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Diagnosis and management of adult Moyamoya angiopathy: An overview of guideline recommendations and identification of future research directions. 成人莫亚莫亚血管病变的诊断和管理:指南建议概述及未来研究方向的确定。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-11-04 DOI: 10.1177/17474930241297031
Nicola Rifino, Dominique Hervè, Francesco Acerbi, Satoshi Kuroda, Giuseppe Lanzino, Peter Vajkoczy, Anna Bersano

Despite the progress made in understanding the management and outcomes of Moyamoya angiopathy (MMA), several aspects of the disease remain largely unknown. In particular, evidence on the disease history and management of MMA is lacking, mainly due to methodological and selection biases in the available studies and the lack of large, randomized prospective studies. Therefore, the care of MMA patients remains limited to a few expert centers worldwide, and management is often based on local expertise and available resources. Over the years, recommendations or expert opinions have been written to provide guidance to physicians in the treatment of this condition with the goal of reducing the risk of stroke recurrence and long-term disability. However, there is no complete agreement between the available guidelines and recommendations due to differences in the articles addressed, methodologies, expertise, and validated approaches to literature review. This lack of consensus on the management of MMA may confuse clinicians and highlight some important issues and points. The aim of this comprehensive review article is to critically examine three recent guidelines and recommendations on MMA, discussing their differences and similarities and highlighting gaps in MMA care that need to be covered.

尽管在了解莫亚莫亚血管病(MMA)的治疗和预后方面取得了进展,但该疾病的几个方面在很大程度上仍不为人所知。特别是缺乏有关 MMA 病史和治疗的证据,这主要是由于现有研究在方法和选择上存在偏差,以及缺乏大型随机前瞻性研究。因此,对 MMA 患者的治疗仍局限于全球少数几个专家中心,而管理往往基于当地的专业知识和可用资源。多年来,人们撰写了一些建议或专家意见,为医生治疗这种疾病提供指导,目的是降低中风复发和长期残疾的风险。然而,由于涉及的文章、方法、专业知识和文献综述的有效方法不同,现有指南和建议之间并不完全一致。对 MMA 的管理缺乏共识可能会使临床医生感到困惑,并突出了一些重要问题和要点。本综合综述论文旨在批判性地研究这三份最新的 MMA 指南,讨论它们之间的异同,并强调 MMA 护理中需要涵盖的空白点。
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引用次数: 0
Early penumbral FLAIR changes predict tissue fate in patients with large vessel occlusions. 早期半影 FLAIR 变化可预测大血管闭塞患者的组织命运。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-21 DOI: 10.1177/17474930241289235
Lauranne Scheldeman, Pierre Seners, Anke Wouters, Patrick Dupont, Soren Christensen, Michael Mlynash, Caroline Arquizan, Adrien Ter Schiphorst, Vincent Costalat, Hilde Henon, Martin Bretzner, Jean-François Albucher, Christophe Cognard, Jean-Marc Olivot, Jeremy J Heit, Gregory W Albers, Maarten G Lansberg, Robin Lemmens

Background: In patients with an acute ischemic stroke, the penumbra is defined as ischemic tissue that remains salvageable when reperfusion occurs. However, the expected clinical recovery congruent with penumbral salvage is not always observed.

Aims: We aimed to determine whether the magnetic resonance imaging (MRI)-defined penumbra includes irreversible neuronal loss that impedes expected clinical recovery after reperfusion.

Methods: In the prospective French Acute Multimodal Imaging Study to Select Patients for Mechanical Thrombectomy (FRAME) and an observational cohort of patients with large vessel occlusions undergoing endovascular treatment, we quantified penumbral integrity by fluid-attenuated inversion recovery (FLAIR) changes. We studied the influence of recanalization status on the evolution of penumbral FLAIR changes and studied penumbral FLAIR changes as predictor of tissue fate and functional outcome on the 90-day modified Rankin Scale (mRS).

Results: Recanalization status did not modify the evolution of rFLAIR signal intensity (SI) over time in the total cohort, but was associated with lower SI in the FRAME subset (b = -0.06, p for interaction = 0.04). Median rFLAIR SI was higher at baseline in the subsequently infarcted penumbra compared to the salvaged (ratio = 1.07, standard deviation (SD) = 0.07 vs 1.03, SD = 0.06 p < 0.0001, n = 150). The severity and extent of rFLAIR SI changes did not predict 90-day functional outcome in univariate (p = 0.09) and multivariate logistic regression (p = 0.4).

Conclusions: Recanalization status did not influence the evolution of penumbral FLAIR changes. FLAIR SI changes in the baseline penumbra were associated with tissue fate, but not functional outcome.

背景:急性缺血性脑卒中患者的半影被定义为再灌注时仍可挽救的缺血组织。目的:我们旨在确定磁共振成像(MRI)定义的半影是否包括阻碍再灌注后预期临床恢复的不可逆神经元损失:在前瞻性的法国急性多模态成像研究(FRAME)和接受血管内治疗的大血管闭塞患者观察队列中,我们通过FLAIR变化量化了半影的完整性。我们研究了再通畅状态对半影FLAIR变化演变的影响,并研究了半影FLAIR变化作为组织命运和90天改良Rankin量表(mRS)功能结果的预测因子:再通畅状态并不改变rFLAIR信号强度(SI)随时间的变化,但在FRAME亚组中与较低的SI相关(b=-0.06,交互作用p=0.04)。随后梗死的半影中位rFLAIR SI基线高于挽救的半影(比值=1.07,标准差[SD] 0.07 vs 1.03,SD 0.06):再通畅状态并不影响半影 FLAIR 变化的演变。基线半影的FLAIR SI变化与组织命运有关,但与功能结果无关:支持本研究的数据可在合理要求下提供,但需签署数据访问协议。
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引用次数: 0
PCSK9 Inhibitor with Statin Therapy for Intracranial Artery Stenosis ( PISTIAS): Rationale and design of a multicenter randomized controlled trial. PCSK9抑制剂与他汀类药物治疗颅内动脉狭窄(PISTIAS):多中心随机对照试验的原理与设计。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 Epub Date: 2024-08-15 DOI: 10.1177/17474930241270447
Xinzhi Hu, Zongmuyu Zhang, Caiyan Liu, Mingli Li, Yiyang Liu, Anqi Cheng, Qiuyu Yu, Haoyao Guo, Yinxi Zou, Li Zhou, Hebo Wang, Bo Song, Yong You, Jian Xia, Jingfen Zhang, Zhibing Ai, Qinjian Sun, Ju Han, Jing Liu, Baoquan Lu, Qiwen Deng, Guanzeng Li, Peng-Fei Wang, Xiangqing Li, Yi An, Bo Wu, Zhongrui Yan, Yining Wang, Wei-Hai Xu

Rationale: Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors enable an additional 54-75% reduction in low-density lipoprotein cholesterol (LDL-C) in statin-treated patients, demonstrating plaque regression in coronary artery disease. However, the impact of achieving an extremely low level of LDL-C with PCSK9 inhibitors (e.g. Evolocumab) on symptomatic intracranial atherosclerosis remains unexplored.

Aim and hypothesis: To determine whether combining Evolocumab and statins achieves a more significant symptomatic intracranial plaque regression than statin therapy alone.

Sample size estimates: With a sample size of 1000 subjects, a two-sided α of 0.05, and 20% lost to follow-up, the study will have 83.3% power to detect the difference in intracranial plaque burden.

Methods and design: This is an investigator-initiated multicenter, randomized, open-label, outcome assessor-blinded trial, evaluating the impact of combining Evolocumab and statins on intracranial plaque burden assessed by high-resolution magnetic resonance imaging at baseline in patients undergoing a clinically indicated acute stroke or transient ischemic attack due to intracranial artery stenosis, and after 24 weeks of treatment. Subjects (n = 1000) were randomized 1:1 into two groups to receive either Evolocumab 140 mg every 2 weeks with statin therapy or statin therapy alone.

Study outcomes: The primary endpoint is the change in intracranial plaque burden assessed by high-resolution magnetic resonance imaging, performed at baseline and at the end of the 24-week treatment period.

Discussion: This trial will explore whether more significant intracranial plaque regression is achievable with the treatment of combining Evolocumab and statins, providing information about efficacy and safety data.

Trial registration number: ChiCTR2300068868; https://www.chictr.org.cn/.

理论依据:Protein convertase subtilisin/kexin type 9 (PCSK9) 抑制剂可使他汀类药物治疗患者的低密度脂蛋白胆固醇(LDL-C)额外降低 54% 至 75%,显示出冠状动脉疾病斑块的消退。然而,使用 PCSK9 抑制剂(如 evolocumabEvolocumab)达到极低水平的 LDL-C 对无症状颅内动脉粥样硬化的影响仍有待探索:目的和假设:确定将 evolocumabEvolocumab 和他汀类药物结合使用是否比单纯他汀类药物治疗能更显著地减少症状性颅内斑块:样本量估计:样本量为1000名受试者,双侧为0.05,20%的受试者失去随访,该研究将有83.3%的力量检测到颅内斑块负担的差异:这是一项由研究者发起的多中心、随机、开放标签、结果评估者盲法试验,旨在评估 EvolocumabEvolocumab 对因颅内动脉狭窄导致的临床急性中风或短暂性脑缺血发作患者基线时和治疗 24 周后通过高分辨率磁共振成像评估的颅内斑块负荷的影响。受试者(n = 1000)将按 1:1 随机分为两组,接受 evolocumabEvolocumab 140 毫克,每两周一次,同时接受他汀类药物治疗或仅接受他汀类药物治疗:主要终点是在基线和24周治疗期结束时通过高分辨率磁共振成像评估斑块负担的变化:该试验将探索他汀类药物和 PCSK9 抑制剂联合治疗是否能实现更显著的斑块消退,提供重要的疗效、机制和安全性数据信息:ChiCTR2300068868;https://www.chictr.org.cn/。
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引用次数: 0
Post-stroke emotionalism: Diagnosis, pathophysiology, and treatment. 中风后的情绪化;诊断、病理生理学和治疗。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 Epub Date: 2024-04-11 DOI: 10.1177/17474930241242952
Niall M Broomfield, Joshua Blake, Fergus Gracey, Tom Steverson

Background: Post-stroke emotionalism affects one in five stroke sufferers 6 months after their stroke, but despite its frequency remains a poorly understood stroke symptom. The literature is limited, especially compared to other frequently observed neurological conditions such as aphasia and visual neglect.

Aim and methods: This narrative review presents a summary of the post-stroke emotionalism literature, to inform clinical practice and future research. We cover discussion of definitions, prevalence, neurobiology, predisposing and precipitating factors, and treatment.

Results: Increasing evidence suggests that damage to specific areas functionally linked to emotion expression or regulation processes, disruption to structural pathways and those related to serotonin production and modulation individually or in concert give rise to emotionalism-type presentations. A range of emotionalism measurement tools have been used in research contexts making between study comparisons difficult. Testing for Emotionalism after Recent Stroke-Questionnaire (TEARS-Q) has recently been developed to allow standardized assessment. Treatment options are limited, and there have been few adequately powered treatment trials. Antidepressants may reduce severity, but more trial data are required. There have been no randomized-controlled trials of non-pharmacological interventions.

Conclusions: More research is needed to improve recognition and treatment of this common and disabling symptom. We conclude with research priorities and recommendations for the field.

每 5 名中风患者中就有 1 人在中风 6 个月后会出现中风后情绪低落,尽管这种情况很常见,但人们对这种中风症状的了解却很少。相关文献十分有限,尤其是与其他常见的神经系统疾病(如失语症和视力障碍)相比。本叙述性综述对这些文献进行了总结,为临床实践和未来研究提供参考。我们将讨论定义、发病率、神经生物学、诱发和促发因素以及治疗方法。越来越多的证据表明,与情绪表达或调节过程功能相关的特定区域受损、结构性通路中断以及相关血清素分泌和调节紊乱单独或共同导致了情绪化类型的表现。研究中使用了一系列情绪化测量工具,因此很难对不同研究进行比较。最近开发的 "近期卒中后情绪测试-问卷"(TEARS-Q)可以进行标准化评估。可供选择的治疗方案有限,而且很少有充分有效的治疗试验。抗抑郁药可能会减轻严重程度,但还需要更多的试验数据。目前还没有非药物干预的随机对照试验。我们需要开展更多的研究,以提高对这一常见致残症状的认识和治疗。最后,我们提出了该领域的研究重点和建议。
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引用次数: 0
Temporal trends of sex differences in acute reperfusion therapy and early outcomes of acute ischemic stroke in South Korea: 10-year analysis of the nationwide stroke registry. 韩国急性再灌注治疗和急性缺血性脑卒中早期预后的性别差异时间趋势:全国脑卒中登记处的十年分析。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 Epub Date: 2024-07-24 DOI: 10.1177/17474930241261877
Darda Chung, Ji Sung Lee, Mi-Sun Oh, Jong-Moo Park, Jong-Won Chung, Oh Young Bang, Gyeong-Moon Kim, Woo-Keun Seo

Background: Sex differences in stroke outcomes are notable, with women experiencing higher incidence rates, greater disability-adjusted life years, and poorer recovery compared to men, even after adjusting for age and comorbidities. Despite the disproportionate burden in women, studies have reported that women are less likely to receive appropriate stroke treatment than men.

Aim: This study investigated temporal trends of sex differences in acute reperfusion therapy and early outcomes in patients with acute ischemic stroke over 10 years in South Korea.

Methods: A retrospective analysis of Korean Stroke Registry included patients with acute ischemic stroke from 2012 to 2021. The study outcomes were the temporal trends of acute reperfusion therapy and early outcomes over 10 years in men and women, respectively. In addition, this study analyzed the temporal trends of sex differences in these parameters during the same period. Early outcomes include the proportions of favorable functional outcomes at discharge, discharge patterns, and in-hospital mortality.

Results: A total of 93,692 patients (68.4 years, 40.1% women) with acute ischemic stroke were finally enrolled. Women had a higher age at stroke onset, a higher prevalence of atrial fibrillation, and more severe strokes than men. Women had lower proportion of favorable functional outcomes at discharge and higher proportion of in-hospital mortality compared to men each year. The proportion of patients who received intravenous thrombolysis was lower or similar in women compared to men in most years, and the proportion of patients who received endovascular thrombectomy did not significantly differ between sexes annually. Sex differences in acute reperfusion therapy remained unchanged over 10 years.

Conclusion: Women have received acute reperfusion therapy at similar or lower rates than men and experienced poorer outcomes, despite having more stroke risk factors and often more severe strokes.

背景:与男性相比,女性的发病率更高、残疾调整生命年数更长、恢复更差,即使在调整年龄和合并症后也是如此。目的:本研究调查了韩国急性缺血性卒中患者急性再灌注治疗和早期预后 10 年来的性别差异时间趋势:方法:对韩国卒中登记处进行回顾性分析,纳入 2012 年至 2021 年的急性缺血性卒中患者。研究结果显示,男性和女性急性再灌注治疗和早期预后的时间趋势分别为 10 年。此外,本研究还分析了同期这些参数的性别差异时间趋势。早期预后包括出院时良好功能预后的比例、出院模式和院内死亡率:共有 93,692 名急性缺血性脑卒中患者(68.4 岁,40.1% 为女性)最终入选。与男性相比,女性中风发病年龄更高,心房颤动发生率更高,中风程度更严重。与男性相比,女性出院时获得良好功能预后的比例较低,每年的院内死亡率较高。在大多数年份中,女性与男性相比接受静脉溶栓治疗的比例较低或相似,而每年接受血管内血栓切除术的患者比例在性别上没有显著差异。急性再灌注治疗的性别差异在10年中保持不变:结论:女性接受急性再灌注治疗的比例与男性相似或更低,尽管她们有更多的中风风险因素,中风程度往往也更严重,但她们的治疗效果却更差。
{"title":"Temporal trends of sex differences in acute reperfusion therapy and early outcomes of acute ischemic stroke in South Korea: 10-year analysis of the nationwide stroke registry.","authors":"Darda Chung, Ji Sung Lee, Mi-Sun Oh, Jong-Moo Park, Jong-Won Chung, Oh Young Bang, Gyeong-Moon Kim, Woo-Keun Seo","doi":"10.1177/17474930241261877","DOIUrl":"10.1177/17474930241261877","url":null,"abstract":"<p><strong>Background: </strong>Sex differences in stroke outcomes are notable, with women experiencing higher incidence rates, greater disability-adjusted life years, and poorer recovery compared to men, even after adjusting for age and comorbidities. Despite the disproportionate burden in women, studies have reported that women are less likely to receive appropriate stroke treatment than men.</p><p><strong>Aim: </strong>This study investigated temporal trends of sex differences in acute reperfusion therapy and early outcomes in patients with acute ischemic stroke over 10 years in South Korea.</p><p><strong>Methods: </strong>A retrospective analysis of Korean Stroke Registry included patients with acute ischemic stroke from 2012 to 2021. The study outcomes were the temporal trends of acute reperfusion therapy and early outcomes over 10 years in men and women, respectively. In addition, this study analyzed the temporal trends of sex differences in these parameters during the same period. Early outcomes include the proportions of favorable functional outcomes at discharge, discharge patterns, and in-hospital mortality.</p><p><strong>Results: </strong>A total of 93,692 patients (68.4 years, 40.1% women) with acute ischemic stroke were finally enrolled. Women had a higher age at stroke onset, a higher prevalence of atrial fibrillation, and more severe strokes than men. Women had lower proportion of favorable functional outcomes at discharge and higher proportion of in-hospital mortality compared to men each year. The proportion of patients who received intravenous thrombolysis was lower or similar in women compared to men in most years, and the proportion of patients who received endovascular thrombectomy did not significantly differ between sexes annually. Sex differences in acute reperfusion therapy remained unchanged over 10 years.</p><p><strong>Conclusion: </strong>Women have received acute reperfusion therapy at similar or lower rates than men and experienced poorer outcomes, despite having more stroke risk factors and often more severe strokes.</p>","PeriodicalId":14442,"journal":{"name":"International Journal of Stroke","volume":" ","pages":"1028-1037"},"PeriodicalIF":6.3,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141247470","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Relationship between carotid web morphology on CT angiography and stroke: A pooled multicenter analysis. CT 血管造影上颈动脉网形态与中风之间的关系:多中心汇总分析
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 Epub Date: 2024-07-31 DOI: 10.1177/17474930241264141
Fouzi Bala, Ibrahim Alhabli, Nishita Singh, Faysal Benali, Shelagh Coutts, Mayank Goyal, Mohammed Almekhlafi, Michael D Hill, Bijoy K Menon

Background: The Carotid web (CaW) is a cause of stroke, particularly in younger individuals. However, the frequency and the radiological features of the web's morphology associated with stroke risk are uncertain. We determined the CaW radiological features on computed tomography (CT) angiography associated with ipsilateral stroke.

Materials and methods: Data from six studies of patients with acute ischemic stroke were pooled. Identification and measurement of CaWs were performed by experienced readers using baseline neck CT angiography. We assessed six 2D CaW radiological features on sagittal oblique images, namely, main axis length, thickness, height, base width, distance to wall, and angle between the web main axis and carotid wall, and CaW volume on 3D images. CaWs were divided into symptomatic if acute ischemic stroke was in the ipsilateral internal carotid artery territory and its etiology was undetermined and asymptomatic if one condition was unmet. Univariable and multivariable analyses were conducted to assess the association between each radiological CaW feature and symptomatic CaW.

Results: Of the 3442 patients in the pooled data with assessable CTAs, 60 (1.7%) had CaW. In patients with CaW, median age was 59 (interquartile range [IQR]: 50-68) years, 60% were women, and 3 patients had bilateral CaWs. There were 39 (62%) symptomatic and 24 (38%) asymptomatic CaWs. Patients with symptomatic CaW were younger (55 (IQR: 49-61) years versus 69 (IQR: 52-75) years), had lower rates of hypertension (9 (25.0%) versus 12 (57.1%)) and more intracranial large vessel occlusions compared to patients with asymptomatic CaWs. After adjusting for age, hypertension, and occlusion location, CaW length (adjusted odds ratio (aOR) 1.84 (95% confidence interval [CI]: 1.03-3.28)), thickness (aOR: 2.31 (95% CI 1.08-4.97)), volume (aOR: 1.07 per 1 mm3 increment (95% CI: 1.01-1.12)), and angle relative to the carotid wall (aOR: 0.95 (95% CI: 0.91-0.99)) were associated with symptomatic CaW.

Conclusion: Radiological assessment of CaW morphology may determine its potential causal role in ischemic stroke etiology. Symptomatic CaWs tend to be longer, larger, and oriented at more acute angles relative to the carotid wall as compared to asymptomatic CaWs.

背景:颈动脉网(CaW)是中风的诱因之一,尤其是在年轻人中。然而,它的发生频率以及与中风风险相关的颈动脉网形态学特征尚不确定。我们确定了 CT 血管造影上与同侧中风相关的颈动脉蛛网膜放射学特征:汇总了六项急性缺血性卒中患者的研究数据。由经验丰富的读者对基线颈部 CT 血管造影上的 CaW 进行识别和测量。我们在矢状斜面图像上评估了六个二维CaW放射学特征,即主轴长度、厚度、高度、基底宽度、与壁的距离、网状主轴与颈动脉壁之间的角度,以及三维图像上的CaW体积。如果急性缺血性卒中发生在同侧颈内动脉区域,且病因未确定,则将CaW分为有症状和无症状两种。研究人员进行了单变量和多变量分析,以评估各放射学CaW特征与无症状CaW之间的关联:在汇集数据的 3442 名可评估 CTA 的患者中,有 60 人(1.7%)有 CaW。CaW患者的中位年龄为59岁(IQR为50-68岁),60%为女性,3名患者为双侧CaW。有症状的 CaW 患者有 39 人(62%),无症状的有 24 人(38%)。与无症状颅脑损伤患者相比,有症状的颅脑损伤患者更年轻(55 [IQR 49-61] 岁对 69 [IQR 52-75] 岁),高血压发病率更低(9 [25.0%] 对 12 [57.1%]),颅内大血管闭塞更多。在对年龄、高血压和闭塞位置进行调整后,CaW 长度(调整后的几率比 [aOR] 1.84 [95%CI 1.03-3.28])、厚度(aOR 2.31 [95%CI 1.08-4.97])、体积(aOR 1.07 per 1 mm3 increment [95%CI 1.01-1.12])和相对于颈动脉壁的角度(aOR 0.95 [95%CI 0.91-0.99])与无症状 CaW 相关:结论:CaW 形态的放射学评估可确定其在缺血性卒中病因中的潜在作用。与无症状的CaW相比,有症状的CaW往往更长、更大,且相对于颈动脉壁的角度更尖锐。
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引用次数: 0
Predicting post-stroke cognitive impairment using electronic health record data. 利用电子健康记录数据预测中风后的认知障碍。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 Epub Date: 2024-04-18 DOI: 10.1177/17474930241246156
Jeffrey M Ashburner, Yuchiao Chang, Bianca Porneala, Sanjula D Singh, Nirupama Yechoor, Jonathan M Rosand, Daniel E Singer, Christopher D Anderson, Steven J Atlas

Background: Secondary prevention interventions to reduce post-stroke cognitive impairment (PSCI) can be aided by the early identification of high-risk individuals who would benefit from risk factor modification.

Aims: To develop and evaluate a predictive model to identify patients at increased risk of PSCI over 5 years using data easily accessible from electronic health records.

Methods: Cohort study that included primary care patients from two academic medical centers. Patients were aged 45 years or older, without prior stroke or prevalent cognitive impairment, with primary care visits and an incident ischemic stroke between 2003 and 2016 (development/internal validation cohort) or 2010 and 2022 (external validation cohort). Predictors of PSCI were ascertained from the electronic health record. The outcome was incident dementia/cognitive impairment within 5 years and beginning 3 months following stroke, ascertained using International Classification of Diseases, Ninth/Tenth Revision (ICD-9/10) codes. For model variable selection, we considered potential predictors of PSCI and constructed 400 bootstrap samples with two-thirds of the model derivation sample. We ran 10-fold cross-validated Cox proportional hazards models using a least absolute shrinkage and selection operator (LASSO) penalty. Variables selected in >25% of samples were included.

Results: The analysis included 332 incident diagnoses of PSCI in the development cohort (n = 3741), and 161 and 128 incident diagnoses in the internal (n = 1925) and external (n = 2237) validation cohorts, respectively. The C-statistic for predicting PSCI was 0.731 (95% confidence interval (CI): 0.694-0.768) in the internal validation cohort, and 0.724 (95% CI: 0.681-0.766) in the external validation cohort. A risk score based on the beta coefficients of predictors from the development cohort stratified patients into low (0-7 points), intermediate (8-11 points), and high (12-23 points) risk groups. The hazard ratios (HRs) for incident PSCI were significantly different by risk categories in internal (high, HR: 6.2, 95% CI: 4.1-9.3; Intermediate, HR: 2.7, 95% CI: 1.8-4.1) and external (high, HR: 6.1, 95% CI: 3.9-9.6; Intermediate, HR: 2.8, 95% CI: 1.9-4.3) validation cohorts.

Conclusion: Five-year risk of PSCI can be accurately predicted using routinely collected data. Model output can be used to risk stratify and identify individuals at increased risk for PSCI for preventive efforts.

Data access statement: Mass General Brigham data contain protected health information and cannot be shared publicly. The data processing scripts used to perform analyses will be made available to interested researchers upon reasonable request to the corresponding author.

背景:目的:利用易于从电子健康记录中获取的数据,开发并评估一个预测模型,以识别5年内卒中后认知障碍(PSCI)风险增加的患者:方法:队列研究,包括两个学术医疗中心的初级保健患者。患者年龄在 45 岁或以上,既往无中风或普遍存在认知障碍,在 2003-2016 年(开发/内部验证队列)或 2010-2022 年(外部验证队列)期间接受过初级保健就诊并发生过缺血性中风。从电子健康记录中确定了 PSCI 的预测因素。结果是中风后 3 个月开始的 5 年内发生的痴呆/认知障碍,使用 ICD-9/10 编码确定。在选择模型变量时,我们考虑了 PSCI 的潜在预测因子,并用模型推导样本的三分之二构建了 400 个引导样本。我们使用最小绝对收缩和选择算子(LASSO)惩罚法运行了 10 倍交叉验证的 Cox 比例危险模型。结果:分析包括开发队列(n=3,741)中的 332 例 PSCI 诊断病例,以及内部(n=1,925)和外部(n=2,237)验证队列中的 161 例和 128 例诊断病例。内部验证队列中预测 PSCI 的 c 统计量为 0.731(95% CI:0.694-0.768),外部验证队列中预测 PSCI 的 c 统计量为 0.724(95% CI:0.681-0.766)。根据开发队列中预测因子的贝塔系数进行风险评分,将患者分为低(0-7 分)、中(8-11 分)和高(12-35 分)风险组。在内部(高危,HR:6.2,95% CI:4.1-9.3;中危,HR:2.7,95% CI:1.8-4.1)和外部(高危,HR:6.1,95% CI:3.9-9.6;中危,HR:2.8,95% CI:1.9-4.3)验证队列中,不同风险类别的患者发生 PSCI 的危险比存在显著差异:结论:利用常规收集的数据可以准确预测五年的 PSCI 风险。模型输出结果可用于风险分层,并识别出 PSCI 风险增加的个体,以便采取预防措施。数据访问声明:Mass General Brigham 数据包含受保护的健康信息,不能公开共享。用于执行分析的数据处理脚本将在向通讯作者提出合理要求后提供给感兴趣的研究人员。
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引用次数: 0
Post-stroke cognitive impairment remains highly prevalent and disabling despite state-of-the-art stroke treatment. 尽管采用了最先进的中风治疗方法,但中风后认知障碍的发生率和致残率仍然很高。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 Epub Date: 2024-03-21 DOI: 10.1177/17474930241238637
Laura Gallucci, Christoph Sperber, Adrian G Guggisberg, Christoph P Kaller, Mirjam R Heldner, Andreas U Monsch, Arsany Hakim, Norbert Silimon, Urs Fischer, Marcel Arnold, Roza M Umarova

Background: State-of-the-art stroke treatment significantly reduces lesion size and stroke severity, but it remains unclear whether these therapeutic advances have diminished the burden of post-stroke cognitive impairment (PSCI).

Aims: In a cohort of patients receiving modern state-of-the-art stroke care including endovascular therapy, we assessed the frequency of PSCI and the pattern of domain-specific cognitive deficits, identified risk factors for PSCI, and determined the impact of acute PSCI on stroke outcome.

Methods: In this prospective monocentric cohort study, we examined patients with first-ever anterior circulation ischemic stroke without pre-stroke cognitive decline, using a comprehensive neuropsychological assessment ⩽10 days after symptom onset. Normative data were stratified by demographic variables. We defined PSCI as at least moderate (<1.5 standard deviation) deficits in ⩾2 cognitive domains. Multivariable regression analysis was applied to define risk factors for PSCI.

Results: We analyzed 329 non-aphasic patients admitted from December 2020 to July 2023 (67.2 ± 14.4 years old, 41.3% female, 13.1 ± 2.7 years of education). Although most patients had mild stroke (median National Institutes of Health Stroke Scale (NIHSS) 24 h = 1.00 (0.00; 3.00); 87.5% with NIHSS ⩽ 5), 69.3% of them presented with PSCI 2.7 ± 2.0 days post-stroke. The most severely and often affected cognitive domains were verbal learning, episodic memory, executive functions, selective attention, and constructive abilities (39.1%-51.2% of patients), whereas spatial neglect was less frequent (18.5%). The risk of PSCI was reduced with more years of education (odds ratio (OR) = 0.47, 95% confidence interval (CI) = 0.23-0.99) and right hemisphere lesions (OR = 0.47, 95% CI = 0.26-0.84), and increased with stroke severity (NIHSS 24 h, OR = 4.19, 95% CI = 2.72-6.45), presence of hyperlipidemia (OR = 1.93, 95% CI = 1.01-3.68), but was not influenced by age. After adjusting for stroke severity and depressive symptoms, acute PSCI was associated with poor functional outcome (modified Rankin Scale > 2, F = 13.695, p < 0.001) and worse global cognition (Montreal Cognitive Assessment (MoCA) score, F = 20.069, p < 0.001) at 3 months post-stroke.

Conclusion: Despite modern stroke therapy and many strokes having mild severity, PSCI in the acute stroke phase remains frequent and associated with worse outcome. The most prevalent were learning and memory deficits. Cognitive reserve operationalized as years of education independently protects post-stroke cognition.

背景:目的:在接受包括血管内治疗在内的现代最先进卒中治疗的患者队列中,我们评估了卒中后认知障碍的频率和特定领域认知障碍的模式,确定了卒中后认知障碍的风险因素,并确定了急性卒中后认知障碍对卒中结局的影响:在这项前瞻性单中心队列研究中,我们对症状发生后 10 天内首次发生前循环缺血性卒中且卒中前无认知功能下降的患者进行了全面的神经心理学评估。根据人口统计学变量对标准数据进行了分层。我们将 PSCI 定义为至少在 ≥ 2 个认知领域存在中度(< 1.5 SD)缺陷。多变量回归分析用于确定 PSCI 的风险因素:我们分析了 2020 年 12 月至 2023 年 7 月期间收治的 329 名非重症患者(67.2±14.4 岁,41.3% 为女性,13.1±2.7 年教育程度)。虽然大多数患者为轻度卒中(NIHSS 24h 中位数=1.00 [0.00; 3.00];87.5%的患者 NIHSS ≥ 5),但其中 69.3%的患者在卒中后 2.7±2.0 天出现 PSCI。受影响最严重和最常见的认知领域是言语学习、外显记忆、执行功能、选择性注意和建构能力(39.1%-51.2%的患者),而空间忽略较少见(18.5%)。受教育年限越长(几率比 [OR] 0.47,95% CI:0.23-0.99)、右半球病变(OR 0.47,95% CI:0.26-0.84),PSCI 的风险越低;中风严重程度(NIHSS 24h,OR 4.19,95% CI:2.72-6.45)、高脂血症(OR 1.93,95% CI:1.01-3.68)越高,PSCI 的风险越高,但不受年龄影响。在对卒中严重程度和抑郁症状进行调整后,急性 PSCI 与不良功能预后相关(改良 Rankin 量表 > 2,F=13.695,pF=20.069,pConclusions):尽管采用了现代中风治疗方法,且许多中风的严重程度较轻,但急性中风阶段的 PSCI 仍很常见,且与较差的预后有关。最常见的是学习和记忆障碍。以受教育年限为标准的认知储备可独立保护卒中后的认知能力。
{"title":"Post-stroke cognitive impairment remains highly prevalent and disabling despite state-of-the-art stroke treatment.","authors":"Laura Gallucci, Christoph Sperber, Adrian G Guggisberg, Christoph P Kaller, Mirjam R Heldner, Andreas U Monsch, Arsany Hakim, Norbert Silimon, Urs Fischer, Marcel Arnold, Roza M Umarova","doi":"10.1177/17474930241238637","DOIUrl":"10.1177/17474930241238637","url":null,"abstract":"<p><strong>Background: </strong>State-of-the-art stroke treatment significantly reduces lesion size and stroke severity, but it remains unclear whether these therapeutic advances have diminished the burden of post-stroke cognitive impairment (PSCI).</p><p><strong>Aims: </strong>In a cohort of patients receiving modern state-of-the-art stroke care including endovascular therapy, we assessed the frequency of PSCI and the pattern of domain-specific cognitive deficits, identified risk factors for PSCI, and determined the impact of acute PSCI on stroke outcome.</p><p><strong>Methods: </strong>In this prospective monocentric cohort study, we examined patients with first-ever anterior circulation ischemic stroke without pre-stroke cognitive decline, using a comprehensive neuropsychological assessment ⩽10 days after symptom onset. Normative data were stratified by demographic variables. We defined PSCI as at least moderate (<1.5 standard deviation) deficits in ⩾2 cognitive domains. Multivariable regression analysis was applied to define risk factors for PSCI.</p><p><strong>Results: </strong>We analyzed 329 non-aphasic patients admitted from December 2020 to July 2023 (67.2 ± 14.4 years old, 41.3% female, 13.1 ± 2.7 years of education). Although most patients had mild stroke (median National Institutes of Health Stroke Scale (NIHSS) 24 h = 1.00 (0.00; 3.00); 87.5% with NIHSS ⩽ 5), 69.3% of them presented with PSCI 2.7 ± 2.0 days post-stroke. The most severely and often affected cognitive domains were verbal learning, episodic memory, executive functions, selective attention, and constructive abilities (39.1%-51.2% of patients), whereas spatial neglect was less frequent (18.5%). The risk of PSCI was reduced with more years of education (odds ratio (OR) = 0.47, 95% confidence interval (CI) = 0.23-0.99) and right hemisphere lesions (OR = 0.47, 95% CI = 0.26-0.84), and increased with stroke severity (NIHSS 24 h, OR = 4.19, 95% CI = 2.72-6.45), presence of hyperlipidemia (OR = 1.93, 95% CI = 1.01-3.68), but was not influenced by age. After adjusting for stroke severity and depressive symptoms, acute PSCI was associated with poor functional outcome (modified Rankin Scale > 2, F = 13.695, p < 0.001) and worse global cognition (Montreal Cognitive Assessment (MoCA) score, F = 20.069, p < 0.001) at 3 months post-stroke.</p><p><strong>Conclusion: </strong>Despite modern stroke therapy and many strokes having mild severity, PSCI in the acute stroke phase remains frequent and associated with worse outcome. The most prevalent were learning and memory deficits. Cognitive reserve operationalized as years of education independently protects post-stroke cognition.</p>","PeriodicalId":14442,"journal":{"name":"International Journal of Stroke","volume":" ","pages":"888-897"},"PeriodicalIF":6.3,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139996210","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Author Index. 作者索引。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 DOI: 10.1177/17474930241293178
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引用次数: 0
Prevalence of right-to-left shunt in stroke patients with cancer. 癌症中风患者右左分流的发病率。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 Epub Date: 2024-06-13 DOI: 10.1177/17474930241260589
Fabienne Steinauer, Philipp Bücke, Eric Buffle, Mattia Branca, Jayan Göcmen, Babak B Navi, Ava L Liberman, Anna Boronylo, Leander Clenin, Martina Goeldlin, Julian Lippert, Bastian Volbers, Thomas R Meinel, David Seiffge, Adnan Mujanovic, Johannes Kaesmacher, Urs Fischer, Marcel Arnold, Thomas Pabst, Martin D Berger, Simon Jung, Morin Beyeler

Background and objectives: Cancer is associated with an increased risk of acute ischemic stroke (AIS) and venous thromboembolism. The role of a cardiac right-to-left shunt (RLS) as a surrogate parameter for paradoxical embolism in cancer-related strokes is uncertain. We sought to investigate the relationship between the presence of an RLS and cancer in AIS patients.

Methods: We included consecutive AIS patients hospitalized at our tertiary stroke center between January 2015 and December 2020 with available RLS status as detected on transesophageal echocardiography (TEE). Active cancers were retrospectively identified and the association with RLS was assessed with multivariable logistic regression and inverse probability of treatment weighting to minimize the ascertainment bias of having a TEE obtained.

Results: Of the 2236 AIS patients included, 103 (4.6%) had active cancer, of whom 24 (23%) were diagnosed with RLS. An RLS was present in 774 out of the 2133 AIS patients without active cancer (36%). After adjustment and weighting, the absence of RLS was associated with active cancer (adjusted odds ratio (aOR) 2.29; 95% confidence interval (CI), 1.14-4.58). When analysis was restricted to patients younger than 60 years of age or those with a high-risk RLS (Risk of Paradoxical Embolism Score ⩾ 6), there was no association between RLS and cancer (aOR, 3.07; 95% CI, 0.79-11.88 and aOR, 0.56; 95% CI, 0.10-3.10, respectively).

Conclusion: RLS was diagnosed less frequently in AIS patients with cancer than in cancer-free patients, suggesting that arterial sources may play a larger role in cancer-related strokes than paradoxical venous embolization. Future studies are needed to validate these findings and evaluate potential therapeutic implications, such as the general indication, or lack thereof, for patent foramen ovale (PFO) closure in this patient population.

背景和目的:癌症与急性缺血性脑卒中(AIS)和静脉血栓栓塞风险增加有关。心脏右左分流(RLS)作为矛盾性栓塞的替代指标在癌症相关中风中的作用尚不确定。我们试图研究 AIS 患者出现 RLS 与癌症之间的关系:我们纳入了 2015 年 1 月至 2020 年 12 月期间在我们的三级卒中中心住院的连续 AIS 患者,这些患者经食道超声心动图(TEE)检测出 RLS 状态。对活动性癌症进行了回顾性鉴别,并通过多变量逻辑回归和逆治疗概率加权评估了与RLS的关系,以尽量减少经食道超声心动图检查的确定偏倚:在纳入的 2236 名 AIS 患者中,103 人(4.6%)患有活动性癌症,其中 24 人(23%)被诊断为 RLS。在2133名无活动性癌症的AIS患者中,有774人(36%)患有RLS。经过调整和加权后,无 RLS 与癌症活动有关(调整后的几率比 [aOR],2.29;95% 置信区间 [CI],1.14-4.58)。当分析对象仅限于年龄小于60岁或RLS风险较高的患者(并发栓塞风险评分≥6分)时,RLS与癌症之间没有关联(aOR,3.07;95% CI,0.79-11.88;aOR,0.56;95% CI,0.10-3.10):结论:与未患癌症的患者相比,AIS 癌症患者被诊断出 RLS 的频率较低,这表明动脉源在癌症相关中风中的作用可能大于矛盾性静脉栓塞。未来的研究需要验证这些发现,并评估潜在的治疗意义,如在这一患者群体中关闭 PFO 的一般适应症或缺乏适应症。
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引用次数: 0
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International Journal of Stroke
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