de Vries Lucas, Robbe M M Quirien, Jansen Ivo G H, Mojtahedi S Mahsa, Hoving Jan W, Olthuis Susanne G H, Knapen Robrecht R M M, Pinckaers Florentina M E, Kappelhof Manon, Beenen Ludo F M, Postma Alida A, van Oostenbrugge Robert J, Dippel Diederik W J, Gavves Efstratios, Emmer Bart J, Majoie Charles B L M, van Zwam Wim H, Marquering Henk A
Biomedical Engineering and Physics, Amsterdam UMC location, University of Amsterdam, Amsterdam, The Netherlands.
Radiology and Nuclear Medicine, Amsterdam UMC location, University of Amsterdam, Amsterdam, The Netherlands.
Eur Radiol. 2025 Apr 14. doi: 10.1007/s00330-025-11442-2.
This study aims to: (1) develop and evaluate a quantitative assessment of collateral status in the downstream area of an occluded intracranial artery in acute ischemic stroke and compare this method to middle cerebral artery (MCA)-based assessment; (2) determine the agreement between the automated occlusion-downstream area collateral score (ODACS) and expert raters' assessments, and compare this to inter-rater agreement.
Patients from MR CLEAN-NO IV and MR CLEAN Registry with a proximal M1, distal M1, or M2 occlusion were included. Using the hypoperfused area from CT perfusion (CTP) as a proxy for the occlusion-downstream territory and automated vessel segmentations from CT angiography (CTA), ODACS is calculated as the vessel volume ratio between downstream ipsilateral and its contralateral regions. ODACS was compared to a whole MCA-territory approach and evaluated against visual scoring by two expert raters that visually estimated ODACS using CTA and CTP, and their inter-rater agreement.
The study included 204 patients with a proximal M1 (52%), distal M1 (32%), or M2 (16%) occlusion. ODACS yielded lower collateral scores than MCA-based scoring for all occlusion locations, with larger differences in more distal occlusions. For M2 occlusions, 58% of patients shifted from good (> 50%) to poor (≤ 50%) collateral filling of the occluded territory using ODACS. Moderate (weighted Cohen's kappa κ = 0.45) inter-rater agreement and fair (κ = 0.35) to moderate (κ = 0.51) ODACS-rater agreement were observed.
ODACS yields lower collateral scores compared to MCA-based scoring and is comparable to scores from expert raters.
Question CT angiography-based collateral assessment in the MCA territory is inadequate to assess the collateral status in patients with distal vessel occlusions. Findings Our automated ODACS revealed lower collateral scores than traditional whole-territory assessment, especially in distal vessel occlusions. Clinical relevance The more precise evaluation of affected brain territories through automated occlusion-downstream area assessments prevents an overestimation of collateral status in distal occlusions, which could lead to improved patient selection and treatment decisions in acute stroke care.
本研究旨在：（1）开发并评估急性缺血性卒中患者颅内动脉闭塞下游区域侧支循环状态的定量评估方法，并将该方法与基于大脑中动脉（MCA）的评估方法进行比较；（2）确定自动闭塞下游区域侧支循环评分（ODACS）与专家评估者评估之间的一致性，并将其与评估者间的一致性进行比较。
纳入来自MR CLEAN-NO IV和MR CLEAN注册研究中存在M1近端、M1远端或M2闭塞的患者。以CT灌注（CTP）的灌注不足区域作为闭塞下游区域的替代指标，并利用CT血管造影（CTA）的自动血管分割，计算ODACS，即同侧下游区域与对侧区域之间的血管体积比。将ODACS与基于整个MCA区域的方法进行比较，并由两名专家评估者根据CTA和CTP对ODACS进行视觉评分来评估，同时评估他们之间的一致性。
该研究纳入了204例存在M1近端闭塞（52%）、M1远端闭塞（32%）或M2闭塞（16%）的患者。对于所有闭塞部位，ODACS得出的侧支循环评分均低于基于MCA的评分，在更远端的闭塞中差异更大。对于M2闭塞，使用ODACS时，58%的患者从闭塞区域侧支循环良好（>50%）转变为侧支循环不良（≤50%）。观察到评估者间一致性为中等（加权Cohen's kappa κ = 0.45），ODACS与评估者之间的一致性为一般（κ = 0.35）至中等（κ = 0.51）。
与基于MCA的评分相比，ODACS得出的侧支循环评分更低，且与专家评估者的评分相当。
问题基于CT血管造影的MCA区域侧支循环评估不足以评估远端血管闭塞患者的侧支循环状态。发现我们的自动ODACS显示出比传统的全区域评估更低的侧支循环评分，特别是在远端血管闭塞中。临床意义通过自动闭塞下游区域评估对受影响脑区进行更精确的评估，可避免高估远端闭塞中的侧支循环状态，这可能会改善急性卒中治疗中的患者选择和治疗决策。
