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Objectives <p>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.</p> Methods <p>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.</p> Results <p>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 (&gt; 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.</p> Conclusions <p>ODACS yields lower collateral scores compared to MCA-based scoring and is comparable to scores from expert raters.</p> Key Points <p><Emphasis Type="BoldItalic">Question</Emphasis> <i>CT angiography-based collateral assessment in the MCA territory is inadequate to assess the collateral status in patients with distal vessel occlusions</i>.</p> <p><Emphasis Type="BoldItalic">Findings</Emphasis> <i>Our automated&#xa0;ODACS revealed lower collateral scores than traditional whole-territory assessment, especially in distal vessel occlusions</i>.</p> <p><Emphasis Type="BoldItalic">Clinical relevance</Emphasis> <i>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</i>.</p> Graphical Abstract <p></p>

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Automated collateral assessment restricted to the hypoperfused area for distal vessel occlusions in ischemic stroke

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  • 发表日期：

    2025年4月14日

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  • Lucas de Vries,
  • M. M. Quirien Robbe,
  • Ivo G. H. Jansen,
  • S. Mahsa Mojtahedi,
  • Jan W. Hoving,
  • Susanne G. H. Olthuis,
  • Robrecht R. M. M. Knapen,
  • Florentina M. E. Pinckaers,
  • Manon Kappelhof,
  • Ludo F. M. Beenen,
  • Alida A. Postma,
  • Robert J. van Oostenbrugge,
  • Diederik W. J. Dippel,
  • Efstratios Gavves,
  • Bart J. Emmer,
  • Charles B. L. M. Majoie,
  • Wim H. van Zwam,
  • Henk A. Marquering,
  • Diederik W. J. Dippel,
  • Aad van der Lugt,
  • Charles B. L. M. Majoie,
  • Yvo B. W. E. M. Roos,
  • Robert J. van Oostenbrugge,
  • Wim H. van Zwam,
  • Jelis Boiten,
  • Jan Albert Vos,
  • Ivo G. H. Jansen,
  • Maxim J. H. L. Mulder,
  • Robert-Jan B. Goldhoorn,
  • Kars C. J. Compagne,
  • Manon Kappelhof,
  • Josje Brouwer,
  • Sanne J. den Hartog,
  • Wouter H. Hinsenveld,
  • Lotte van den Heuvel,
  • Bob Roozenbeek,
  • Pieter Jan van Doormaal,
  • Bart J. Emmer,
  • Jonathan M. Coutinho,
  • Wouter J. Schonewille,
  • Marieke J. H. Wermer,
  • Marianne A. A. van Walderveen,
  • Adriaan C. G. M. van Es,
  • Julie Staals,
  • Jeannette Hofmeijer,
  • Jasper M. Martens,
  • Geert J. Lycklama à Nijeholt,
  • Sebastiaan F. de Bruijn,
  • Lukas C. van Dijk,
  • H. Bart van der Worp,
  • Rob H. Lo,
  • Ewoud J. van Dijk,
  • Hieronymus D. Boogaarts,
  • J. de Vries,
  • Paul L. M. de Kort,
  • Julia van Tuijl,
  • Issam Boukrab,
  • Jo P. Peluso,
  • Puck Fransen,
  • Jan S. P. van den Berg,
  • Heleen M. den Hertog,
  • Boudewijn A. A. M. van Hasselt,
  • Leo A. M. Aerden,
  • René J. Dallinga,
  • Maarten Uyttenboogaart,
  • Omid Eschgi,
  • Reinoud P. H. Bokkers,
  • Tobien H. C. M. L. Schreuder,
  • Roel J. J. Heijboer,
  • Koos Keizer,
  • Rob A. R. Gons,
  • Lonneke S. F. Yo,
  • Emiel J. C. Sturm,
  • Tomas Bulut,
  • Paul J. A. M. Brouwers,
  • Anouk D. Rozeman,
  • Otto Elgersma,
  • Michel J. M. Remmers,
  • Thijs E. A. M. de Jong,
  • Marieke E. S. Sprengers,
  • Sjoerd F. M. Jenniskens,
  • René van den Berg,
  • Albert J. Yoo,
  • Ludo F. M. Beenen,
  • Alida A. Postma,
  • Stefan D. Roosendaal,
  • Bas F. W. van der Kallen,
  • Ido R. van den Wijngaard,
  • Joost Bot,
  • Pieter-Jan van Doormaal,
  • Anton Meijer,
  • Elyas Ghariq,
  • Marc P. van Proosdij,
  • G. Menno Krietemeijer,
  • Rob Lo,
  • Wouter Dinkelaar,
  • Auke P. A. Appelman,
  • Bas Hammer,
  • Sjoert Pegge,
  • Anouk van der Hoorn,
  • Saman Vinke,
  • Sandra Cornelissen,
  • Christiaan van der Leij,
  • Rutger Brans,
  • Jeanette Bakker,
  • Miou Koopman,
  • Lucas Smagge,
  • Olvert A. Berkhemer,
  • Jeroen Markenstein,
  • Eef Hendriks,
  • Patrick Brouwer,
  • Dick Gerrits,
  • H. Zwenneke Flach,
  • Hester F. Lingsma,
  • Naziha el Ghannouti,
  • Martin Sterrenberg,
  • Wilma Pellikaan,
  • Rita Sprengers,
  • Marjan Elfrink,
  • Michelle Simons,
  • Marjolein Vossers,
  • Joke de Meris,
  • Tamara Vermeulen,
  • Annet Geerlings,
  • Gina van Vemde,
  • Tiny Simons,
  • Gert Messchendorp,
  • Nynke Nicolaij,
  • Hester Bongenaar,
  • Karin Bodde,
  • Sandra Kleijn,
  • Jasmijn Lodico,
  • Hanneke Droste,
  • Maureen Wollaert,
  • Sabrina Verheesen,
  • D. Jeurrissen,
  • Erna Bos,
  • Yvonne Drabbe,
  • Michelle Sandiman,
  • Nicoline Aaldering,
  • Berber Zweedijk,
  • Jocova Vervoort,
  • Eva Ponjee,
  • Sharon Romviel,
  • Karin Kanselaar,
  • Denn Barning,
  • Laurine van der Steen,
  • Esmee Venema,
  • Vicky Chalos,
  • Ralph R. Geuskens,
  • Tim van Straaten,
  • Saliha Ergezen,
  • Roger R. M. Harmsma,
  • Daan Muijres,
  • Anouk de Jong,
  • Anna M. M. Boers,
  • J. Huguet,
  • P. F. C. Groot,
  • Marieke A. Mens,
  • Katinka R. van Kranendonk,
  • Kilian M. Treurniet,
  • Manon L. Tolhuisen,
  • Heitor Alves,
  • Annick J. Weterings,
  • Eleonora L. F. Kirkels,
  • Eva J. H. F. Voogd,
  • Lieve M. Schupp,
  • Sabine L. Collette,
  • Adrien E. D. Groot,
  • Natalie E. LeCouffe,
  • Praneeta R. Konduri,
  • Haryadi Prasetya,
  • Nerea Arrarte-Terreros,
  • Lucas A. Ramos,
  • Nikki Boodt,
  • Anne F. A. V. Pirson,
  • Agnetha A. E. Bruggeman,
  • Nadinda A. M. van der Ende,
  • Rabia Deniz,
  • Susanne G. H. Olthuis,
  • Floor Pinckaers

摘要

Objectives

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.

Methods

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.

Results

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.

Conclusions

ODACS yields lower collateral scores compared to MCA-based scoring and is comparable to scores from expert raters.

Key Points

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.

Graphical Abstract