late lesion growth.Late, subacute, lesion growth occurring between 1 day and 1 week after ischemic stroke treatment is influenced by lower collateral capacity, longer time to treatment, unsuccessful recanalization, and larger midline shift. Notably, these risk factors are similar to the risk factors of acute lesion growth, suggesting that understanding and minimizing the effects of the predictors for late lesion growth could be beneficial to mitigate the effects of ischemia.

  View details for DOI 10.3389/fneur.2022.977608

  View details for Web of Science ID 000874625300001

  View details for PubMedID 36277932

  View details for PubMedCentralID PMC9581245

• Unsupervised Deep Learning for Stroke Lesion Segmentation on Follow-up CT Based on Generative Adversarial Networks. AJNR. American journal of neuroradiology van Voorst, H., Konduri, P. R., van Poppel, L. M., van der Steen, W., van der Sluijs, P. M., Slot, E. M., Emmer, B. J., van Zwam, W. H., Roos, Y. B., Majoie, C. B., Zaharchuk, G., Caan, M. W., Marquering, H. A., CONTRAST Consortium Collaborators, Research Leaders, Consortium Coordinator, Imaging Assessment Committee, Adverse Events Committee, Outcome Assessment Committee, Data Management Group, Imaging Data Management, Biomaterials and Translational Group, Local Collaborators, Research Nurses, Study Monitors, Dippel, D., Majoie, C., van Nuland, R., Majoie, C., van der Lugt, A., van Es, A., van Doormaal, P., van den Berg, R., Beenen, L., Emmer, B., Roosendaal, S., van Zwam, W., Annechien Postma, A., Yo, L., Krietemeijer, M., Lycklama, G., Martens, J., Hammer, S., Meijer, A., Bokkers, R., van der Hoorn, A., van den Wijngaard, I., Yoo, A., Gerrits, D., van Oostenbrugge, R., Emmer, B., Coutinho, J. M., Truijman, M., Staals, J., van der Worp, B., Boogaarts, J., Jansen, B., Zinkstok, S., Roos, Y., Koudstaal, P., Dippel, D., Coutinho, J. M., Keizer, K., Manschot, S., Boiten, J., Kerkhoff, H., van den Wijngaard, I., Lingsma, H., Dippel, D., Chalos, V., Berkhemer, O., van der Lugt, A., Majoie, C., Versteeg, A., Wolff, L., van der Sluijs, M., van Voorst, H., Tolhuisen, M., Ten Cate, H., de Maat, M., Donse-Donkel, S., van Beusekom, H., Taha, A., Barakzie, A., Chalos, V., van de Graaf, R., van der Steen, W., Taha, A., Donse-Donkel, S., Wolff, L., Treurniet, K., van den Berg, S., LeCouffe, N., Kappelhof, M., Reinink, R., Tolhuisen, M., Rinkel, L., Brouwer, J., Bruggeman, A., van Voorst, H., Goldhoorn, R., Hinsenveld, W., Pirson, A., Olthuis, S., Uniken Venema, S., Teeselink, S., Sondag, L., Collette, S., Sterrenberg, M., El Ghannouti, N., van der Steen, L., Verheesen, S., Vranken, J., van Ahee, A., Bongenaar, H., Smallegange, M., Tilet, L., de Meris, J., Simons, M., Pellikaan, W., van Wijngaarden, W., Blauwendraat, K., Drabbe, Y., Sandiman-Lefeber, M., Katthofer, A., Ponjee, E., Eilander, R., van Loon, A., Kraus, K., Kooij, S., Slotboom, A., de Jong, M., van der Minne, F., Santegoets, E., Heiligers, L., Martens, Y., El Ghannouti, N. 2022

  Abstract

  BACKGROUND AND PURPOSE: Supervised deep learning is the state-of-the-art method for stroke lesion segmentation on NCCT. Supervised methods require manual lesion annotations for model development, while unsupervised deep learning methods such as generative adversarial networks do not. The aim of this study was to develop and evaluate a generative adversarial network to segment infarct and hemorrhagic stroke lesions on follow-up NCCT scans.MATERIALS AND METHODS: Training data consisted of 820 patients with baseline and follow-up NCCT from 3 Dutch acute ischemic stroke trials. A generative adversarial network was optimized to transform a follow-up scan with a lesion to a generated baseline scan without a lesion by generating a difference map that was subtracted from the follow-up scan. The generated difference map was used to automatically extract lesion segmentations. Segmentation of primary hemorrhagic lesions, hemorrhagic transformation of ischemic stroke, and 24-hour and 1-week follow-up infarct lesions were evaluated relative to expert annotations with the Dice similarity coefficient, Bland-Altman analysis, and intraclass correlation coefficient.RESULTS: The median Dice similarity coefficient was 0.31 (interquartile range, 0.08-0.59) and 0.59 (interquartile range, 0.29-0.74) for the 24-hour and 1-week infarct lesions, respectively. A much lower Dice similarity coefficient was measured for hemorrhagic transformation (median, 0.02; interquartile range, 0-0.14) and primary hemorrhage lesions (median, 0.08; interquartile range, 0.01-0.35). Predicted lesion volume and the intraclass correlation coefficient were good for the 24-hour (bias, 3 mL; limits of agreement, -64-59mL; intraclass correlation coefficient, 0.83; 95% CI, 0.78-0.88) and excellent for the 1-week (bias, -4 m; limits of agreement,-66-58 mL; intraclass correlation coefficient, 0.90; 95% CI, 0.83-0.93) follow-up infarct lesions.CONCLUSIONS: An unsupervised generative adversarial network can be used to obtain automated infarct lesion segmentations with a moderate Dice similarity coefficient and good volumetric correspondence.

  View details for DOI 10.3174/ajnr.A7582

  View details for PubMedID 35902122

• Thrombus radiomics in patients with anterior circulation acute ischemic stroke undergoing endovascular treatment JOURNAL OF NEUROINTERVENTIONAL SURGERY van Voorst, H., Bruggeman, A. A. E., Yang, W., Andriessen, J., Welberg, E., Dutra, B. G., Konduri, P. R., Terreros, N., Hoving, J. W., Tolhuisen, M. L., Kappelhof, M., Brouwer, J., Boodt, N., van Kranendonk, K. R., Koopman, M. S., Hund, H. M., Krietemeijer, M., van Zwam, W. H., van Beusekom, H. M. M., van der Lugt, A., Emmer, B. J., Marquering, H. A., Roos, Y. M., Caan, M. W. A., Majoie, C. M., MR CLEAN Registry Investigators 2022: e79-e85

  Abstract

  Thrombus radiomics (TR) describe complex shape and textural thrombus imaging features. We aimed to study the relationship of TR extracted from non-contrast CT with procedural and functional outcome in endovascular-treated patients with acute ischemic stroke.Thrombi were segmented on thin-slice non-contrast CT (≤1 mm) from 699 patients included in the MR CLEAN Registry. In a pilot study, we selected 51 TR with consistent values across two raters' segmentations (ICC >0.75). Random forest models using TR in addition or as a substitute to baseline clinical variables (CV) and manual thrombus measurements (MTM) were trained with 499 patients and evaluated on 200 patients for predicting successful reperfusion (extended Thrombolysis in Cerebral Ischemia (eTICI) ≥2B), first attempt reperfusion, reperfusion within three attempts, and functional independence (modified Rankin Scale (mRS) ≤2). Three texture and shape features were selected based on feature importance and related to eTICI ≥2B, number of attempts to eTICI ≥2B, and 90-day mRS with ordinal logistic regression.Random forest models using TR, CV or MTM had comparable predictive performance. Thrombus texture (inverse difference moment normalized) was independently associated with reperfusion (adjusted common OR (acOR) 0.85, 95% CI 0.72 to 0.99). Thrombus volume and texture were also independently associated with the number of attempts to successful reperfusion (acOR 1.36, 95% CI 1.03 to 1.88 and acOR 1.24, 95% CI 1.04 to 1.49).TR describing thrombus volume and texture were associated with more attempts to successful reperfusion. Compared with models using CV and MTM, TR had no added value for predicting procedural and functional outcome.

  View details for DOI 10.1136/jnis-2022-019085

  View details for Web of Science ID 000831303200001

  View details for PubMedID 35882552

• Thrombus imaging characteristics within acute ischemic stroke: similarities and interdependence JOURNAL OF NEUROINTERVENTIONAL SURGERY Arrarte Terreros, N., Bruggeman, A. A. E., Kappelhof, M., Tolhuisen, M. L., Brouwer, J., Hoving, J. W., Konduri, P. R., van Kranendonk, K. R., Dutra, B. G., Alves, H. R., Dippel, D. W. J., van Zwam, W. H., Beenen, L. F. M., Yo, L. S. F., van Bavel, E., Majoie, C. M., Marquering, H. A., MR CLEAN Registry Investigators 2023; 15 (E1): E60-E68

  Abstract

  The effects of thrombus imaging characteristics on procedural and clinical outcomes after ischemic stroke are increasingly being studied. These thrombus characteristics - for eg, size, location, and density - are commonly analyzed as separate entities. However, it is known that some of these thrombus characteristics are strongly related. Multicollinearity can lead to unreliable prediction models. We aimed to determine the distribution, correlation and clustering of thrombus imaging characteristics based on a large dataset of anterior-circulation acute ischemic stroke patients.We measured thrombus imaging characteristics in the MR CLEAN Registry dataset, which included occlusion location, distance from the intracranial carotid artery to the thrombus (DT), thrombus length, density, perviousness, and clot burden score (CBS). We assessed intercorrelations with Spearman's coefficient (ρ) and grouped thrombi based on 1) occlusion location and 2) thrombus length, density and perviousness using unsupervised clustering.We included 934 patients, of which 22% had an internal carotid artery (ICA) occlusion, 61% M1, 16% M2, and 1% another occlusion location. All thrombus characteristics were significantly correlated. Higher CBS was strongly correlated with longer DT (ρ=0.67, p<0.01), and moderately correlated with shorter thrombus length (ρ=-0.41, p<0.01). In more proximal occlusion locations, thrombi were significantly longer, denser, and less pervious. Unsupervised clustering analysis resulted in four thrombus groups; however, the cohesion within and distinction between the groups were weak.Thrombus imaging characteristics are significantly intercorrelated - strong correlations should be considered in future predictive modeling studies. Clustering analysis showed there are no distinct thrombus archetypes - novel treatments should consider this thrombus variability.

  View details for DOI 10.1136/jnis-2022-019134

  View details for Web of Science ID 000827089700001

  View details for PubMedID 35835463

  View details for PubMedCentralID PMC10715487

• Association of thrombus density and endovascular treatment outcomes in patients with acute ischemic stroke due to M1 occlusions NEURORADIOLOGY Bruggeman, A. A. E., Aberson, N., Kappelhof, M., Dutra, B. G., Hoving, J. W., Brouwer, J., Tolhuisen, M. L., Terreros, N., Konduri, P. R., Boodt, N., Roos, Y. M., van Zwam, W. H., Bokkers, R., Martens, J., Marquering, H. A., Emmer, B. J., Majoie, C. M., MR CLEAN Registry Investigators 2022; 64 (9): 1857-1867

  Abstract

  We aimed to study the association of non-contrast CT (NCCT) thrombus density with procedural and clinical outcomes in patients with acute ischemic stroke who underwent endovascular treatment (EVT). Since thrombus density is associated with thrombus location, we focused on M1 occlusions only.Patients with available thin-slice (< 2.5 mm) NCCT were included from a nationwide registry. Regression models were used to assess the relation between thrombus density (per Hounsfield unit [HU]) and the following outcomes. For reperfusion grade, adjusted common odds ratios (acOR) indicated a 1-step shift towards improved outcome per HU increase in thrombus density. For the binary outcomes of first-pass reperfusion (first-pass extended thrombolysis in cerebral infarction [eTICI] 2C-3, FPR), functional independence [90-day modified Rankin Scale (mRS) score of 0-2] and mortality), aORs were reported. Adjusted β coefficients (aβ) were reported for 24-h NIHSS and procedure duration in minutes. Outcome differences between first-line treatment devices (stent retriever versus aspiration) were assessed with interaction terms.In 566 patients with M1 occlusions, thrombus density was not associated with reperfusion (acOR 1.01, 95% CI 0.99-1.02), FPR (aOR 1.01, 95% CI 0.99-1.03), mortality (aOR 0.98, 95% CI 0.95-1.00), 24-h NIHSS (aβ - 0.7%, 95% CI - 1.4-0.2), or procedure duration (aβ 0.27, 95% CI - 0.05-0.58). In multivariable analysis, thrombus density was associated with functional independence (aOR 1.02, 95% CI 1.00-1.05). No interaction was found between thrombus density and first-line treatment device for any outcome.In patients with M1 occlusions, thrombus density was not clearly associated with procedural and clinical outcomes after EVT.

  View details for DOI 10.1007/s00234-022-02971-4

  View details for Web of Science ID 000795762900001

  View details for PubMedID 35570210

  View details for PubMedCentralID PMC9365751

• Bifurcation occlusions and endovascular treatment outcome in acute ischemic stroke JOURNAL OF NEUROINTERVENTIONAL SURGERY Terreros, N., Bruggeman, A. A. E., van Voorst, H., Konduri, P. R., Jansen, I. G. H., Kappelhof, M., Tolhuisen, M. L., Boodt, N., Dippel, D. W. J., van der Lugt, A., van Zwam, W. H., van Oostenbrugge, R. J., van der Worp, H., Emmer, B. J., Meijer, F. J. A., Roos, Y. M., van Bavel, E., Marquering, H. A., Majoie, C. M. 2023; 15 (4): 355-362

  Abstract

  A thrombus in the M1 segment of the middle cerebral artery (MCA) can occlude this main stem only or extend into the M1-M2 bifurcation. The occlusion pattern may affect endovascular treatment (EVT) success, as a bifurcated thrombus may be more prone to fragmentation during retrieval.To investigate whether bifurcated thrombus patterns are associated with EVT procedural and clinical outcomes.Occlusion patterns of MCA thrombi on CT angiography from MR CLEAN Registry patients were classified into three groups: main stem occlusion, bifurcation occlusion extending into one M2 branch, and bifurcation occlusion extending into both M2 branches. Procedural parameters, procedural outcomes (reperfusion grade and embolization to new territory), and clinical outcomes (24-48 hour National Institutes of Health Stroke Scale [NIHSSFU] score, change in NIHSS scores between 24 and 48 hours and baseline ∆ [NIHSS], and 90-day modified Rankin Scale [mRS] scores) were compared between occlusion patterns.We identified 1023 patients with an MCA occlusion of whom 370 (36%) had a main stem occlusion, 151 (15%) a single branch, and 502 (49%) a double branch bifurcation occlusion. There were no statistically significant differences in retrieval method, procedure time, number of retrieval attempts, reperfusion grade, and embolization to new territory between occlusion patterns. Patients with main stem occlusions had lower NIHSSFU scores than patients with single (7 vs 11, p=0.01) or double branch occlusions (7 vs 9, p=0.04). However, there were no statistically significant differences in ∆ NIHSS or in 90-day mRS scores.In our population, EVT procedural and long-term clinical outcomes were similar for MCA bifurcation occlusions and MCA main stem occlusions.

  View details for DOI 10.1136/neurintsurg-2021-018560

  View details for Web of Science ID 000772408200001

  View details for PubMedID 35318957

  View details for PubMedCentralID PMC10086510

• Fully Automated Thrombus Segmentation on CT Images of Patients with Acute Ischemic Stroke DIAGNOSTICS Mojtahedi, M., Kappelhof, M., Ponomareva, E., Tolhuisen, M., Jansen, I., Bruggeman, A. A. E., Dutra, B. G., Yo, L., LeCouffe, N., Hoving, J. W., van Voorst, H., Brouwer, J., Terreros, N., Konduri, P., Meijer, F. J. A., Appelman, A., Treurniet, K. M., Coutinho, J. M., Roos, Y., van Zwam, W., Dippel, D., Gavves, E., Emmer, B. J., Majoie, C., Marquering, H. 2022; 12 (3)

  Abstract

  Thrombus imaging characteristics are associated with treatment success and functional outcomes in stroke patients. However, assessing these characteristics based on manual annotations is labor intensive and subject to observer bias. Therefore, we aimed to create an automated pipeline for consistent and fast full thrombus segmentation. We used multi-center, multi-scanner datasets of anterior circulation stroke patients with baseline NCCT and CTA for training (n = 228) and testing (n = 100). We first found the occlusion location using StrokeViewer LVO and created a bounding box around it. Subsequently, we trained dual modality U-Net based convolutional neural networks (CNNs) to segment the thrombus inside this bounding box. We experimented with: (1) U-Net with two input channels for NCCT and CTA, and U-Nets with two encoders where (2) concatenate, (3) add, and (4) weighted-sum operators were used for feature fusion. Furthermore, we proposed a dynamic bounding box algorithm to adjust the bounding box. The dynamic bounding box algorithm reduces the missed cases but does not improve Dice. The two-encoder U-Net with a weighted-sum feature fusion shows the best performance (surface Dice 0.78, Dice 0.62, and 4% missed cases). Final segmentation results have high spatial accuracies and can therefore be used to determine thrombus characteristics and potentially benefit radiologists in clinical practice.

  View details for DOI 10.3390/diagnostics12030698

  View details for Web of Science ID 000775406600001

  View details for PubMedID 35328251

  View details for PubMedCentralID PMC8947334

• Development of a patient-specific cerebral vasculature fluid-structure-interaction model JOURNAL OF BIOMECHANICS Moerman, K. M., Konduri, P., Fereidoonnezhad, B., Marquering, H., van der Lugt, A., Luraghi, G., Bridio, S., Migliavacca, F., Matas, J., McGarry, P. 2022; 133: 110896

  Abstract

  Development of in-silico models of patient-specific cerebral artery networks presents several significant technical challenges: (i) The resolution and smoothness of medical CT images are much lower than the required element/cell length for FEA/CFD/FSI models; (ii) contact between vessels, and indeed self contact of high tortuosity vessel segments are not clearly identifiable from medical CT images. Commercial model construction software does not provide customised solutions for such technical challenges, with the result that accurate, efficient and automated development of patient-specific models of the cerebral vessels is not facilitated. This paper presents the development of a customised and highly automated platform for the generation of high resolution patient-specific FEA/CFD/FSI models from clinical images. This platform is used to perform the first fluid-structure-interaction patient-specific analysis of blood flow and artery deformation of an occluded cerebral vessel. Results demonstrate that in addition to flow disruption, clot occlusion significantly alters the geometry and strain distribution in the vessel network, with the blocked M2 segment undergoing axial elongation. The new computational approach presented in this study can be further developed as a clinical diagnostic tool and as a platform for thrombectomy device design.

  View details for DOI 10.1016/j.jbiomech.2021.110896

  View details for Web of Science ID 000804677000006

  View details for PubMedID 35124518

• Endovascular treatment for calcified cerebral emboli in patients with acute ischemic stroke JOURNAL OF NEUROSURGERY Bruggeman, A. A. E., Kappelhof, M., Terreros, N., Tolhuisen, M. L., Konduri, P. R., Boodt, N., van Beusekom, H. M. M., Hund, H. M., Taha, A., van der Lugt, A., Roos, Y. M., van Es, A. M., van Zwam, W. H., Postma, A. A., Dippel, D. W. J., Lingsma, H. F., Marquering, H. A., Emmer, B. J., Majoie, C. M., MR CLEAN Registry Investigators 2021; 135 (5): 1402-1412

  Abstract

  Calcified cerebral emboli (CCE) are a rare cause of acute ischemic stroke. The authors aimed to assess the association of CCE with functional outcome, successful reperfusion, and mortality. Furthermore, they aimed to assess the effectiveness of intravenous alteplase treatment and endovascular treatment (EVT), as well as the best first-line EVT approach in patients with CCE.The Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry is a prospective, observational multicenter registry of patients treated with EVT for acute ischemic stroke in 16 intervention hospitals in the Netherlands. The association of CCE with functional outcome, reperfusion, and mortality was evaluated using logistic regression models. Univariable comparisons were made to determine the effectiveness of intravenous alteplase treatment and the best first-line EVT approach in CCE patients.The study included 3077 patients from the MR CLEAN Registry. Fifty-five patients (1.8%) had CCE. CCE were not significantly associated with worse functional outcome (adjusted common OR 0.71, 95% CI 0.44-1.15), and 29% of CCE patients achieved functional independence. An extended Thrombolysis in Cerebral Infarction score ≥ 2B was significantly less often achieved in CCE patients compared to non-CCE patients (adjusted OR [aOR] 0.52, 95% CI 0.28-0.97). Symptomatic intracranial hemorrhage occurred in 8 CCE patients (15%) vs 171 of 3022 non-CCE patients (6%; p = 0.01). The median improvement on the National Institutes of Health Stroke Scale (NIHSS) was 2 in CCE patients versus 4 in non-CCE patients (p = 0.008). CCE were not significantly associated with mortality (aOR 1.16, 95% CI 0.64-2.12). Intravenous alteplase use in CCE patients was not associated with functional outcome or reperfusion. In CCE patients with successful reperfusion, stent retrievers were more often used as the primary treatment device (p = 0.04).While patients with CCE had significantly lower reperfusion rates and less improvement on the NIHSS after EVT, CCE were not significantly associated with worse functional outcome or higher mortality rates. Therefore, EVT should still be considered in this specific group of patients.

  View details for DOI 10.3171/2020.9.JNS201798

  View details for Web of Science ID 000714983500002

  View details for PubMedID 33799302

• Posttreatment Ischemic Lesion Evolution Is Associated With Reduced Favorable Functional Outcome in Patients With Stroke STROKE Konduri, P., van Voorst, H., Bucker, A., van Kranendonk, K., Boers, A., Treurniet, K., Berkhemer, O., Yoo, A. J., van Zwam, W., van Oostenbrugge, R., van der Lugt, A., Dippel, D., Roos, Y., Bot, J., Majoie, C., Marquering, H., MR CLEAN Trial Investigators 2021; 52 (11): 3523-3531

  Abstract

  Ischemic lesion volume can increase even 24 hours after onset of an acute ischemic stroke. In this study, we investigated the association of lesion evolution with functional outcome and the influence of successful recanalization on this association.We included patients from the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) who received good quality noncontrast CT images 24 hours and 1 week after stroke onset. The ischemic lesion delineations included infarct, edema, and hemorrhagic transformation. Lesion evolution was defined as the difference between the volumes measured on the 1-week and 24-hour noncontrast CTs. The association of lesion evolution with functional outcome was evaluated using unadjusted and adjusted logistic regression. Adjustments were made for baseline, clinical, and imaging parameters that were associated P<0.10) in univariate analysis with favorable functional outcome, defined as modified Rankin Scale score of ≤2. Interaction analysis was performed to evaluate the influence of successful recanalization, defined as modified Arterial Occlusion Lesion score of 3 points, on this association.Of the 226 patients who were included, 69 (31%) patients achieved the favorable functional outcome. Median lesion evolution was 22 (interquartile range, 10–45) mL. Lesion evolution was significantly inversely correlated with favourable functional outcome: unadjusted odds ratio, 0.76 (95% CI, 0.66–0.86; per 10 mL of lesion evolution; P<0.01) and adjusted odds ratio: 0.85 (95% CI, 0.72–0.97; per 10 mL of lesion evolution; P=0.03). There was no significant interaction of successful recanalization on the association of lesion evolution and favorable functional outcome (odds ratio, 1.01 [95% CI, 0.77–1.36]; P=0.94).In our population, subacute ischemic lesion evolution is associated with unfavorable functional outcome. This study suggests that even 24 hours after onset of stroke, deterioration of the brain continues, which has a negative effect on functional outcome. This finding may warrant additional treatment in the subacute phase.

  View details for DOI 10.1161/STROKEAHA.120.032331

  View details for Web of Science ID 000710623500032

  View details for PubMedID 34289708

• Automated Final Lesion Segmentation in Posterior Circulation Acute Ischemic Stroke Using Deep Learning DIAGNOSTICS Zoetmulder, R., Konduri, P. R., Obdeijn, I., Gavves, E., Isgum, I., Majoie, C. M., Dippel, D. W. J., Roos, Y. M., Goyal, M., Mitchell, P. J., Campbell, B. C., Lopes, D. K., Reimann, G., Jovin, T. G., Saver, J. L., Muir, K. W., White, P., Bracard, S., Chen, B., Brown, S., Schonewille, W. J., van der Hoeven, E., Puetz, V., Marquering, H. A. 2021; 11 (9)

  Abstract

  Final lesion volume (FLV) is a surrogate outcome measure in anterior circulation stroke (ACS). In posterior circulation stroke (PCS), this relation is plausibly understudied due to a lack of methods that automatically quantify FLV. The applicability of deep learning approaches to PCS is limited due to its lower incidence compared to ACS. We evaluated strategies to develop a convolutional neural network (CNN) for PCS lesion segmentation by using image data from both ACS and PCS patients. We included follow-up non-contrast computed tomography scans of 1018 patients with ACS and 107 patients with PCS. To assess whether an ACS lesion segmentation generalizes to PCS, a CNN was trained on ACS data (ACS-CNN). Second, to evaluate the performance of only including PCS patients, a CNN was trained on PCS data. Third, to evaluate the performance when combining the datasets, a CNN was trained on both datasets. Finally, to evaluate the performance of transfer learning, the ACS-CNN was fine-tuned using PCS patients. The transfer learning strategy outperformed the other strategies in volume agreement with an intra-class correlation of 0.88 (95% CI: 0.83-0.92) vs. 0.55 to 0.83 and a lesion detection rate of 87% vs. 41-77 for the other strategies. Hence, transfer learning improved the FLV quantification and detection rate of PCS lesions compared to the other strategies.

  View details for DOI 10.3390/diagnostics11091621

  View details for Web of Science ID 000699291900001

  View details for PubMedID 34573963

  View details for PubMedCentralID PMC8466415

• Impact of the Internal Carotid Artery Morphology on <i>in silico</i> Stent-Retriever Thrombectomy Outcome FRONTIERS IN MEDICAL TECHNOLOGY Bridio, S., Luraghi, G., Matas, J. F., Dubini, G., Giassi, G. G., Maggio, G., Kawamoto, J. N., Moerman, K. M., McGarry, P., Konduri, P. R., Terreros, N., Marquering, H. A., van Bavel, E., Majoie, C. M., Migliavacca, F., INSIST Investigators 2021; 3: 719909

  Abstract

  The aim of this work is to propose a methodology for identifying relationships between morphological features of the cerebral vasculature and the outcome of in silico simulations of thrombectomy, the mechanical treatment for acute ischemic stroke. Fourteen patient-specific cerebral vasculature segmentations were collected and used for geometric characterization of the intracranial arteries mostly affected by large vessel occlusions, i.e., internal carotid artery (ICA), middle cerebral artery (MCA) and anterior cerebral artery (ACA). First, a set of global parameters was created, including the geometrical information commonly provided in the clinical context, namely the total length, the average diameter and the tortuosity (length over head-tail distance) of the intracranial ICA. Then, a more exhaustive geometrical analysis was performed to collect a set of local parameters. A total of 27 parameters was measured from each patient-specific vascular configuration. Fourteen virtual thrombectomy simulations were performed with a blood clot with the same length and composition placed in the middle of the MCA. The model of TREVO ProVue stent-retriever was used for all the simulations. Results from simulations produced five unsuccessful outcomes, i.e., the clot was not removed from the vessels. The geometric parameters of the successful and unsuccessful simulations were compared to find relations between the vascular geometry and the outcome. None of the global parameters alone or combined proved able to discriminate between positive and negative outcome, while a combination of local parameters allowed to correctly identify the successful from the unsuccessful simulations. Although these results are limited by the number of patients considered, this study indicates a promising methodology to relate patient-specific geometry to virtual thrombectomy outcome, which might eventually guide decision making in the treatment of acute ischemic stroke.

  View details for DOI 10.3389/fmedt.2021.719909

  View details for Web of Science ID 001007812800001

  View details for PubMedID 35047950

  View details for PubMedCentralID PMC8757691

• The first virtual patient-specific thrombectomy procedure JOURNAL OF BIOMECHANICS Luraghi, G., Bridio, S., Matas, J., Dubini, G., Boodt, N., Gijsen, F. J. H., van der Lugt, A., Fereidoonnezhad, B., Moerman, K. M., McGarry, P., Konduri, P. R., Terreros, N., Marquering, H. A., Majoie, C. M., Migliavacca, F., INSIST Investigators 2021; 126: 110622

  Abstract

  Treatment of acute ischemic stroke has been recently improved with the introduction of endovascular mechanical thrombectomy, a minimally invasive procedure able to remove a clot using aspiration devices and/or stent-retrievers. Despite the promising and encouraging results, improvements to the procedure and to the stent design are the focus of the recent efforts. Computational studies can pave the road to these improvements, providing their ability to describe and accurately reproduce a real procedure. A patient with ischemic stroke due to intracranial large vessel occlusion was selected and after the creation of the cerebral vasculature from computed tomography images and a histologic analysis to determine the clot composition, the entire thrombectomy procedure was virtually replicated. As in the real situation, the computational replica showed that two attempts were necessary to remove the clot, as a result of the position of the stent retriever with respect to the clot. Furthermore, the results indicated that clot fragmentation did not occur as the deformations were mainly in a compressive state without the possibility for clot cracks to propagate. The accurate representation of the procedure can be used as an important step for operative optimization planning and future improvements of stent designs.

  View details for DOI 10.1016/j.jbiomech.2021.110622

  View details for Web of Science ID 000701936800006

  View details for PubMedID 34298290

• The Role of Edema in Subacute Lesion Progression After Treatment of Acute Ischemic Stroke FRONTIERS IN NEUROLOGY Konduri, P., van Kranendonk, K., Boers, A., Treurniet, K., Berkhemer, O., Yoo, A. J., van Zwam, W., van Oostenbrugge, R., van der Lugt, A., Dippel, D., Roos, Y., Bot, J., Majoie, C., Marquering, H., Mr Clean Trial Investigators Mul 2021; 12: 705221

  Abstract

  Background: Ischemic lesions commonly continue to progress even days after treatment, and this lesion growth is associated with unfavorable functional outcome in acute ischemic stroke patients. The aim of this study is to elucidate the role of edema in subacute lesion progression and its influence on unfavorable functional outcome by quantifying net water uptake. Methods: We included all 187 patients from the MR CLEAN trial who had high quality follow-up non-contrast CT at 24 h and 1 week. Using a CT densitometry-based method to calculate the net water uptake, we differentiated total ischemic lesion volume (TILV) into edema volume (EV) and edema-corrected infarct volume (ecIV). We calculated these volumes at 24 h and 1 week after stroke and determined their progression in the subacute period. We assessed the effect of 24-h lesion characteristics on EV and ecIV progression. We evaluated the influence of edema and edema-corrected infarct progression on favorable functional outcome after 90 days (modified Rankin Scale: 0-2) after correcting for potential confounders. Lastly, we compared these volumes between subgroups of patients with and without successful recanalization using the Mann-Whitney U-test. Results: Median TILV increased from 37 (IQR: 18-81) ml to 68 (IQR: 30-130) ml between 24 h and 1 week after stroke, while the net water uptake increased from 22 (IQR: 16-26)% to 27 (IQR: 22-32)%. The TILV progression of 20 (8.8-40) ml was mostly caused by ecIV with a median increase of 12 (2.4-21) ml vs. 6.5 (2.7-15) ml of EV progression. Larger TILV, EV, and ecIV volumes at 24 h were all associated with more edema and lesion progression. Edema progression was associated with unfavorable functional outcome [aOR: 0.53 (0.28-0.94) per 10 ml; p-value: 0.05], while edema-corrected infarct progression showed a similar, non-significant association [aOR: 0.80 (0.62-0.99); p-value: 0.06]. Lastly, edema progression was larger in patients without successful recanalization, whereas ecIV progression was comparable between the subgroups. Conclusion: EV increases in evolving ischemic lesions in the period between 1 day and 1 week after acute ischemic stroke. This progression is larger in patients without successful recanalization and is associated with unfavorable functional outcome. However, the extent of edema cannot explain the total expansion of ischemic lesions since edema-corrected infarct progression is larger than the edema progression.

  View details for DOI 10.3389/fneur.2021.705221

  View details for Web of Science ID 000680411200001

  View details for PubMedID 34354669

  View details for PubMedCentralID PMC8329530

• Coupling one-dimensional arterial blood flow to three-dimensional tissue perfusion models for <i>in silico</i> trials of acute ischaemic stroke INTERFACE FOCUS Padmos, R. M., Jozsa, T., El-Bouri, W. K., Konduri, P. R., Payne, S. J., Hoekstra, A. G. 2021; 11 (1): 20190125

  Abstract

  An acute ischaemic stroke is due to the sudden blockage of an intracranial blood vessel by an embolized thrombus. In the context of setting up in silico trials for the treatment of acute ischaemic stroke, the effect of a stroke on perfusion and metabolism of brain tissue should be modelled to predict final infarcted brain tissue. This requires coupling of blood flow and tissue perfusion models. A one-dimensional intracranial blood flow model and a method to couple this to a brain tissue perfusion model for patient-specific simulations is presented. Image-based patient-specific data on the anatomy of the circle of Willis are combined with literature data and models for vessel anatomy not visible in the images, to create an extended model for each patient from the larger vessels down to the pial surface. The coupling between arterial blood flow and tissue perfusion occurs at the pial surface through the estimation of perfusion territories. The coupling method is able to accurately estimate perfusion territories. Finally, we argue that blood flow can be approximated as steady-state flow at the interface between arterial blood flow and tissue perfusion to reduce the cost of organ-scale simulations.

  View details for DOI 10.1098/rsfs.2019.0125

  View details for Web of Science ID 000600128700006

  View details for PubMedID 33335706

  View details for PubMedCentralID PMC7739918

• <i>In-Silico</i> Trials for Treatment of Acute Ischemic Stroke FRONTIERS IN NEUROLOGY Konduri, P. R., Marquering, H. A., van Bavel, E. E., Hoekstra, A., Majoie, C. M., INSIST Investigators 2020; 11

  View details for DOI 10.3389/fneur.2020.558125

  View details for Web of Science ID 000576269200001