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

现在有一级证据表明，在中风发作后6小时内，机械取栓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近端血管闭塞的优越性（MR-CLEAN、ESCAPE、EXTEND-IA、SWIFT-PRIME、REVASCAT、THRACE和THERAPY）。因此，机械取栓已成为三级护理卒中中心实现近端闭塞血管早期和持续血运重建的治疗选择。这些研究表明，机械取栓支架是一种非常有效的治疗方法，并发症发生率低。然而，由于纳入标准狭窄和治疗时间窗有限，这些研究不能为大多数不符合纳入标准的临床患者提供指导1，例如，在初始成像时出现超过6小时的时间窗或梗死核心较大。血管内卒中治疗决策的目的是最大限度地使患者受益于再通，并尽量减少患者在血管内卒中治疗后无效再通。为了促进这一点，有必要建立一个与自然历史相比较的再通情况下神经系统结果的个性化预测模型。这些研究强调了根据半暗带和缺血核心的大小选择患者的潜力，但也提出了需要解决的新问题：“与疾病的自然过程相比，如果成功应用机械取栓，我们能否预测组织存活的益处？”这个问题在很大程度上取决于是否存在“充足与不足的抵押品”。获得快速、安全、可重复和可靠的预期组织挽救信息不仅使我们能够选择从机械取栓中获益的患者，而且还允许在更灵活的时间窗口内选择患者进行血运重建，如果足够的侧支血流能够维持组织存活，则可能超过6小时。该项目的目标是提供一个能够基于介入前成像的影像特征和侧支血流量化来评估急性中风患者风险的系统。通过为神经放射科医生和中风神经科医生提供对多个不同信息源的快速、准确、可重复的解释，这些信息将使中风患者受益。来自我们系统的证据将通过改进对不可逆损伤与潜在可修复的半影组织及其各自对大脑重要区域的损伤负荷的估计，使更好的治疗选择成为可能。精确的计算机辅助治疗选择模块提供了选择稳定侧支和保留半影的患者的潜力，甚至超过了目前推荐的中风发作后6小时的窗口。

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.