Publications by authors named "Jayesh Modi"

38 Publications

White Matter Hyperintensity Volume Influences Symptoms in Patients Presenting With Minor Neurological Deficits.

Stroke 2020 02 4;51(2):409-415. Epub 2019 Dec 4.

From the Department of Community Health Sciences (C.Z., S.B.C.), University of Calgary, AB, Canada.

Background and Purpose- Acute minor neurological deficits are a common complaint in the emergency department and differentiation of transient ischemic attack/minor stroke from a stroke mimic is difficult. We sought to assess the ability of white matter hyperintensity (WMH) volume to aid the diagnosis in such patients. Methods- This is a post hoc analysis of the previously published SpecTRA study (Spectrometry in TIA Rapid Assessment) of adult patients that presented to the emergency department with acute minor neurological deficits between December 2013 and March 2017. WMH volumes were measured if fluid-attenuated inversion recovery imaging was available. Outcomes of interest were final diagnosis, symptoms at presentation, and 90-day stroke recurrence. Results- WMH volume was available for 1485 patients. Median age was 70 years (interquartile range, 59-80), and 46.7% were female. Mean WMH volume was higher in transient ischemic attack/minor strokes compared with stroke mimics (1.71 ln mL [95% CI, 1.63-1.79 ln mL] versus 1.15 ln mL [95% CI, 1.02-1.27 ln mL], <0.001). In multivariable-adjusted logistic regression analysis, WMH volume was not associated with final diagnosis. However, the combination of both diffusion-weighted imaging positivity and high WMH volume led to lower odds of focal symptoms at presentation (=0.035). Conclusions- The combination of diffusion-weighted imaging positivity and high WMH volume was associated with lower odds of focal symptoms at presentation in patients seen with minor neurological deficits in the emergency department. This suggests that WMH volume might be an important consideration and the absence of focal symptoms at presentation should not discourage clinicians from further investigating patients with suspected cerebral ischemia.
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http://dx.doi.org/10.1161/STROKEAHA.119.027213DOI Listing
February 2020

Validation of a proteomic biomarker panel to diagnose minor-stroke and transient ischaemic attack: phase 2 of SpecTRA, a large scale translational study.

Biomarkers 2018 Dec 23;23(8):793-803. Epub 2018 Aug 23.

g Genome British Columbia Proteomics Centre, University of Victoria , Victoria , Canada.

Objective: To validate our previously developed 16 plasma-protein biomarker panel to differentiate between transient ischaemic attack (TIA) and non-cerebrovascular emergency department (ED) patients.

Method: Two consecutive cohorts of ED patients prospectively enrolled at two urban medical centers into the second phase of SpecTRA study (training, cohort 2A, n = 575; test, cohort 2B, n = 528). Plasma samples were analyzed using liquid chromatography/multiple reaction monitoring-mass spectrometry. Logistic regression models which fit cohort 2A were validated on cohort 2B.

Results: Three of the panel proteins failed quality control and were removed from the panel. During validation, panel models did not outperform a simple motor/speech (M/S) deficit variable. Post-hoc analyses suggested the measured behaviour of L-selectin and coagulation factor V contributed to poor model performance. Removal of these proteins increased the external performance of a model containing the panel and the M/S variable.

Conclusions: Univariate analyses suggest insulin-like growth factor-binding protein 3 and serum paraoxonase/lactonase 3 are reliable and reproducible biomarkers for TIA status. Logistic regression models indicated L-selectin, apolipoprotein B-100, coagulation factor IX, and thrombospondin-1 to be significant multivariate predictors of TIA. We discuss multivariate feature subset analyses as an exploratory technique to better understand a panel's full predictive potential.
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http://dx.doi.org/10.1080/1354750X.2018.1499130DOI Listing
December 2018

Association of White Matter Hyperintensities With Short-Term Outcomes in Patients With Minor Cerebrovascular Events.

Stroke 2018 04 14;49(4):919-923. Epub 2018 Mar 14.

From the Department of Clinical Neurosciences (C.Z., A.Y.X.Y., S.K.P, J.I.C., E.E.S., S.B.C.) and the Hotchkiss Brain Institute (E.E.S., S.B.C.), University of Calgary, Alberta, Canada; and Medanta - The Medicity Hospital, Gurgaon, India (J.M.).

Background And Purpose: White matter lesions (WML) are associated with cognitive decline, increased stroke risk, and disability in old age. We hypothesized that superimposed acute cerebrovascular occlusion on chronic preexisting injury (leukoaraiosis) leads to worse outcome after minor cerebrovascular event, both using quantitative (volumetric) and qualitative (Fazekas scale) assessment, as well as relative total brain volume.

Methods: WML volume assessment was performed in 425 patients with high-risk transient ischemic attack (TIA; motor/speech deficits >5 minutes) or minor strokes from the CATCH study (CT and MRI in the Triage of TIA and Minor Cerebrovascular Events to Identify High Risk Patients). Complete baseline characteristics and outcome assessment were available in 412 patients. Primary outcome was disability at 90 days, defined as modified Rankin Scale score of >1. Secondary outcomes were stroke progression, TIA recurrence, and stroke recurrence. Analysis was performed using descriptive statistics and regression models including interaction terms.

Results: Median age was 69 years, 39.8% were female. Sixty-two patients (15%) had unfavorable outcome with disability at 90 days (modified Rankin Scale score >1). Higher Fazekas scores were strongly correlated with higher WML volume (=0.79). Both higher Fazekas score and higher WMH volume were associated with disability at 90 days in univariate regression (odds ratio 1.22; 95% confidence interval, 1.04-1.43 and odds ratio, 1.25 per milliliter increase; 95% confidence interval, 1.02-1.54, respectively) but not with stroke progression, TIA recurrence, or stroke recurrence. In multivariable-adjusted analyses, additive interaction terms were associated with unfavorable outcome (adjusted odds ratio 3.99, 95% confidence interval, 1.87-8.49).

Conclusions: Our data suggest that quantitative and qualitative WML assessments are highly correlated and comparable in TIA/minor stroke patients. WML burden is associated with short-term outcome of patients with good prestroke function in the presence of intracranial stenosis/occlusion.
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http://dx.doi.org/10.1161/STROKEAHA.117.017429DOI Listing
April 2018

Modulated Radiotherapy with Concurrent and Adjuvant Temozolomide for Anaplastic Gliomas: Indian Single-center Data.

Indian J Med Paediatr Oncol 2017 Oct-Dec;38(4):495-501

Department of Radiology and Imaging, Medanta The Medicity, Gurgaon, Haryana, India.

Objective: To evaluate early clinical outcome for anaplastic gliomas (AG) treated in the era of modulated radiotherapy (RT) and concurrent plus adjuvant temozolomide (TMZ) in an Indian setting.

Materials And Methods: Fifty-three patients with AGs treated with modulated RT and concurrent (95%) and adjuvant TMZ (90%) were analyzed. About 80% of patients had Karnofsky performance status (KPS) at least 90 with 30% seizure at presentation. Postoperative magnetic resonance imaging was available in 65% cases and RT dose was 60 Gy in 30 fractions. First posttreatment imaging was performed at 1 month and then at 3 and 6 months post-RT and then every 3 months. Kaplan-Meier analysis was used to estimate disease-free survival (DFS) and overall survival (OS), and analysis was done using SPSS version 18.0.

Results: With median follow-up of 25 months, 2-year DFS and OS were 75% and 88%. There were only 5% symptomatic central nerves system and 8% symptomatic hematological toxicities. At the 1 evaluation, 30.4% had complete response (CR), at 3 months 40%, and at 6 months 43%. At 6 months, only 4% had progressive disease. Forty-six patients were evaluable till the last follow-up with and 55% had stable to CR. On univariate analysis for DFS, KPS at presentation >90 ( = 0.001) and response at 6 months ( = 0.02) were significant and for OS KPS at presentation ( = 0.004) alone.

Conclusion: Modulated RT with TMZ among Grade III glioma patients resulted in minimum treatment-related toxicities and encouraging survival. Molecular prognostic markers will determine most favorable groups in future.
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http://dx.doi.org/10.4103/ijmpo.ijmpo_200_16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5759071PMC
January 2018

Progressive Perineal Urethroplasty for Pelvic Fracture Urethral Distraction Defect in Prepubertal Children: The Outcome.

J Indian Assoc Pediatr Surg 2017 Jan-Mar;22(1):23-28

Department of Urology and Transplantation Surgery, Institute of Kidney Diseases and Research Center and Dr. H.L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Ahmedabad, Gujarat, India.

Background: Urethroplasty in pediatric patients is a challenging task. In this study, we have tried to assess the complexity and evaluate the outcome of progressive perineal anastomotic urethroplasty in prepubertal children.

Materials And Methods: Retrospective data of all the prepubertal children who underwent progressive perineal urethroplasty between March 2009 and April 2014 were analyzed. Patients were evaluated with history, examination, essential laboratory investigations, retrograde urethrogram, and voiding cystourethrogram. Before subjecting the patients for definitive surgery, antegrade and retrograde endoscopic assessment was done. The surgery was performed by the transperineal route with the help of ×2.5 magnification. Patients were followed up with uroflowmetry for every 3 months in the 1 year and for every 6 months in the subsequent years.

Results: Mean age of the patients was 7.3 (range 5-11) years. Mean urethral distraction defect was 1.7 (range 1-2.5) cm. All the patients were successfully managed by the perineal approach. Crural separation was performed in all the patients while additional inferior pubectomy was required in six patients. Mean operating time was 298 (range 180-400) min. Mean blood loss was 174 (range 100-500) ml. One patient had the left calf hematoma in the immediate postoperative period. Seven out of nine (77.7%) patients had successful urethroplasty. Two patients had failed urethroplasty who were successfully managed by redo-urethroplasty. Transient incontinence was observed in one patient. Erectile function could not be assessed in these patients.

Conclusion: This study shows the feasibility of progressive perineal urethroplasty by the perineal route in prepubertal children. An endoscopic assessment should be performed before the definitive surgery. Use of loupe helps in performing better anastomosis and hence yielding a better result.
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http://dx.doi.org/10.4103/0971-9261.194616DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5217134PMC
January 2017

Cerebral Microbleeds and Cortical Superficial Siderosis in Patients Presenting With Minor Cerebrovascular Events.

Stroke 2016 09 9;47(9):2236-41. Epub 2016 Aug 9.

From the Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (C.Z., L.B., S.B.C., E.E.S.); Medanta - The Medicity Hospital, Gurgaon, India (J.M.); and Division of Neurology, Department of Medicine, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada (A.S.).

Background And Purpose: Transient focal neurological episodes occur in cerebral amyloid angiopathy (CAA) and can mimic transient ischemic attack (TIA). Risk factors and outcomes of minor ischemic stroke or TIA might differ in patients with and without cerebral microbleeds (CMBs), including CAA-consistent lobar CMB.

Methods: Baseline magnetic resonance imaging (MRI) was analyzed for CMBs and cortical superficial siderosis in 416 patients in the prospective computed tomography and MRI in the CATCH study (Triage of TIA and Minor Cerebrovascular Events to Identify High Risk Patients). Clinical symptoms, baseline characteristics, recurrence, and 90-day modified Rankin Scale were prospectively collected. MRI white-matter hyperintensity was measured using the Fazekas scale.

Results: CMBs were detected in 65 (15.6%) and cortical superficial siderosis in 11 patients (2.6%). Lobar CMBs were present in 49 (11.8%). In multivariable logistic regression adjusted for risk factors and age, subcortical Fazekas score was associated with lobar CMB (odds ratio, 2.07; 95% confidence interval, 1.23-3.48; P=0.006). Forty-two patients (10.1%) had lobar-only CMBs with or without cortical superficial siderosis consistent with modified Boston criteria for possible/probable CAA. The possible/probable CAA pattern was not predictive of recurrent TIA (odds ratio, 0.42; 95% confidence interval, 0.05-3.31; P=0.41), stroke (odds ratio, 1.24; 95% confidence interval, 0.26-5.99; P=0.79), or 90-day modified Rankin Scale score ≥2 (odds ratio, 1.38; 95% confidence interval, 0.62-3.07; P=0.42).

Conclusions: CMBs in TIA and minor stroke are moderately common but do not predict recurrence or 90-day outcome. CAA-related transient focal neurological episodes and TIA have overlapping clinical symptoms, suggesting that MRI may be needed for differentiation.
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http://dx.doi.org/10.1161/STROKEAHA.116.013418DOI Listing
September 2016

Can deceased donor with recurrent primary brain tumor donate kidneys for transplantation?

Indian J Urol 2016 Jan-Mar;32(1):74-6

Department of Urology, Institute of Kidney Disease and Research Centre, Institute of Transplant Sciences (IKDRC-ITS), Ahmedabad, India.

Kidney transplantation from deceased donors is in its infancy in India. Cadaver organ donation was accepted legally in 1994 by the "Human Organs Transplantation Act." Marginal donors are now accepted by many centers for kidney transplantation. We report a case of procurement of both kidneys from a young deceased donor having recurrent primary brain tumor, transplanted into two adult recipients with successful outcome.
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http://dx.doi.org/10.4103/0970-1591.173104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4756557PMC
March 2016

Imaging in Hirayama disease.

J Neurosci Rural Pract 2016 Jan-Mar;7(1):164-7

Department of Radiology, Medanta, The Medicity Hospital, Gurgaon, Haryana, India.

Hirayama disease, also known as Sobue disease is a rare nonprogressive spinal muscular atrophy. Here, we report a case series of three young males presenting with atrophy of distal upper limb and Hirayama disease as their clinico-radiological diagnosis. Magnetic resonance imaging (MRI) revealed loss of cervical lordosis with focal areas of lower cervical cord atrophy in a neutral position. MRI in flexion position revealed, anterior displacement of the detached posterior dura from the underlying lamina compressing the thecal sac and widened posterior epidural space with flow voids seen better on 3D-CISS images. All the three patients were managed conservatively.
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http://dx.doi.org/10.4103/0976-3147.172174DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4750322PMC
March 2016

Calcification in transitional cell carcinoma of urinary bladder: Does it have any implication on calcium metabolism and its management?

J Cancer Res Ther 2015 Oct-Dec;11(4):1028

Department of Urology, Institute of Kidney Disease and Research Centre, Institute of Transplant Sciences, Ahmedabad, Gujrat, India.

Although transitional cell carcinoma (TCC) is most common histological subtype, calcification in TCC is rarely seen. We report a 64-year-old gentleman who on evaluation found to have calcification in TCC of urinary bladder and its implication on calcium metabolism and management.
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http://dx.doi.org/10.4103/0973-1482.153659DOI Listing
November 2016

Bilateral Wilms' tumors in an infant with Denys-Drash syndrome and rarely seen truncation mutation in the WT1 gene-exon 6.

J Indian Assoc Pediatr Surg 2015 Oct-Dec;20(4):197-8

Department of Urology and Renal Transplantation, Smt. Gulabben Rasiklal Doshi and Smt. Kamlaben Mafatlal Mehta Institute of Kidney Diseases and Research Centre & Dr. H. L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India.

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http://dx.doi.org/10.4103/0971-9261.154641DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4586985PMC
December 2015

Role of Vitamin C and E supplementation in reduction of serum level of renal injury marker following shock wave lithotripsy: Prospective single centre experience.

Urol Ann 2015 Jul-Sep;7(3):350-4

Department of Urology, Smt. Gulabben Rasiklal Doshi and Smt. Kamlaben Mafatlal Mehta Institute of Kidney Diseases and Research Centre and Dr. H. L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India.

Introduction: Shock wave lithotripsy has become first line treatment modality for renal calculi due to its noninvasiveness. However, the destructive forces like dispersion of cavitation bubbles can cause trauma to thin-walled vessels and renal parenchyma during fragmentation of the stones. Antioxidants are our first line of defense against oxidative stress. The aim of this study was to investigate whether oral administration of Vitamin C and E help in a reduction of the serum level of inflammatory mediator by serial measurement of high sensitivity C-reactive protein (hs-CRP) and by this reduction in the risk of renal damage.

Patients And Methods: A total of 107 subjects were recruited in three groups. Group A served as a control group, and Group B and Group C received oral medication of Vitamin E 800 mg/day and Vitamin C 1000 mg/day respectively, start from 2 days prior the lithotripsy and continued for total 7 days. The level of hs-CRP was used as a mediator of the inflammatory response following lithotripsy and thus for long term renal injury. Serum level of hs-CRP was measured on 2 days prior the lithotripsy and day 2, 7 and 28 after the lithotripsy.

Results: Patients who were given either Vitamin C or Vitamin E showed a significant reduction of serum level of hs-CRP when compared to control the group.

Conclusion: Oral administration of Vitamin C and E helps in reduction of serum levels of the inflammatory marker for acute renal injury and thus they can be useful in minimizing the kidney injury following lithotripsy for renal stone disease.
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http://dx.doi.org/10.4103/0974-7796.156143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518373PMC
August 2015

Acute urinary retention caused by seminoma in a case of persistent Mullerian duct syndrome.

Indian J Pathol Microbiol 2015 Jan-Mar;58(1):83-5

Department of Urology and Renal Transplantation, Smt. Gulabben Rasiklal Doshi and Smt. Kamlaben Mafatlal Mehta Institute of Kidney Diseases and Research Centre & Dr. H. L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India.

Urinary symptoms have been described secondary to a pelvic mass originating from the ovary, uterus, cervix, prostate, or rectum. Persistent Mullerian duct syndrome is a rare form of intersex disorder, characterized by the presence of uterus and fallopian tubes in an otherwise 46 XY male. We report an adult male with bilateral cryptorchidism and a pelvic mass, who presented with acute urinary retention, and was diagnosed with a seminoma of the right testis, intratubular germ cell neoplasia of the left testis with the presence of Mullerian remnants. Pelvic mass was caused due to seminoma is a rare cause of urinary retention.
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http://dx.doi.org/10.4103/0377-4929.151196DOI Listing
August 2015

Early cerebral small vessel disease and brain volume, cognition, and gait.

Ann Neurol 2015 Feb;77(2):251-61

Hotchkiss Brain Institute; Department of Clinical Neurosciences; Department of Radiology; Seaman Family Centre, University of Calgary, Calgary, Alberta.

Objective: Decline in cognitive function begins by the 40s, and may be related to future dementia risk. We used data from a community-representative study to determine whether there are age-related differences in simple cognitive and gait tests by the 40s, and whether these differences were associated with covert cerebrovascular disease on magnetic resonance imaging (MRI).

Methods: Between 2010 and 2012, 803 participants aged 40 to 75 years in the Prospective Urban Rural Epidemiological (PURE) study, recruited from prespecified postal code regions centered on 4 Canadian cities, underwent brain MRI and simple tests of cognition and gait as part of a substudy (PURE-MIND).

Results: Mean age was 58 ± 8 years. Linear decreases in performance on the Montreal Cognitive Assessment, Digit Symbol Substitution Test (DSST), and Timed Up and Go test of gait were seen with each age decade from the 40s to the 70s. Silent brain infarcts were observed in 3% of 40- to 49-year-olds, with increasing prevalence up to 18.9% in 70-year-olds. Silent brain infarcts were associated with slower timed gait and lower volume of supratentorial white matter. Higher volume of supratentorial MRI white matter hyperintensity was associated with slower timed gait and worse performance on DSST, and lower volumes of the supratentorial cortex and white matter, and cerebellum.

Interpretation: Covert cerebrovascular disease and its consequences on cognitive and gait performance and brain atrophy are manifest in some clinically asymptomatic persons as early as the 5th decade of life.
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http://dx.doi.org/10.1002/ana.24320DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4338762PMC
February 2015

TIA and minor stroke patients with intracranial occlusions in both proximal and distal vessels are most at risk for symptom progression.

Cerebrovasc Dis 2014 25;38(5):389-90. Epub 2014 Nov 25.

Calgary Stroke Program, University of Calgary, Calgary, Alta., Canada.

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http://dx.doi.org/10.1159/000368886DOI Listing
September 2015

Re: Sabharwal S, Macaden AR, Abrol N, Mukha RP, Kekre NS. A novel computer based stent registry to prevent retained stents: Will patient directed automated short message service and letter generator help? Indian J Urol 2014;30:150-2.

Indian J Urol 2014 Oct;30(4):457-8

Department of Urology and Renal Transplantation, Smt. Gulabben Rasiklal Doshi and Smt. Kamlaben Mafatlal Mehta Institute of Kidney Diseases and Research Centre and Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India.

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http://dx.doi.org/10.4103/0970-1591.142082DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4220393PMC
October 2014

Etiologic classification of TIA and minor stroke by A-S-C-O and causative classification system as compared to TOAST reduces the proportion of patients categorized as cause undetermined.

Cerebrovasc Dis 2014 2;38(2):121-6. Epub 2014 Oct 2.

Department of Clinical Neurosciences, Radiology, King Abdulaziz University, Jeddah, Saudi Arabia.

Background: The assortment of patients based on the underlying pathophysiology is central to preventing recurrent stroke after a transient ischemic attack and minor stroke (TIA-MS). The causative classification of stroke (CCS) and the A-S-C-O (A for atherosclerosis, S for small vessel disease, C for Cardiac source, O for other cause) classification schemes have recently been developed. These systems have not been specifically applied to the TIA-MS population. We hypothesized that both CCS and A-S-C-O would increase the proportion of patients with a definitive etiologic mechanism for TIA-MS as compared with TOAST.

Methods: Patients were analyzed from the CATCH study. A single-stroke physician assigned all patients to an etiologic subtype using published algorithms for TOAST, CCS and ASCO. We compared the proportions in the various categories for each classification scheme and then the association with stroke progression or recurrence was assessed.

Results: TOAST, CCS and A-S-C-O classification schemes were applied in 469 TIA-MS patients. When compared to TOAST both CCS (58.0 vs. 65.3%; p < 0.0001) and ASCO grade 1 or 2 (37.5 vs. 65.3%; p < 0.0001) assigned fewer patients as cause undetermined. CCS had increased assignment of cardioembolism (+3.8%, p = 0.0001) as compared with TOAST. ASCO grade 1 or 2 had increased assignment of cardioembolism (+8.5%, p < 0.0001), large artery atherosclerosis (+14.9%, p < 0.0001) and small artery occlusion (+4.3%, p < 0.0001) as compared with TOAST. Compared with CCS, using ASCO resulted in a 20.5% absolute reduction in patients assigned to the 'cause undetermined' category (p < 0.0001). Patients who had multiple high-risk etiologies either by CCS or ASCO classification or an ASCO undetermined classification had a higher chance of having a recurrent event.

Conclusion: Both CCS and ASCO schemes reduce the proportion of TIA and minor stroke patients classified as 'cause undetermined.' ASCO resulted in the fewest patients classified as cause undetermined. Stroke recurrence after TIA-MS is highest in patients with multiple high-risk etiologies or cryptogenic stroke classified by ASCO.
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http://dx.doi.org/10.1159/000365500DOI Listing
August 2015

Robotic assisted kidney transplantation.

Indian J Urol 2014 Jul;30(3):287-92

Henry Ford Hospital, Detroit, Michigan, USA.

Kidney transplantation is the standard of care for patients with end stage renal disease. While open surgery remains the gold standard, minimally invasive surgery has recently been introduced for the recipient undergoing kidney transplantation. We review the evolution of techniques of minimally invasive surgery for kidney transplantation with specific emphasis on technical aspects of robotic assisted kidney transplantation.
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http://dx.doi.org/10.4103/0970-1591.135669DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4120216PMC
July 2014

Validity of the diagnostic criteria for chronic cerebrospinal venous insufficiency and association with multiple sclerosis.

CMAJ 2014 Aug 2;186(11):E418-26. Epub 2014 Jun 2.

Departments of Clinical Neurosciences (Costello, Modi, Scott, Davenport, Trufyn, Frayne, Ciura, Goyal, Hill), Surgery (Costello), Radiology (Modi, Lautner, Bhayana, Scott, Frayne, Ciura, Goyal), Pediatrics (Mah), Medical Genetics (Davenport), Medicine (Hill) and Community Health Sciences (Hill); Hotchkiss Brain Institute (Costello, Davenport, Hill); and Seaman Family Centre, Foothills Medical Centre, Alberta Health Services (Bhayana, Scott, Frayne, Goyal), University of Calgary, Calgary, Alta.

Background: The chronic cerebrospinal venous insufficiency theory proposes that altered cerebral venous hemodynamics play a role in the pathophysiology of multiple sclerosis. We aimed to explore the validity of this hypothesis by assessing the diagnostic criteria for chronic cerebrospinal venous insufficiency in persons with and without multiple sclerosis.

Methods: We compared the proportion of venous outflow abnormalities between patients with multiple sclerosis and healthy controls using extracranial Doppler ultrasonography and gadolinium-enhanced magnetic resonance venography. Interpreting radiologists were blinded to the clinical status of participants.

Results: We enrolled 120 patients with multiple sclerosis and 60 healthy controls. High proportions of both patients (67/115 [58%]) and controls (38/60 [63%]) met 1 or more of the proposed ultrasound criteria for diagnosis of chronic cerebrospinal venous insufficiency (p = 0.6). A minority of patients (23/115 [20%]) and controls (6/60 [10%]) fulfilled 2 or more of the proposed criteria (p = 0.1). There were no differences between patients and controls in the prevalence of each individual ultrasound criterion. Similarly, there were no differences in intracranial or extracranial venous patency between groups, as measured by magnetic resonance venography.

Interpretation: We detected no differences in the proportion of venous outflow abnormalities between patients with multiple sclerosis and healthy controls. Moreover, our study revealed significant methodologic concerns regarding the proposed diagnostic criteria for chronic cerebrospinal venous insufficiency that challenge their validity.
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http://dx.doi.org/10.1503/cmaj.131431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4119167PMC
August 2014

Magnetic Resonance Imaging versus Computed Tomography in Transient Ischemic Attack and Minor Stroke: The More Υou See the More You Know.

Cerebrovasc Dis Extra 2013 8;3(1):130-6. Epub 2013 Oct 8.

Department of Clinical Neurosciences, University of Calgary, Calgary, Alta., Canada ; Department of Radiology, University of Calgary, Calgary, Alta., Canada ; Department of Hotchkiss Brain Institute, University of Calgary, Calgary, Alta., Canada.

Background: Magnetic resonance imaging (MRI) is proposed as the preferred imaging modality to investigate patients with transient ischemic attack (TIA). This is mainly based on a higher yield of small acute ischemic lesions; however, direct prospective comparisons are lacking. In this study, we aimed to directly compare the yield of acute ischemic lesions on MRI and computed tomography (CT) in the emergency diagnosis of suspected TIA or minor stroke.

Methods: Consecutive patients aged 18 years or older presenting with minor stroke (NIHSS <4) or high-risk TIA and who were examined by a stroke neurologist within 24 h of symptom onset were prospectively enrolled in the CATCH study. Patients who had undergone both a baseline CT and an MRI within 24 h of symptom onset were included in this substudy. Baseline MRI and CT were interpreted independently to identify an acute ischemic lesion. The rates of acute ischemic lesions on CT and MRI were compared, and the volume of acute ischemic lesions was measured on MRI. In addition, the volume of acute ischemic lesions on MRI was compared between patients who had evidence of acute ischemia on CT and in those who did not.

Results: A total of 347 patients were included, 168 with TIAs, 147 with minor strokes and 32 with a final diagnosis of a mimic. Acute ischemic lesions were detected in 39% of TIAs by using MRI versus 8% by using CT (p < 0.0001) and in 86% of minor strokes by using MRI versus 18% by using CT (p < 0.0001). Compared to MRI, CT had a sensitivity of 20% and a specificity of 98% in identifying an acute ischemic lesion. The infarct volume on diffusion-weighted MRI was larger in cases where the CT also showed an acute ischemic lesion (median 5.07 ml, IQR 10) as compared to lesions seen only on MRI (median 0.68 ml, IQR 1.31, p < 0.0001).

Conclusion: MRI is superior to CT in detecting the small ischemic lesions occurring after TIA and minor stroke. Since these lesions are clinically relevant, MRI should be the preferred imaging modality in this setting.
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http://dx.doi.org/10.1159/000355024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3884208PMC
January 2014

Spontaneous closure of urethrovaginal fistula associated with pelvic fracture.

Indian J Urol 2013 Jul;29(3):251-2

Department of Urology and Renal Transplantation, Institute of Kidney Diseases and Research Centre Institute of Transplantation Sciences, Ahmedabad, Gujrat, India.

Female urethral injury following pelvic fracture is a rare entity. Due to the absence of large series, management guidelines are still not standardized. Patients can have associated urethrovaginal or vesicovaginal fistula, management of which poses a major challenge to the reconstructive urologist. Spontaneous closure of fistula produced by gynecological or obstetrical injuries have been described in the literature. Spontaneous closure of fistula caused due to pelvic fracture has not been described in the literature.
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http://dx.doi.org/10.4103/0970-1591.117262DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3783708PMC
July 2013

Perfusion MR predicts outcome in high-risk transient ischemic attack/minor stroke: a derivation-validation study.

Stroke 2013 Sep 1;44(9):2486-92. Epub 2013 Aug 1.

Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.

Background And Purpose: Transient or minor ischemic stroke is associated with an early risk of deterioration. Baseline perfusion-diffusion mismatch may predict clinical deterioration and infarct growth in this population.

Methods: High-risk transient ischemic attack and minor stroke (National Institutes of Health Stroke Scale ≤3) subjects were prospectively enrolled and imaged with MRI within 24 hours of symptom onset as part of sequential derivation and validation cohorts. Baseline diffusion-weighted imaging, perfusion-weighted imaging (Tmax≥4 s), mismatch (Tmax≥4 s-diffusion-weighted imaging), and follow-up fluid-attenuated inversion recovery infarct volumes were measured. Primary outcome was infarct growth on fluid-attenuated inversion recovery, and secondary outcome was symptom progression.

Results: One hundred thirty-seven and 281 subjects were included in the derivation and validation cohorts, respectively. Infarct growth occurred in 18.5% of the derivation and 5.5% of the validation cohorts. Symptom progression occurred in 9.5% of the derivation and 4.5% of the validation cohorts. In the derivation cohort, subjects with baseline mismatch were significantly more likely to show infarct growth on fluid-attenuated inversion recovery (relative risk [RR], 13.5; 95% confidence interval [CI], 4.2-38.9) and symptom progression (RR, 7.0; 95% CI, 2.0-7.3). A baseline mismatch volume of 10 mL in the derivation cohort was the optimal threshold to predict infarct growth (area under the curve, 0.89; 95% CI, 0.80-0.98). This threshold was highly predictive of infarct growth in the validation cohort (P=0.001). Baseline mismatch was associated with clinical deterioration in the derivation (area under the curve, 0.81; 95% CI, 0.67-0.96) and validation cohorts (area under the curve, 0.66; 95% CI, 0.46-0.85).

Conclusions: Among subjects with high-risk transient ischemic attack and minor stroke, diffusion-weighted imaging-perfusion-weighted imaging mismatch predicts infarct growth and clinical deterioration. These findings suggest that reperfusion strategies would be beneficial in this population.
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http://dx.doi.org/10.1161/STROKEAHA.111.000208DOI Listing
September 2013

Refinement of Imaging Predictors of Recurrent Events following Transient Ischemic Attack and Minor Stroke.

PLoS One 2013 21;8(6):e65752. Epub 2013 Jun 21.

Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.

Background: TIA and minor stroke have a high risk of recurrent stroke. Abnormalities on CT/CTA and MRI predict recurrent events in TIA and minor stroke. However there are many other imaging abnormalities that could potentially predict outcome that have not been assessed in this population. Also the definition of recurrent events used includes deterioration due to stroke progression or recurrent stroke and whether imaging is either of these is not known.

Aims: To improve upon the clinical, CT/CTA and MRI parameters that predict recurrent events after TIA and minor stroke by assessing further imaging parameters. Secondary aim was to explore predictors of stroke progression versus recurrent stroke.

Methods: 510 consecutive TIA and minor stroke patients had CT/CTA and most had MRI. Primary outcome was recurrent events (stroke progression or recurrent stroke) within 90 days. Further imaging parameters were assessed for prediction of recurrent events (combined outcome of stroke progression and recurrent stroke). We also explored predictors of symptom progression versus recurrence individually.

Results: 36 recurrent events (36/510, 7.1% (95% CI: 5.0-9.6)) including 19 progression and 17 recurrent strokes. On CT/CTA: white matter disease, prior stroke, aortic arch focal plaque≥4 mm, or intraluminal thrombus did not predict recurrent events (progression or recurrent stroke). On MRI: white matter disease, prior stroke, and microbleeds did not predict recurrent events. Parameters predicting the individual outcome of symptom progression included: ongoing symptoms at initial assessment, symptom fluctuation, intracranial occlusion, intracranial occlusion or stenosis, and the CT/CTA metric. No parameter was strongly predictive of a distinct recurrent stroke.

Conclusions: There was no imaging parameter that could improve upon our original CT/CTA or MRI metrics to predict the combined outcome of stroke progression or a recurrent stroke after TIA and minor stroke. We are better at using imaging to predict stroke progression rather than recurrent stroke.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0065752PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3689749PMC
October 2017

Validation study of a fast, accurate, and precise brain tumor volume measurement.

Comput Methods Programs Biomed 2013 Aug 18;111(2):480-7. Epub 2013 May 18.

Imaging Informatics Lab, 2500 University Drive NW, Calgary, AB T2N 1N4, Canada.

Unlabelled: Precision and accuracy are sometimes sacrificed to ensure that medical image processing is rapid. To address this, our lab had developed a novel level set segmentation algorithm that is 16× faster and >96% accurate on realistic brain phantoms.

Methods: This study reports speed, precision and estimated accuracy of our algorithm when measuring MRIs of meningioma brain tumors and compares it to manual tracing and modified MacDonald (MM) ellipsoid criteria. A repeated-measures study allowed us to determine measurement precisions (MPs) - clinically relevant thresholds for statistically significant change.

Results: Speed: the level set, MM, and trace methods required 1:20, 1:35, and 9:35 (mm:ss) respectively on average to complete a volume measurement (p<0.05). Accuracy: the level set was not statistically different to the estimated true lesion volumes (p>0.05). Precision: the MM's within-operator and between-operator MPs were significantly higher (worse) than the other methods (p<0.05). The observed difference in MP between the level set and trace methods did not reach statistical significance (p>0.05).

Conclusion: Our level set is faster on average than MM, yet has accuracy and precision comparable to manual tracing.
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http://dx.doi.org/10.1016/j.cmpb.2013.04.011DOI Listing
August 2013

The ICV sign as a marker of increased cerebral blood transit time.

Can J Neurol Sci 2013 Mar;40(2):187-91

Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.

Objective/background: We describe the internal cerebral vein (ICV) sign, which is a hypo-opacification of the ICV on computed tomogram angiography (CTA) as a new marker of increased cerebral blood transit-time in ipsilateral internal carotid artery occlusions (ICAO).

Methods: A retrospective analysis of 153 patients with acute unilateral M1 middle cerebral artery (MCA) occlusions ± ICAOs was performed. The degree of contrast opacification of the ICV on the ipsilesional side was compared to that of the unaffected side.

Results: Of 153 patients in our study, 135 had M1 MCA occlusions ± intra-cranial ICAO (M1±iICAO) and 18 had isolated extracranial ICAO (eICAO). In the patients with proximal M1±iICAO, 57/65 (87.1%) showed the ICV sign. Of the 8 patients without the ICV sign in this group, 6 had prominent lenticulostriate arteries arising from the non-occluded M1 segment, 1 had a recurrent artery of Huebner, and 1 had filling of distal ICA/M1 segment through prominent Circle of Willis collaterals. For the 70 patients with isolated distal M1±iICAO, 7/70 (10%) showed the ICV sign, with all 7 showing occluded lenticulostriate arteries. Of the patients with eICAO, 8/18 showed the ICV sign, all 8 with the ICV sign had poor Circle of Willis collaterals.

Conclusions: The ICV sign correlates well with presence of proximal M1±iICAO in patients with either occluded lenticulostriate arteries or poor Circle of Willis collaterals. In patients with eICAO, the sign correlates with reduced Circle of Willis collaterals and may be a marker of increased ipsilateral cerebral blood transit time.
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http://dx.doi.org/10.1017/s0317167100013718DOI Listing
March 2013

Early magnetic resonance imaging in transient ischemic attack and minor stroke: do it or lose it.

Stroke 2013 Mar 6;44(3):671-4. Epub 2013 Feb 6.

Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada.

Background And Purpose: The use of magnetic resonance imaging (MRI) after transient ischemic attack (TIA) or minor stroke may be affected by the relative timing of imaging. We measured the impact of scanning an individual patient late versus early after TIA and minor stroke.

Methods: Two hundred sixty-three TIA or minor stroke (National Institute of Health Stroke Scale score ≤3) patients with a baseline MRI completed within 24 hours of symptom onset and a follow-up MRI at 90 days were included. Baseline and 90-day scans were assessed independently for the presence of any stroke lesions that could explain the presenting symptoms. The presence and pattern of any stroke lesions were compared at the 2 time points.

Results: The presence of a stroke (acute or chronic) in any location was more common on baseline MRI versus 90-day MRI (68% vs 56%; P=0.005). Thirty percent of subjects with negative scans at 90 days had a clearly identifiable stroke at baseline. When interpreted blinded to the baseline scan, the presumed relevant lesion on the 90-day MR scan was the correct lesion in only 53% patients. One-third (34%) of patients had a different lesion pattern on the baseline scan compared with the 90-day scan. Ninety percent (80/89) of these patients had more lesions on the baseline MRI and 10% (9/89) had new lesions on the 90-day MRI.

Conclusions: Delayed MRI after TIA or minor stroke reduces the diagnostic yield and results in missed understanding of the lesion pattern. MRI of minor stroke and TIA patients should occur early after symptom onset, and delayed imaging should be interpreted with caution.
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http://dx.doi.org/10.1161/STROKEAHA.111.680033DOI Listing
March 2013

Retroperitoneoscopic living-donor nephrectomy and laparoscopic kidney transplantation: experience of initial 72 cases.

Transplantation 2013 Jan;95(1):100-5

Institute of Kidney Diseases and Research Centre, Institute of Transplantation Sciences, Ahmedabad, Gujarat, India.

Background: To evaluate the feasibility, safety, and outcome of laparoscopic kidney transplantation (LKT) after retroperitoneoscopic living-donor nephrectomy.

Methods: Between February 2010 and January 2012, a total of 217 renal transplantations were performed from living donors by a single surgical unit. All living-donor nephrectomies were performed by retroperitoneoscopic approach. Recipient surgery was performed either laparoscopically (n=72) or by conventional open approach (n=145). In the LKT group, a 5 to 6 cm Pfannenstiel incision was placed and the kidney was dropped into abdomen. Renal vessels were anastomosed by freehand suturing technique. Calcineurin inhibitor-based immunosuppressants were given.

Results: The mean operative time was 223.8 and 175.7 min (P=0.07) and the rewarming time was 60.3 and 30.3 min (P=0.03) in the LKT and open kidney transplantation (OKT) groups, respectively. The estimated glomerular filtration rate value on days 7 and 30 was significantly less in the LKT group, but no difference was found at 3, 6, 12, and 18 months. The mean wound length was 5.5 and 17.8 cm (P=0.0001) and the analgesic requirement was 1.4 and 3.2 mg morphine equivalent in first 24 hr (P=0.005) in the LKT and OKT groups, respectively. In the LKT group, four cases required conversion to open surgery due to vascular complications and one for urinary leak. Kaplan-Meier curve shows 86.5% and 94.6% (P=0.086) and patient survival is 94.1% and 94.7% (P=0.745) at 22.3 months of follow-up.

Conclusions: LKT after living-donor nephrectomy is feasible, but it has steep learning curve. Graft fixation with peritoneal fold is necessary to avoid torsion and related graft loss. Pain after LKT is significantly less compared with conventional OKT.
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http://dx.doi.org/10.1097/TP.0b013e3182795beeDOI Listing
January 2013

High rate of magnetic resonance imaging stroke recurrence in cryptogenic transient ischemic attack and minor stroke patients.

Stroke 2012 Dec 2;43(12):3387-8. Epub 2012 Oct 2.

Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, and Foothills Hospital, C1261, 1403 29 St NW, Calgary, AB, T2N 2T9, Canada.

Background And Purpose: Cryptogenic stroke is common in patients with transient ischemic attack (TIA) and minor stroke. It is likely that the imaging recurrence risk is higher than the clinical recurrence rate. We sought to determine the rate of clinical and radiographic stroke recurrence in a population of cryptogenic TIA and minor stroke.

Methods: Patients with TIA/minor stroke (National Institutes of Health Stroke Scale score≤3) were prospectively enrolled and imaged within 24 hours of symptom onset as part of 2 cohorts. Patients were assessed at 3 months to document any clinical recurrence and underwent repeat magnetic resonance imaging (MRI) at either 30 or 90 days. Stroke mechanism was categorized as cryptogenic after standard etiologic work-up was completed and was negative. Follow-up MRI was assessed for any new lesions in comparison with baseline imaging.

Results: Three hundred thirty-three of 693 (48%) patients had cryptogenic stroke. Of these cryptogenic patients, 207 (62%) had follow-up imaging. At 30-day MRI follow-up, 6.6% (5/76) had new lesions (3 in a remote arterial territory). At 90-day MRI follow-up, 14.5% (19/131) had new lesions (9 in a remote arterial territory). Clinical recurrent stroke was seen in 1.2% (4/333) of patients within 90 days.

Conclusions: Cryptogenic etiology is common in a TIA/minor stroke population. This population shows a high rate of silent radiographic recurrence, suggesting active disease. Use of MRI as a surrogate marker of disease activity is 1 potential way of assessing efficacy of new treatments in this population with reduced sample size.
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http://dx.doi.org/10.1161/STROKEAHA.112.671172DOI Listing
December 2012

What causes disability after transient ischemic attack and minor stroke?: Results from the CT and MRI in the Triage of TIA and minor Cerebrovascular Events to Identify High Risk Patients (CATCH) Study.

Stroke 2012 Nov 13;43(11):3018-22. Epub 2012 Sep 13.

Department of Clinical Nuerosciences, University of Calgary, Foothills Hospital, C1261, 1403 29 Street NW, Calgary, AB, T2N 2T9, Canada.

Background And Purpose: Minor stroke and transient ischemic attack portend a significant risk of disability. Three possible mechanisms for this include disability not captured by the National Institutes of Health Stroke Scale, symptom progression, or recurrent stroke. We sought to assess the relative impact of these mechanisms on disability in a population of patients with transient ischemic attack and minor stroke.

Methods: Five hundred ten consecutive minor stroke (National Institutes of Health Stroke Scale<4) or patients with transient ischemic attack who were previously not disabled and had a CT/CT angiography completed within 24 hours of symptom onset were prospectively enrolled. Disability was assessed at 90 days using the modified Rankin Scale. Predictors of disability (modified Rankin Scale≥2) and the relative impact of the initial event versus recurrent events were assessed.

Results: Seventy-four of 499 (15%; 95% CI, 12%-18%) patients had a disabled outcome. Baseline factors predicting disability were: age≥60 years, diabetes mellitus, premorbid modified Rankin Scale 1, ongoing symptoms, baseline National Institutes of Health Stroke Scale, CT/CT angiography-positive metric, and diffusion-weighted imaging positivity. In the multivariable analysis ongoing symptoms (OR, 2.4; 95% CI, 1.3-4.4; P=0.004), diabetes mellitus (OR, 2.3; 95% CI, 1.2-4.3; P=0.009), female sex (OR, 1.8; 95% CI, 1.1-3; P=0.025), and CT/CT angiography-positive metric (OR, 2.4; 95% CI, 1.4-4; P=0.001) predicted disability. Of the 463 patients who did not have a recurrent event, 55 were disabled (12%). By contrast 19 of 36 (53%) patients were disabled after a recurrent event (risk ratio, 4.4; 95% CI, 3-6.6; P<0.0001).

Conclusions: We found that a substantial proportion of patients with transient ischemic attack and minor stroke become disabled. In terms of absolute numbers, most patients have disability as a result of their presenting event; however, recurrent events have the largest relative impact on outcome.
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http://dx.doi.org/10.1161/STROKEAHA.112.665141DOI Listing
November 2012

Time dependence of reliability of noncontrast computed tomography in comparison to computed tomography angiography source image in acute ischemic stroke.

Int J Stroke 2015 Jan 13;10(1):55-60. Epub 2012 Sep 13.

Department of Clinical Neurosciences, Hotchkiss Brain Institute University of Calgary, Calgary, Alberta, Canada; Section of Neurology, Department of Internal Medicine, Health sciences Centre, Winnipeg, Canada.

There is no consensus on how the reliability and predictive ability of noncontrast computed tomography (NCCT) and computed tomography angiography source image (CTASI) change over time from acute ischemic stroke onset. We hypothesized that the reliability for detecting early ischemic changes (EIC) would be lower in early time periods and that changes identified on CTASI would be more reliable across examiners than changes identified on NCCT. To address this, we compared the relationships between CTASI, NCCT, and final infarct in patients with initial computed tomography (CT) imaging at different time points after stroke onset. Patients with acute ischemic stroke with proximal anterior circulation occlusions (internal carotid artery, middle carotid artery M1, proximal M2) from Calgary CT Angiography (CTA) database were studied. The cohort was categorized in four groups based on time from stroke onset to baseline NCCT/CTA: 0-90 mins (n = 69), 91-180 mins (n = 88), 181-360 mins (n = 46), and >360 mins (n = 58). Median scores of NCCT-Alberta Stroke Program Early CT Score (ASPECTS), CTASI ASPECTS, and follow-up ASPECTS among different time categories were compared. To determine reliability, a subsample of NCCT brain and CTASI were interpreted at separate sessions weeks apart by two neuroradiologists and two stroke neurologists in random order. Median and mean ASPECTS ratings on NCCT and CTASI were higher than final ASPECTS in each time category (P < 0·001 for all comparisons). CTASI ASPECTS was lower than NCCT ASPECTS in each time category, and differences were significant at 0-90 mins and 91-180 mins (P < 0·001). The least agreement among readers was in detection of EIC on NCCT brain in the ultra-early phase (<90 mins) [intraclass correlation coefficient (ICC) = 0·48. By contrast, there was excellent agreement on EIC on CTASI regardless of time period (ICC = 0·87-0·96). Using ASPECTS methodology, CTASI is more reliable than NCCT at predicting final infarct extent particularly in the early time windows.
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http://dx.doi.org/10.1111/j.1747-4949.2012.00859.xDOI Listing
January 2015