Publications by authors named "Thien J Huynh"

18 Publications

  • Page 1 of 1

Clinical and radiographic characteristics of sacral arteriovenous fistulas: a multicenter experience.

J Neurosurg Spine 2021 Oct 8:1-11. Epub 2021 Oct 8.

1Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida.

Objective: Available data on management of sacral arteriovenous fistulas (sAVFs) are limited to individual case reports and small series. Management includes observation, endovascular embolization, or surgical ligation, with no clear guidelines on the optimal treatment modality. The authors' objective was to report their multiinstitutional experience with management of sAVF patients, including clinical and radiographic characteristics and postprocedural outcomes.

Methods: The electronic medical records of patients with a diagnosis of spinal arteriovenous fistula treated from January 2004 to December 2019 at the authors' institutions were reviewed, and data were summarized using descriptive statistics, including percentage and count for categorical data, median as a measure of central tendency for continuous variables, and interquartile range (IQR) as a measure of dispersion.

Results: A total of 26 patients with sAVFs were included. The median (IQR) age was 65 (57-73) years, and 73% (n = 19) of patients were male. Lower-extremity weakness was the most common presenting symptom (n = 24 [92%]), and half the patients (n = 13 [50%]) reported bowel and bladder sphincter dysfunction. The median (IQR) time from symptom onset to treatment was 12 (5.25-26.25) months. Radiographically, all patients had T2 hyperintensity at the level of the conus medullaris (CM) (n = 26 [100%]). Intradural flow voids were identified in 85% (n = 22) of patients. The majority of the lesions had a single identifiable arterial feeder (n = 19 [73%]). The fistula was located most commonly at the S1 level (n = 13 [50%]). The site where the draining vein connects to the pial venous plexus was seen predominantly at the lumbar level (n = 16 [62%]). In total, 29 procedures were performed: 10 open surgeries and 19 endovascular embolization procedures. Complete occlusion was achieved in 90% (n = 9) of patients after open surgery and 79% (n = 15) after endovascular embolization. Motor improvement was seen in 68% of patients (n = 15), and bladder and bowel function improved in 9 patients (41%). At last follow-up, 73% (n = 16) of patients had either resolution or improvement of the pretreatment intramedullary T2 signal hyperintensity.

Conclusions: T2 hyperintensity of the CM and a dilated filum terminale vein are consistent radiographic signs of sAVF, and delayed presentation is common. Complete occlusion was achieved in almost all patients after surgery, and endovascular embolization was effective in 70% of the patients. Further studies are needed to determine the best treatment modality based on case-specific characteristics.
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http://dx.doi.org/10.3171/2021.5.SPINE21119DOI Listing
October 2021

Management of Ruptured Intracranial Aneurysms in the Post-International Subarachnoid Aneurysm Trial Era: A Single-Centre Prospective Series.

Can J Neurol Sci 2021 Mar 17:1-8. Epub 2021 Mar 17.

Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada.

Background: Aneurysmal subarachnoid haemorrhage (aSAH) is associated with significant morbidity and mortality. The International Subarachnoid Aneurysm Trial (ISAT) reported reduced morbidity in patients treated with endovascular coiling versus surgical clipping. However, recent studies suggest that there is no significant difference in clinical outcomes. This study examines the outcomes of either technique for treating aSAH during the 15 years post-ISAT at a Canadian quaternary centre.

Methods: We reviewed prospectively collected data of patients admitted with aSAH from January 2002 to December 2017. Glasgow Outcome Scale (GOS) was compared at discharge, 6 months and 12 months' follow-up using univariate and multivariable ordinal logistic regression. Post-operative complications were assessed using binary logistic regression.

Results: Two-hundred and eighty-seven patients were treated with coiling and 95 patients with clipping. The mean age of clipped patients was significantly younger, and hypertension was significantly commoner in coiled patients. A greater proportion of coiled aneurysms were located in the posterior circulation. No difference in the odds of having a favourable GOS was seen between patients who were clipped versus coiled at any of follow-up time points on univariate or multivariable analysis. In both treatment groups, patient recovery to independence (GOS 4-5) was seen from discharge to 6 months, but not from 6 to 12 months' follow-up, without difference between clipping and coiling.

Conclusion: These real-world findings suggest clipping remains an effective and important treatment option for patients with aSAH who do not meet ISAT inclusion criteria. The results can assist in clinical decision-making processes and understanding of the natural recovery progression of aSAH.
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http://dx.doi.org/10.1017/cjn.2021.45DOI Listing
March 2021

Republished: Successful treatment of direct carotid-cavernous fistula in a patient with Ehlers-Danlos syndrome type IV without arterial puncture: the transvenous triple-overlay embolization (TAILOREd) technique.

J Neurointerv Surg 2020 Nov 21;12(11):e8. Epub 2020 Aug 21.

Department of Radiology, University of Washington, Seattle, Washington, USA

We report successful transvenous treatment of direct carotid-cavernous fistula in a patient with Ehlers-Danlos syndrome type IV using a novel triple-overlay embolization (TAILOREd) technique without the need for arterial puncture, which is known to be highly risky in this patient group. The TAILOREd technique allowed for successful treatment using preoperative MR angiography as a three-dimensional overlay roadmap combined with cone beam CT and live fluoroscopy, precluding the need for an arterial puncture.
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http://dx.doi.org/10.1136/neurintsurg-2017-013052.repDOI Listing
November 2020

Vascular Trauma in the Head and Neck and Endovascular Neurointerventional Management.

J Clin Imaging Sci 2020 30;10:44. Epub 2020 Jul 30.

Departments of Neurosurgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, United States.

Traumatic vascular injuries of the head and neck can pose life-threatening emergencies, and therefore, the detection and accurate characterization of these injuries by the radiologist is essential. Computed tomographic angiography (CTA) is commonly performed as part of the initial imaging work-up of patients who have sustained blunt or penetrating craniocervical injuries and are suspected to have or are at risk for vascular injuries. This pictorial essay reviews the CTA and conventional angiographic imaging appearance of various vascular injuries that can occur from trauma in the head and neck and also explores the neurointerventional management of these types of injuries.
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http://dx.doi.org/10.25259/JCIS_96_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7451169PMC
July 2020

Republished: Competitive flow diversion of multiple P1 aneurysms: proposed classification.

J Neurointerv Surg 2020 Sep 22;12(9):e7. Epub 2020 Jun 22.

Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada

We report the case of a patient with subarachnoid hemorrhage and three aneurysms arising from the posterior communicating artery (Pcomm)-P1 complex, treated with endovascular coiling and competitive flow diversion. The largest and likely ruptured Pcomm aneurysm was treated with traditional coiling. Two smaller potentially ruptured aneurysms arose from the distal right posterior cerebral artery (PCA) P1 segment. After a failed attempt to treat with conventional flow diversion across the PCA-P1 segment, the P1 aneurysms were successfully treated with competitive flow diversion distal to the PCA-P1 segment from Pcomm to the P2 segment. Over 12 months, competitive flow diversion redirected flow to the right PCA territory via the internal carotid artery-Pcomm-P2, reducing the size of the PCA-P1 segment and obliterating the P1 aneurysms. Competitive flow diversion treatment should be considered for aneurysms occurring at the circle of Willis when traditional methods are not feasible. Herein, we introduce a novel classification for competitive flow diversion treatment.
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http://dx.doi.org/10.1136/neurintsurg-2019-015581.repDOI Listing
September 2020

Competitive flow diversion of multiple P1 aneurysms: proposed classification.

BMJ Case Rep 2020 Jun 3;13(6). Epub 2020 Jun 3.

Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada

We report the case of a patient with subarachnoid hemorrhage and three aneurysms arising from the posterior communicating artery (Pcomm)-P1 complex, treated with endovascular coiling and competitive flow diversion. The largest and likely ruptured Pcomm aneurysm was treated with traditional coiling. Two smaller potentially ruptured aneurysms arose from the distal right posterior cerebral artery (PCA) P1 segment. After a failed attempt to treat with conventional flow diversion across the PCA-P1 segment, the P1 aneurysms were successfully treated with competitive flow diversion distal to the PCA-P1 segment from Pcomm to the P2 segment. Over 12 months, competitive flow diversion redirected flow to the right PCA territory via the internal carotid artery-Pcomm-P2, reducing the size of the PCA-P1 segment and obliterating the P1 aneurysms. Competitive flow diversion treatment should be considered for aneurysms occurring at the circle of Willis when traditional methods are not feasible. Herein, we introduce a novel classification for competitive flow diversion treatment.
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http://dx.doi.org/10.1136/bcr-2019-015581DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7279675PMC
June 2020

The ability of magnetic resonance black blood vessel wall imaging to evaluate blunt cerebrovascular injury following acute trauma.

J Neuroradiol 2020 May 21;47(3):210-215. Epub 2019 Jan 21.

University of Washington Department of Radiology, United States.

Background And Purpose: Blunt cerebrovascular injury (BCVI) is associated with a significant risk of ischemic stroke when left untreated. Cross-sectional imaging is vital to early BCVI diagnosis and treatment; however, conventional luminal vessel imaging is limited in its ability to evaluate for vessel wall pathology. The purpose of this study is to evaluate the ability of vessel wall magnetic resonance imaging (VWI) to detect and evaluate BCVI in acutely injured trauma patients relative to neck computed tomographic angiography (CTA).

Materials And Methods: Trauma patients with suspected BCVI on initial neck CTA were prospectively recruited for VWI evaluation. Two neuroradiologists blinded to patient clinical history and CTA findings evaluated each artery independently on VWI and noted the presence and grade of BCVI. These results were subsequently compared to neck CTA findings relative to expert clinical consensus review. Interrater reliability of VWI for detecting BCVI was evaluated using a weighted Cohen κ-statistic.

Results: Ten trauma patients (40 cervical arteries) were prospectively evaluated using both CTA and VWI. Out of 18 vascular lesions identified as suspicious for BCVI on CTA, six lesions were determined to represent true BCVI by expert consensus review. There was almost perfect agreement between VWI and expert consensus regarding the presence and grade of BCVI (κ=0.82). This agreement increased when considering only low grade BCVI. There was only fair agreement between CTA and expert clinical consensus (κ=0.36). This agreement decreased when considering only low grade BCVI.

Conclusions: VWI can potentially accurately identify and evaluate BCVI in acutely injured trauma patients with excellent inter-rater reliability.
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http://dx.doi.org/10.1016/j.neurad.2019.01.091DOI Listing
May 2020

Vessel wall MRI characteristics of endovascularly treated aneurysms: association with angiographic vasospasm.

J Neurosurg 2018 09;131(3):859-867

Departments of1Radiology.

Objective: The aim of this paper was to evaluate the association between intracranial vessel wall MRI enhancement characteristics and the development of angiographic vasospasm in endovascularly treated aneurysm patients.

Methods: Consecutive cases of both ruptured and unruptured intracranial aneurysms that were treated endovascularly, followed by intracranial vessel wall MRI in the immediate postoperative period, were included. Two raters blinded to clinical data and follow-up imaging independently evaluated for the presence, pattern, and intensity of wall enhancement. Development of angiographic vasospasm was independently evaluated. Delayed cerebral ischemia; cerebral infarct; procedural details; and presence and grade of subarachnoid, parenchymal, and intraventricular hemorrhage were evaluated. Statistical associations were determined on a per-vessel segment and per-patient basis.

Results: Twenty-nine patients with 30 treated aneurysms (8 unruptured and 22 ruptured) were included in this study. Interobserver agreement was substantial for the presence of enhancement (κ = 0.67) and nearly perfect for distribution (κ = 0.87) and intensity (κ = 0.84) of wall enhancement. Patients with ruptured aneurysms had a significantly greater number of enhancing segments than those with unruptured aneurysms (29.9% vs 7.2%; OR 5.5, 95% CI 2.2-13.7). For ruptured cases, wall enhancement was significantly associated with subsequent angiographic vasospasm while controlling for grade of hemorrhage (adjusted OR 3.9, 95% CI 1.7-9.4). Vessel segments affected by balloon, stent, or flow-diverter use demonstrated greater enhancement than those not affected (OR 22.7, 95% CI 5.3-97.2 for ruptured; and OR 12.9, 95% CI 3.3-49.8 for unruptured).

Conclusions: Vessel wall enhancement after endovascular treatment of ruptured aneurysms is associated with subsequent angiographic vasospasm.
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http://dx.doi.org/10.3171/2018.4.JNS172829DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719715PMC
September 2018

Combining Spot Sign and Intracerebral Hemorrhage Score to Estimate Functional Outcome: Analysis From the PREDICT Cohort.

Stroke 2018 06 2;49(6):1511-1514. Epub 2018 May 2.

Department of Neurology, Elblandklinikum Meissen, Academic Teaching Hospital of Dresden University of Technology, Meissen, Germany (I.D.).

Background And Purpose: The intracerebral hemorrhage (ICH) score is the most commonly used grading scale for stratifying functional outcome in patients with acute ICH. We sought to determine whether a combination of the ICH score and the computed tomographic angiography spot sign may improve outcome prediction in the cohort of a prospective multicenter hemorrhage trial.

Methods: Prospectively collected data from 241 patients from the observational PREDICT study (Prediction of Hematoma Growth and Outcome in Patients With Intracerebral Hemorrhage Using the CT-Angiography Spot Sign) were analyzed. Functional outcome at 3 months was dichotomized using the modified Rankin Scale (0-3 versus 4-6). Performance of (1) the ICH score and (2) the spot sign ICH score-a scoring scale combining ICH score and spot sign number-was tested.

Results: Multivariable analysis demonstrated that ICH score (odds ratio, 3.2; 95% confidence interval, 2.2-4.8) and spot sign number (n=1: odds ratio, 2.7; 95% confidence interval, 1.1-7.4; n>1: odds ratio, 3.8; 95% confidence interval, 1.2-17.1) were independently predictive of functional outcome at 3 months with similar odds ratios. Prediction of functional outcome was not significantly different using the spot sign ICH score compared with the ICH score alone (spot sign ICH score area under curve versus ICH score area under curve: =0.14).

Conclusions: In the PREDICT cohort, a prognostic score adding the computed tomographic angiography-based spot sign to the established ICH score did not improve functional outcome prediction compared with the ICH score.
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http://dx.doi.org/10.1161/STROKEAHA.118.020679DOI Listing
June 2018

Successful treatment of direct carotid-cavernous fistula in a patient with Ehlers-Danlos syndrome type IV without arterial puncture: the transvenous triple-overlay embolization (TAILOREd) technique.

BMJ Case Rep 2017 Aug 18;2017. Epub 2017 Aug 18.

Department of Radiology, University of Washington, Seattle, Washington, USA.

We report successful transvenous treatment of direct carotid-cavernous fistula in a patient with Ehlers-Danlos syndrome type IV using a novel triple-overlay embolization (TAILOREd) technique without the need for arterial puncture, which is known to be highly risky in this patient group. The TAILOREd technique allowed for successful treatment using preoperative MR angiography as a three-dimensional overlay roadmap combined with cone beam CT and live fluoroscopy, precluding the need for an arterial puncture.
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http://dx.doi.org/10.1136/bcr-2017-013052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5753709PMC
August 2017

Intradural spinal varix: the "doughnut" sign on weighted MR and confirmation with gadolinium-enhanced arterial and blood pool MR angiography.

BJR Case Rep 2017 22;3(1):20160078. Epub 2016 Sep 22.

Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.

Intradural spinal varices are rare lesions, with only three cases being previously reported in the literature. Previously described patients underwent MRI for non-specific low back pain and radiculopathy and were found to have an intradural lesion adjacent to the cauda equina, mimicking a nerve sheath tumour or ependymoma. Consideration of an intradural varix in the differential diagnosis of an intradural extramedullary spinal lesion is necessary to guide appropriate management. We report a case of an intradural spinal varix diagnosed with first-pass arterial and blood pool phase gadolinium-enhanced auto-triggered elliptic centric-ordered MR angiography. Digital subtraction angiography confirmed that there was no shunt but failed to demonstrate the varix. We reviewed the existing literature to look for common clinical and imaging features.
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http://dx.doi.org/10.1259/bjrcr.20160078DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6159294PMC
September 2016

Validation of the 9-Point and 24-Point Hematoma Expansion Prediction Scores and Derivation of the PREDICT A/B Scores.

Stroke 2015 Nov 13;46(11):3105-10. Epub 2015 Oct 13.

From the Division of Neuroradiology and Department of Medical Imaging (T.J.H., R.I.A., S.P.S.) and Division of Neurology, Department of Medicine and Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (M.D.H., A.M.D.); Department of Medicine (Neurology) (D.D.) and Department of Diagnostic Imaging, Neuroradiology Section, The Ottawa Hospital (C.L.), University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada; Department of Medicine and Institute of Health Policy Management and Evaluation, University of Toronto and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada (A.L.); Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada (A.K.); Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain (C.A.M., D.R.-L.); Department Neurology, Elblandklinikum Meissen, Academic Teaching Hospital of University of Dresden, Meissen, Germany (I.D.); Department of Neurology, Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona (IDIBGi) Foundation, Girona, Spain (Y.S.); Second Department of Neurology, Institute of Psychiatry and Neurology of Warsaw, Warsaw, Poland (A.K.); Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada (J.-M.B.); Division of Neurology, Department of Medicine, Dalhousie University, Halifax, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi, India (R.B., V.P.); Department of Neuromedicine, AMRI Hospitals, Mukundapur, Kolkata, India (J.R.); and Department of Neurology, Boston Medical Center, MA (C.S.K.).

Background And Purpose: Nine- and 24-point prediction scores have recently been published to predict hematoma expansion (HE) in acute intracerebral hemorrhage. We sought to validate these scores and perform an independent analysis of HE predictors.

Methods: We retrospectively studied 301 primary or anticoagulation-associated intracerebral hemorrhage patients presenting <6 hours post ictus prospectively enrolled in the Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus Computed Tomography (PREDICT) study. Patients underwent baseline computed tomography angiography and 24-hour noncontrast computed tomography follow-up for HE analysis. Discrimination and calibration of the 9- and 24-point scores was assessed. Independent predictors of HE were identified using multivariable regression and incorporated into the PREDICT A/B scores, which were then compared with existing scores.

Results: The 9- and 24-point HE scores demonstrated acceptable discrimination for HE>6 mL or 33% and >6 mL, respectively (area under the curve of 0.706 and 0.755, respectively). The 24-point score demonstrated appropriate calibration in the PREDICT cohort (χ2 statistic, 11.5; P=0.175), whereas the 9-point score demonstrated poor calibration (χ2 statistic, 34.3; P<0.001). Independent HE predictors included spot sign number, time from onset, warfarin use or international normalized ratio>1.5, Glasgow Coma Scale, and National Institutes of Health Stroke Scale and were included in PREDICT A/B scores. PREDICT A showed improved discrimination compared with both existing scores, whereas performance of PREDICT B varied by definition of expansion.

Conclusions: The 9- and 24-point expansion scores demonstrate acceptable discrimination in an independent multicenter cohort; however, calibration was suboptimal for the 9-point score. The PREDICT A score showed improved discrimination for HE prediction but requires independent validation.
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http://dx.doi.org/10.1161/STROKEAHA.115.009893DOI Listing
November 2015

Venous phase of computed tomography angiography increases spot sign detection, but intracerebral hemorrhage expansion is greater in spot signs detected in arterial phase.

Stroke 2014 Mar 30;45(3):734-9. Epub 2014 Jan 30.

From the Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain (D.R.-L., C.A.M.); Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (D.R.-L., T.S., M.D.H., A.M.D.); Departments of Medicine (Neurology) (D.D.) and Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Division of Neuroradiology, Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (R.I.A., T.J.H.); Department of Neurology, Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona (IDIBGI) Foundation, Girona, Spain (Y.S.); Department of Neurology, University of Dresden, Dresden, Germany (I.D.); 2nd Department of Neurology, Institute of Psychiatry and Neurology of Warsaw, Warsaw, Poland (A.C.); Department of Neurology, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Quebec, Canada (J.-M.B.); Department of Neurology, Boston Medical Center, MA (C.S.K.); Department of Neurology, Dalhousie University, Halifax, Nova Scotia, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi, India (R.B., V.P.); and Department of Neuromedicine, AMRI Hospital Kolkata, Kolkata, India (J.R.).

Background And Purpose: Variability in computed tomography angiography (CTA) acquisitions may be one explanation for the modest accuracy of the spot sign for predicting intracerebral hemorrhage expansion detected in the multicenter Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT (PREDICT) study. This study aimed to determine the frequency of the spot sign in intracerebral hemorrhage and its relationship with hematoma expansion depending on the phase of image acquisition.

Methods: PREDICT study was a prospective observational cohort study of patients with intracerebral hemorrhage presenting within 6 hours from onset. A post hoc analysis of the Hounsfield units of an artery and venous structure were measured on CTA source images of the entire PREDICT cohort in a core laboratory. Each CTA study was classified into arterial or venous phase and into 1 of 5 specific image acquisition phases. Significant hematoma expansion and total hematoma enlargement were recorded at 24 hours.

Results: Overall (n=371), 77.9% of CTA were acquired in arterial phase. The spot sign, present in 29.9% of patients, was more frequently seen in venous phase as compared with arterial phase (39% versus 27.3%; P=0.041) and the later the phase of image acquisition (P=0.095). Significant hematoma expansion (P=0.253) and higher total hematoma enlargement (P=0.019) were observed more frequently among spot sign-positive patients with earlier phases of image acquisition.

Conclusions: Later image acquisition of CTA improves the frequency of spot sign detection. However, spot signs identified in earlier phases may be associated with greater absolute enlargement. A multiphase CTA including arterial and venous acquisitions could be optimal in patients with intracerebral hemorrhage.
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http://dx.doi.org/10.1161/STROKEAHA.113.003007DOI Listing
March 2014

Multicenter accuracy and interobserver agreement of spot sign identification in acute intracerebral hemorrhage.

Stroke 2014 Jan 26;45(1):107-12. Epub 2013 Nov 26.

From the Divisions of Neuroradiology (T.J.H., T.L.C., S.P.S., R.I.A.) and Division of Neurology, Department of Medicine, and Brain Sciences Program (D.J.G.), and Department of Emergency Medicine (J.C.), Sunnybrook Health Sciences and University of Toronto, Toronto, Canada; Department of Neurology, University of Cincinnati, OH (M.L.F., J.P.B.); Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calagary, Canada (A.M.D.); Department of Neurology, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Canada (D.D.); Departments of Medicine and Neurology (A.M., S.M.D.) and Neurointerventional Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia; and Department of Public Health Sciences, University of Toronto, Toronto, Canada (G.A.T.).

Background And Purpose: Rapid, accurate, and reliable identification of the computed tomography angiography spot sign is required to identify patients with intracerebral hemorrhage for trials of acute hemostatic therapy. We sought to assess the accuracy and interobserver agreement for spot sign identification.

Methods: A total of 131 neurology, emergency medicine, and neuroradiology staff and fellows underwent imaging certification for spot sign identification before enrolling patients in 3 trials targeting spot-positive intracerebral hemorrhage for hemostatic intervention (STOP-IT, SPOTLIGHT, STOP-AUST). Ten intracerebral hemorrhage cases (spot-positive/negative ratio, 1:1) were presented for evaluation of spot sign presence, number, and mimics. True spot positivity was determined by consensus of 2 experienced neuroradiologists. Diagnostic performance, agreement, and differences by training level were analyzed.

Results: Mean accuracy, sensitivity, and specificity for spot sign identification were 87%, 78%, and 96%, respectively. Overall sensitivity was lower than specificity (P<0.001) because of true spot signs incorrectly perceived as spot mimics. Interobserver agreement for spot sign presence was moderate (k=0.60). When true spots were correctly identified, 81% correctly identified the presence of single or multiple spots. Median time needed to evaluate the presence of a spot sign was 1.9 minutes (interquartile range, 1.2-3.1 minutes). Diagnostic performance, interobserver agreement, and time needed for spot sign evaluation were similar among staff physicians and fellows.

Conclusions: Accuracy for spot identification is high with opportunity for improvement in spot interpretation sensitivity and interobserver agreement particularly through greater reliance on computed tomography angiography source data and awareness of limitations of multiplanar images. Further prospective study is needed.
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http://dx.doi.org/10.1161/STROKEAHA.113.002502DOI Listing
January 2014

Response Evaluation Criteria in Solid Tumors (RECIST) criteria are superior to European Association for Study of the Liver (EASL) criteria at 1 month follow-up for predicting long-term survival in patients treated with transarterial chemoembolization before liver transplantation for hepatocellular cancer.

J Vasc Interv Radiol 2013 Jun 4;24(6):805-12. Epub 2013 Apr 4.

Department of Medical Imaging, Division of Vascular/Interventional Radiology, University Health Network & Mount Sinai Hospital, University of Toronto, 600 University Ave, Toronto, ON M5G 1X5, Canada.

Purpose: To determine whether response to transarterial chemoembolization can predict survival in patients with hepatocellular carcinoma (HCC) who are candidates for orthotopic liver transplantation (LT) and if either European Association for Study of the Liver (EASL) criteria or Response Evaluation Criteria in Solid Tumors (RECIST) criteria are more accurate for this purpose.

Materials And Methods: A retrospective review of all patients who underwent LT after transarterial chemoembolization between January 2005 and June 2011 was performed. Follow-up imaging with multiphasic computed tomography or magnetic resonance imaging was performed 1 month after transarterial chemoembolization and every 3 months thereafter until LT. Treatment response was evaluated at each imaging time point using RECIST criteria and EASL criteria. The relationship between survival and objective response (OR), time to response (TTR), time to progression (TTP), and time interval between transarterial chemoembolization and LT was assessed.

Results: A median of one transarterial chemoembolization procedure was performed before LT in 58 patients (52 men, 6 women; mean age, 57 y). OR was shown by 28 (48%) patients and 51 (88%) patients at 1 month by EASL criteria and RECIST criteria, respectively. OR at 1-month follow-up using RECIST criteria was associated with increased survival compared with patients with no response (NR) (P = .03). Using RECIST criteria, 5-year survival in the OR group was 66.7% versus 0% in the NR group (P = .015). There was no significant difference in survival in patients who showed OR at 1 month using EASL criteria. There was poor agreement between RECIST and EASL response assessments (κ = 0.23). There was no significant association between survival and TTR, TTP, or time interval between transarterial chemoembolization and LT.

Conclusions: Patients with objective response to transarterial chemoembolization at 1 month using RECIST criteria showed improved survival over nonresponders. RECIST criteria demonstrated better accuracy compared with EASL criteria for predicting survival in patients after LT who had transarterial chemoembolization as a "bridge."
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http://dx.doi.org/10.1016/j.jvir.2013.01.499DOI Listing
June 2013

Spot sign number is the most important spot sign characteristic for predicting hematoma expansion using first-pass computed tomography angiography: analysis from the PREDICT study.

Stroke 2013 Apr 26;44(4):972-7. Epub 2013 Feb 26.

Division of Neuroradiology and Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.

Background And Purpose: The spot sign score (SSS) provides risk stratification for hematoma expansion in acute intracerebral hemorrhage; however, external validation is needed. We sought to validate the SSS and assess prognostic performance of individual spot characteristics associated with hematoma expansion from a prospective multicenter intracerebral hemorrhage study.

Methods: Two hundred twenty-eight intracerebral hemorrhage patients within 6 hours after ictus were enrolled in the Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT (PREDICT) study, a multicenter prospective intracerebral hemorrhage cohort study. Patients were evaluated with baseline noncontrast computerized tomography, computerized tomography angiography, and 24-hour follow-up computerized tomography. Primary outcome was significant hematoma expansion (>6 mL or >33%) and secondary outcome was absolute and relative expansion. Blinded computerized tomography angiography spot sign characterization and SSS calculation were independently performed by 2 neuroradiologists and a radiology resident. Diagnostic performance of the SSS and individual spot characteristics were examined with multivariable regression, receiver operating characteristic analysis, and tests for trend.

Results: SSS and spot number independently predicted significant, absolute, and relative hematoma expansion (P<0.05 each) and demonstrated near perfect interobserver agreement (κ=0.82 and κ=0.85, respectively). Incremental risk of hematoma expansion among spot-positive patients was not identified for SSS (P trend=0.720) but was demonstrated for spot number (P trend=0.050). Spot number and SSS demonstrated similar area under the curve (0.69 versus 0.68; P=0.306) for hematoma expansion.

Conclusions: Multicenter external validation of the SSS demonstrates that the spot number alone provides similar prediction but improved risk stratification of hematoma expansion compared with the SSS.
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http://dx.doi.org/10.1161/STROKEAHA.111.000410DOI Listing
April 2013
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