Stroke treatment goes personalized: Gaining added diagnostic yield bycomputer-assisted treatment selection

现在有I类证据表明，在中风发病后6小时内，机械血栓摘除术是一种安全有效的治疗方法。最近有7项前瞻性研究证实了这种方法在近端血管闭塞中的优越性(MR-CLEAN、ELEVE、EXTEND-IA、SWIFT-PRIME、REVASCAT、THRACE和TRANSION)。因此，机械性血栓切除术已成为三级护理卒中中心早期和持续地实现近端闭塞血管再血管化的治疗选择。这些研究表明，使用支架取回器的机械取栓术是一种并发症发生率低、疗效高的治疗方法。然而，由于纳入标准较窄，治疗时间窗口有限，这些研究没有为大多数临床患者提供指南，这些患者1不符合纳入标准，例如超过6小时的时间窗口或在初始成像时有较大的梗塞核心。卒中血管内治疗决策的目的是最大化受益于再通的患者数量，最大限度地减少血管内治疗后无效再通的患者。为了促进这一点，有必要建立一个个性化的预测模型，以预测与自然病程相比的再通情况下的神经结果。这些研究强调了根据半影区和缺血核心的大小来选择患者的潜力，但也提出了新的有待解决的问题：“与自然病程相比，如果成功地应用机械血栓切除术，我们能否预测组织存活的好处？”这个问题在很大程度上取决于是否存在“充足与不足的抵押”。有关预期组织挽救的快速、安全、可重复和可靠的信息的可用性将使我们不仅能够选择将从机械血栓切除术中受益的患者，而且还将允许在更灵活的时间窗口内选择患者进行血运重建，如果有足够的侧支循环使组织能够持续存活，该时间窗口可能超过6小时。该项目的目标是提供一种能够根据介入前成像的成像特征和侧支血流的量化来评估急性中风患者风险的系统。这些信息将使中风患者受益，为神经放射科医生和中风神经科医生提供对多种不同信息源的快速、准确、可重复的解释。我们系统的证据将使更好的治疗选择，通过完善不可逆转的损害与潜在的可挽救的半影区组织及其各自的损害负荷的估计大脑的有效区域。准确的计算机辅助治疗选择模块提供了选择侧支稳定且半暗带保留的患者的可能性，即使在目前建议的中风发病后6小时窗口之外。

There is now class I evidence that mechanical thrombectomy is a safe and effective therapy within an estimated time frame of 6 h after stroke onset. Seven prospective studies have recently evidenced the superiority in proximal vessel occlusions (MR-CLEAN, ESCAPE, EXTEND-IA, SWIFT-PRIME, REVASCAT, THRACE, and THERAPY). Mechanical thrombectomy has thus become the treatment option of choice to achieve an early and sustained revascularization of proximally occluded vessels in tertiary care stroke centers. These studies have illustrated that mechanical thrombectomy using stent retrievers is a highly effective treatment with low complication rates. However, due to the narrow inclusion criteria and limed time window for treatment, the studies do not provide a guide for the majority of clinical patients1 who do not match inclusion criteria such as for example presentation beyond the time window of 6 hours of or with large infarct core at initial imaging. The aim of decision making for endovascular stroke treatment is to maximized the number of patients who will benefit from recanalization and minimized the patients will futile recanalization after endovascular stroke treatment. To facilitate this, an individualized prediction model of the neurological outcome in case of recanalization compared to the natural history is necessary.These studies have highlighted the potential to select patients based on the size of the penumbra and ischemic core, but have raised new questions to be solved: 'can we predict a benefit in tissue survival if mechanical thrombectomy is successfully applied compared to the natural course of disease'. This question is strongly dependent on the presence of 'sufficient vs. insufficient collaterals'. The availability of a fast, safe, reproducible and reliable information about the expected tissue salvage would allow us not only to select patients that would benefit from mechanical thrombectomy, it would also permit selection of patients for revascularization in a more flexible time window that might exceed 6 h if sufficient collateral flow enables sustained tissue survival. The goal of the project is to provide a system capable of assessing patient risk in acute stroke, based on imaging features and quantification of collateral flow derived from pre-interventional imaging. This information will benefit stroke patients, by providing neuroradiologists and stroke neurologists with a fast, accurate, repeatable interpretation of multiple disparate information sources. Evidence from our system will enable better treatment selection by refining the estimation of irreversibly damaged vs. potentially salvageable penumbral tissue and its respective lesion load on eloquent areas of the brain. An accurate computer-assisted treatment selection module offers the potential to select patients with stable collaterals and preserved penumbral from even beyond the currently recommended window of 6 hours after stroke onset.