Pub Date : 2023-09-01Epub Date: 2023-08-24DOI: 10.5853/jos.2023.00668
Lu Wang, Ying-Jie Dai, Yu Cui, Hong Zhang, Chang-Hao Jiang, Ying-Jie Duan, Yong Zhao, Ye-Fang Feng, Shi-Mei Geng, Zai-Hui Zhang, Jiang Lu, Ping Zhang, Li-Wei Zhao, Hang Zhao, Yu-Tong Ma, Cheng-Guang Song, Yi Zhang, Hui-Sheng Chen
Background and purpose: Intravenous tenecteplase (TNK) efficacy has not been well demonstrated in acute ischemic stroke (AIS) beyond 4.5 hours after onset. This study aimed to determine the effect of intravenous TNK for AIS within 4.5 to 24 hours of onset.
Methods: In this pilot trial, eligible AIS patients with diffusion-weighted imaging (DWI)-fluid attenuated inversion recovery (FLAIR) mismatch were randomly allocated to intravenous TNK (0.25 mg/kg) or standard care within 4.5-24 hours of onset. The primary endpoint was excellent functional outcome at 90 days (modified Rankin Scale [mRS] score of 0-1). The primary safety endpoint was symptomatic intracranial hemorrhage (sICH).
Results: Of the randomly assigned 80 patients, the primary endpoint occurred in 52.5% (21/40) of TNK group and 50.0% (20/40) of control group, with no significant difference (unadjusted odds ratio, 1.11; 95% confidence interval 0.46-2.66; P=0.82). More early neurological improvement occurred in TNK group than in control group (11 vs. 3, P=0.03), but no significant differences were found in other secondary endpoints, such as mRS 0-2 at 90 days, shift analysis of mRS at 90 days, and change in National Institutes of Health Stroke Scale score at 24 hours and 7 days. There were no cases of sICH in this trial; however, asymptomatic intracranial hemorrhage occurred in 3 of the 40 patients (7.5%) in the TNK group.
Conclusion: This phase 2, randomized, multicenter study suggests that intravenous TNK within 4.5-24 hours of onset may be safe and feasible in AIS patients with a DWI-FLAIR mismatch.
{"title":"Intravenous Tenecteplase for Acute Ischemic Stroke Within 4.5-24 Hours of Onset (ROSE-TNK): A Phase 2, Randomized, Multicenter Study.","authors":"Lu Wang, Ying-Jie Dai, Yu Cui, Hong Zhang, Chang-Hao Jiang, Ying-Jie Duan, Yong Zhao, Ye-Fang Feng, Shi-Mei Geng, Zai-Hui Zhang, Jiang Lu, Ping Zhang, Li-Wei Zhao, Hang Zhao, Yu-Tong Ma, Cheng-Guang Song, Yi Zhang, Hui-Sheng Chen","doi":"10.5853/jos.2023.00668","DOIUrl":"10.5853/jos.2023.00668","url":null,"abstract":"<p><strong>Background and purpose: </strong>Intravenous tenecteplase (TNK) efficacy has not been well demonstrated in acute ischemic stroke (AIS) beyond 4.5 hours after onset. This study aimed to determine the effect of intravenous TNK for AIS within 4.5 to 24 hours of onset.</p><p><strong>Methods: </strong>In this pilot trial, eligible AIS patients with diffusion-weighted imaging (DWI)-fluid attenuated inversion recovery (FLAIR) mismatch were randomly allocated to intravenous TNK (0.25 mg/kg) or standard care within 4.5-24 hours of onset. The primary endpoint was excellent functional outcome at 90 days (modified Rankin Scale [mRS] score of 0-1). The primary safety endpoint was symptomatic intracranial hemorrhage (sICH).</p><p><strong>Results: </strong>Of the randomly assigned 80 patients, the primary endpoint occurred in 52.5% (21/40) of TNK group and 50.0% (20/40) of control group, with no significant difference (unadjusted odds ratio, 1.11; 95% confidence interval 0.46-2.66; P=0.82). More early neurological improvement occurred in TNK group than in control group (11 vs. 3, P=0.03), but no significant differences were found in other secondary endpoints, such as mRS 0-2 at 90 days, shift analysis of mRS at 90 days, and change in National Institutes of Health Stroke Scale score at 24 hours and 7 days. There were no cases of sICH in this trial; however, asymptomatic intracranial hemorrhage occurred in 3 of the 40 patients (7.5%) in the TNK group.</p><p><strong>Conclusion: </strong>This phase 2, randomized, multicenter study suggests that intravenous TNK within 4.5-24 hours of onset may be safe and feasible in AIS patients with a DWI-FLAIR mismatch.</p>","PeriodicalId":17135,"journal":{"name":"Journal of Stroke","volume":"25 3","pages":"371-377"},"PeriodicalIF":8.2,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/57/cf/jos-2023-00668.PMC10574303.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10041956","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01Epub Date: 2023-09-06DOI: 10.5853/jos.2023.01074
Jong-Su Kim, Eung-Joon Lee, Han-Yeong Jeong, Keun-Hwa Jung
The clinical findings obtained in this study included demographic characteristics and vascular risk factors such as hypertension, diabetes, dyslipidemia, smoking, obesity, and previous history of stroke. Stroke severity was measured using the National Institutes of Health Stroke Scale by well-trained neurologists upon admission and discharge. The risk of paradoxical embolism score was calculated to evaluate the possibility of stroke associated with patent foramen ovale (PFO). The characteristics of magnetic resonance imaging performed within 7 days of the onset of symptoms were classified according to stroke lesion patterns, vascular territories, and angiographic findings. Stroke lesion patterns were categorized as single solitary, single territory multiple, multiple territory scattered, and large territory and/or additional. Vascular territories were categorized as anterior (anterior and middle cerebral arteries), posterior (vertebrobasilar artery), and both. Angiographic findings were categorized according to the presence of major arterial occlusions. Patients whose stroke lesions were not confirmed were classified separately as having a transient ischemic attack. D-dimer levels were assessed using a quantitative D-dimer latex agglutination assay. The size of the left atrium was measured using echocardiography, and measurements exceeding 40 mm were considered indicative of left atrial enlargement. Frequent atrial premature complexes were defined as cases where atrial premature complexes exceeded 1% of all heartbeats. Additional tests performed within 2 weeks of the onset of symptoms to determine the etiology of cryptogenic stroke were as follows: transcranial Doppler (TCD) sonography bubble study, transesophageal echocardiography (TEE), and contrast-enhanced chest computed tomography (CT). The TCD bubble study was performed using a TCD monitoring device (PMD 150; Spencer Technologies, Redmond, WA, USA) and two 2-MHz probes fixed in a metal headframe (Marc 1500; Spencer Technologies). Microembolic signals (MESs) were detected by the monitoring device and probes heading toward the bilateral middle cerebral artery at depths of 40–60 mm through the temporal window. Agitated saline was prepared by mixing two syringes, one with 9 mL of 0.9% saline and the other with 1 mL of air connected by a three-way stopcock, which was injected three times through the antecubital vein. The procedure was performed during the Valsalva maneuver and at rest. MESs were recorded and counted using the computer software embedded in the device. All standardized protocols were performed by skilled sonographers. Right-to-left shunt (RLS) was classified as grade I (1–10 microbubbles), grade II (11–30 microbubbles), grade III (31–100 microbubbles), grade IV (101–300 microbubbles), and grade V (>300 microbubbles); including “shower” or “curtain” shunt patterns, defined as “massive RLS” in this study. In all patients with massive RLS in the TCD bubble study, the presence of PFO
{"title":"Chronic Lung Parenchymal Disease May Be Causally Associated With Cryptogenic Stroke With Massive Right-to-Left Shunt.","authors":"Jong-Su Kim, Eung-Joon Lee, Han-Yeong Jeong, Keun-Hwa Jung","doi":"10.5853/jos.2023.01074","DOIUrl":"10.5853/jos.2023.01074","url":null,"abstract":"The clinical findings obtained in this study included demographic characteristics and vascular risk factors such as hypertension, diabetes, dyslipidemia, smoking, obesity, and previous history of stroke. Stroke severity was measured using the National Institutes of Health Stroke Scale by well-trained neurologists upon admission and discharge. The risk of paradoxical embolism score was calculated to evaluate the possibility of stroke associated with patent foramen ovale (PFO). The characteristics of magnetic resonance imaging performed within 7 days of the onset of symptoms were classified according to stroke lesion patterns, vascular territories, and angiographic findings. Stroke lesion patterns were categorized as single solitary, single territory multiple, multiple territory scattered, and large territory and/or additional. Vascular territories were categorized as anterior (anterior and middle cerebral arteries), posterior (vertebrobasilar artery), and both. Angiographic findings were categorized according to the presence of major arterial occlusions. Patients whose stroke lesions were not confirmed were classified separately as having a transient ischemic attack. D-dimer levels were assessed using a quantitative D-dimer latex agglutination assay. The size of the left atrium was measured using echocardiography, and measurements exceeding 40 mm were considered indicative of left atrial enlargement. Frequent atrial premature complexes were defined as cases where atrial premature complexes exceeded 1% of all heartbeats. Additional tests performed within 2 weeks of the onset of symptoms to determine the etiology of cryptogenic stroke were as follows: transcranial Doppler (TCD) sonography bubble study, transesophageal echocardiography (TEE), and contrast-enhanced chest computed tomography (CT). The TCD bubble study was performed using a TCD monitoring device (PMD 150; Spencer Technologies, Redmond, WA, USA) and two 2-MHz probes fixed in a metal headframe (Marc 1500; Spencer Technologies). Microembolic signals (MESs) were detected by the monitoring device and probes heading toward the bilateral middle cerebral artery at depths of 40–60 mm through the temporal window. Agitated saline was prepared by mixing two syringes, one with 9 mL of 0.9% saline and the other with 1 mL of air connected by a three-way stopcock, which was injected three times through the antecubital vein. The procedure was performed during the Valsalva maneuver and at rest. MESs were recorded and counted using the computer software embedded in the device. All standardized protocols were performed by skilled sonographers. Right-to-left shunt (RLS) was classified as grade I (1–10 microbubbles), grade II (11–30 microbubbles), grade III (31–100 microbubbles), grade IV (101–300 microbubbles), and grade V (>300 microbubbles); including “shower” or “curtain” shunt patterns, defined as “massive RLS” in this study. In all patients with massive RLS in the TCD bubble study, the presence of PFO ","PeriodicalId":17135,"journal":{"name":"Journal of Stroke","volume":"25 3","pages":"413-416"},"PeriodicalIF":8.2,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/38/23/jos-2023-01074.PMC10574306.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10145053","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01Epub Date: 2023-09-26DOI: 10.5853/jos.2023.01753
Sang Hee Ha, Soo Jeong, Jae Young Park, So Young Yang, Myung-Jin Cha, Min-Soo Cho, Jun Young Chang, Dong-Wha Kang, Sun U Kwon, Bum Joon Kim
Atrial fibrillation (AF)-related strokes usually have a higher initial stroke severity and frequently lead to severe disability and mortality. Stroke recurrence was not found to be linked to heart rate (HR); however, there was an association between HR and mortality in patients with AF-related stroke. While AF typically presents with tachycardia, a slow ventricular response (SVR) is also observed, albeit less frequently. Hemodynamic changes associated with AF have been studied, and AF with SVR may lead to intracardiac hemodynamic alterations, thrombus formation, and hypoperfusion in the ischemic area. However, the association between SVR and initial stroke severity, early neurological deterioration, and functional outcome in patients with AF-related stroke is not known. We retrospectively reviewed the data of patients who had acute AF-related stroke (within 7 days of stroke onset) and were admitted to Asan Medical Center between January 2017 and March 2022. We included patients who fulfilled the following criteria: (1) cardioembolic stroke, (2) known or newly diagnosed AF, and (3) relevant acute ischemic lesions on diffusion-weighted imaging (DWI). We excluded patients who had (1) AF with rapid ventricular rate in the initial twelve-lead electrocardiogram (ECG), (2) poor initial magnetic resonance imaging (MRI) quality, (3) incomplete clinical data, (4) presence of stroke mechanisms other than cardioembolism, and (5) presence of low temperature or electrolyte abnormalities that may systematically reduce the HR. The study protocol was approved by the Institutional Review Board Committee of Asan Medical Center (IRB number: 2022-1178) and informed consent was waived because of the retrospective nature of the study. Demographic data and risk factors were obtained by reviewing the medical records. Neurological deficits at admission were evaluated using the National Institutes of Health Stroke Scale (NIHSS) score, and severe stroke was defined as patients whose NIHSS score at admission was >15 points. All patients underwent neurovascular MRI with a 3.0T Philips scanner (Philips Healthcare, Eindhoven, The Netherlands) within 24 hours of admission. We also used the Olea Sphere® imaging system (Olea Medical SAS, La Ciotat, France) for automatic post-processing and measurement of the DWI lesion volumes. ECGs were obtained from the emergency department after >5 minutes of rest in the supine position. Paroxysmal AF was defined as the spontaneous restoration of normal sinus rhythm within 7 days, and persistent AF was defined as AF lasting >7 days. In terms of ventricular response, patients with an HR <60 beats per minute on an initial ECG were considered to have SVR. Diagnosis of AF and transthoracic echocardiography were performed during admission by an experienced cardiologist and ejection fraction (EF) and left atrium (LA) diameters were measured. The baseline characteristics were compared according to the presence of SVR. The chi-square test, Fisher’s exa
{"title":"Association Between Slow Ventricular Response and Severe Stroke in Atrial Fibrillation-Related Cardioembolic Stroke.","authors":"Sang Hee Ha, Soo Jeong, Jae Young Park, So Young Yang, Myung-Jin Cha, Min-Soo Cho, Jun Young Chang, Dong-Wha Kang, Sun U Kwon, Bum Joon Kim","doi":"10.5853/jos.2023.01753","DOIUrl":"10.5853/jos.2023.01753","url":null,"abstract":"Atrial fibrillation (AF)-related strokes usually have a higher initial stroke severity and frequently lead to severe disability and mortality. Stroke recurrence was not found to be linked to heart rate (HR); however, there was an association between HR and mortality in patients with AF-related stroke. While AF typically presents with tachycardia, a slow ventricular response (SVR) is also observed, albeit less frequently. Hemodynamic changes associated with AF have been studied, and AF with SVR may lead to intracardiac hemodynamic alterations, thrombus formation, and hypoperfusion in the ischemic area. However, the association between SVR and initial stroke severity, early neurological deterioration, and functional outcome in patients with AF-related stroke is not known. We retrospectively reviewed the data of patients who had acute AF-related stroke (within 7 days of stroke onset) and were admitted to Asan Medical Center between January 2017 and March 2022. We included patients who fulfilled the following criteria: (1) cardioembolic stroke, (2) known or newly diagnosed AF, and (3) relevant acute ischemic lesions on diffusion-weighted imaging (DWI). We excluded patients who had (1) AF with rapid ventricular rate in the initial twelve-lead electrocardiogram (ECG), (2) poor initial magnetic resonance imaging (MRI) quality, (3) incomplete clinical data, (4) presence of stroke mechanisms other than cardioembolism, and (5) presence of low temperature or electrolyte abnormalities that may systematically reduce the HR. The study protocol was approved by the Institutional Review Board Committee of Asan Medical Center (IRB number: 2022-1178) and informed consent was waived because of the retrospective nature of the study. Demographic data and risk factors were obtained by reviewing the medical records. Neurological deficits at admission were evaluated using the National Institutes of Health Stroke Scale (NIHSS) score, and severe stroke was defined as patients whose NIHSS score at admission was >15 points. All patients underwent neurovascular MRI with a 3.0T Philips scanner (Philips Healthcare, Eindhoven, The Netherlands) within 24 hours of admission. We also used the Olea Sphere® imaging system (Olea Medical SAS, La Ciotat, France) for automatic post-processing and measurement of the DWI lesion volumes. ECGs were obtained from the emergency department after >5 minutes of rest in the supine position. Paroxysmal AF was defined as the spontaneous restoration of normal sinus rhythm within 7 days, and persistent AF was defined as AF lasting >7 days. In terms of ventricular response, patients with an HR <60 beats per minute on an initial ECG were considered to have SVR. Diagnosis of AF and transthoracic echocardiography were performed during admission by an experienced cardiologist and ejection fraction (EF) and left atrium (LA) diameters were measured. The baseline characteristics were compared according to the presence of SVR. The chi-square test, Fisher’s exa","PeriodicalId":17135,"journal":{"name":"Journal of Stroke","volume":"25 3","pages":"421-424"},"PeriodicalIF":8.2,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/6d/7b/jos-2023-01753.PMC10574304.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41182934","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background and purpose: Differences in measurement of the extent of acute ischemic stroke using the Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) by non-contrast computed tomography (CT-ASPECTS stratum) and diffusion-weighted imaging (DWI-ASPECTS stratum) may impact the efficacy of endovascular therapy (EVT) in patients with a large ischemic core.
Methods: The RESCUE-Japan LIMIT (Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism Japan-Large IscheMIc core Trial) was a multicenter, open-label, randomized clinical trial that evaluated the efficacy and safety of EVT in patients with ASPECTS of 3-5. CT-ASPECTS was prioritized when both CT-ASPECTS and DWI-ASPECTS were measured. The effects of EVT on the modified Rankin Scale (mRS) score at 90 days were assessed separately for each stratum.
Results: Among 183 patients, 112 (EVT group, 53; No-EVT group, 59) were in the CT-ASPECTS stratum and 71 (EVT group, 40; No-EVT group, 31) in the DWI-ASPECTS stratum. The common odds ratio (OR) (95% confidence interval) of the EVT group for one scale shift of the mRS score toward 0 was 1.29 (0.65-2.54) compared to the No-EVT group in CT-ASPECTS stratum, and 6.15 (2.46-16.3) in DWI-ASPECTS stratum with significant interaction between treatment assignment and mode of imaging study (P=0.002). There were significant interactions in the improvement of the National Institutes of Health Stroke Scale score at 48 hours (CT-ASPECTS stratum: OR, 1.95; DWIASPECTS stratum: OR, 14.5; interaction P=0.035) and mortality at 90 days (CT-ASPECTS stratum: OR, 2.07; DWI-ASPECTS stratum: OR, 0.23; interaction P=0.008).
Conclusion: Patients with ASPECTS of 3-5 on MRI benefitted more from EVT than those with ASPECTS of 3-5 on CT.
背景和目的：使用阿尔伯塔省卒中项目早期计算机断层扫描评分（ASPECTS）通过非对比计算机断层扫描（CT-ASPECTS层）和扩散加权成像（DWI-ASPECTS层）测量急性缺血性卒中程度的差异可能会影响血管内治疗（EVT）对大缺血核心患者的疗效。方法：RESCUE Japan LIMIT（通过血管内抢救恢复大脑超急性栓塞日本大型IscheMIc核心试验）是一项多中心、开放标签、随机临床试验，评估EVT对3-5岁ASPECTS患者的疗效和安全性。当测量CT-ASPECTS和DWI-ASPECTS时，优先考虑CT-ASPECT。EVT在90天时对每个阶层的改良兰金量表（mRS）评分的影响分别进行评估。结果：183例患者中，112例（EVT组，53例；无EVT组（59例））位于CT-ASPECTS层，71例（EVT组，40例；无EV组，31例）位于DWI-ASPECTS层。与CT-ASPECTS层中的无EVT组相比，EVT组的mRS评分向0的一个量表偏移的共同优势比（OR）（95%置信区间）为1.29（0.65-2.54），DWI-ASPECTS评分为6.15（2.46-16.3），治疗分配和影像学研究模式之间存在显著的相互作用（P=0.002）。在48小时时美国国立卫生研究院卒中量表评分的改善（CT-ASPECTS评分：OR，1.95；DWIASPECTS分别：OR，14.5；相互作用P=0.035）和90天时的死亡率方面存在显著的交互作用（CT-ASPECTS分级：OR，2.07；DWI-ASPECTS分级：OR为0.23；交互作用P=0.008）。
{"title":"Mode of Imaging Study and Endovascular Therapy for a Large Ischemic Core: Insights From the RESCUE-Japan LIMIT.","authors":"Fumihiro Sakakibara, Kazutaka Uchida, Shinichi Yoshimura, Nobuyuki Sakai, Hiroshi Yamagami, Kazunori Toyoda, Yuji Matsumaru, Yasushi Matsumoto, Kazumi Kimura, Reiichi Ishikura, Manabu Inoue, Kumiko Ando, Atsushi Yoshida, Kanta Tanaka, Takeshi Yoshimoto, Junpei Koge, Mikiya Beppu, Manabu Shirakawa, Takeshi Morimoto","doi":"10.5853/jos.2023.01641","DOIUrl":"10.5853/jos.2023.01641","url":null,"abstract":"<p><strong>Background and purpose: </strong>Differences in measurement of the extent of acute ischemic stroke using the Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) by non-contrast computed tomography (CT-ASPECTS stratum) and diffusion-weighted imaging (DWI-ASPECTS stratum) may impact the efficacy of endovascular therapy (EVT) in patients with a large ischemic core.</p><p><strong>Methods: </strong>The RESCUE-Japan LIMIT (Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism Japan-Large IscheMIc core Trial) was a multicenter, open-label, randomized clinical trial that evaluated the efficacy and safety of EVT in patients with ASPECTS of 3-5. CT-ASPECTS was prioritized when both CT-ASPECTS and DWI-ASPECTS were measured. The effects of EVT on the modified Rankin Scale (mRS) score at 90 days were assessed separately for each stratum.</p><p><strong>Results: </strong>Among 183 patients, 112 (EVT group, 53; No-EVT group, 59) were in the CT-ASPECTS stratum and 71 (EVT group, 40; No-EVT group, 31) in the DWI-ASPECTS stratum. The common odds ratio (OR) (95% confidence interval) of the EVT group for one scale shift of the mRS score toward 0 was 1.29 (0.65-2.54) compared to the No-EVT group in CT-ASPECTS stratum, and 6.15 (2.46-16.3) in DWI-ASPECTS stratum with significant interaction between treatment assignment and mode of imaging study (P=0.002). There were significant interactions in the improvement of the National Institutes of Health Stroke Scale score at 48 hours (CT-ASPECTS stratum: OR, 1.95; DWIASPECTS stratum: OR, 14.5; interaction P=0.035) and mortality at 90 days (CT-ASPECTS stratum: OR, 2.07; DWI-ASPECTS stratum: OR, 0.23; interaction P=0.008).</p><p><strong>Conclusion: </strong>Patients with ASPECTS of 3-5 on MRI benefitted more from EVT than those with ASPECTS of 3-5 on CT.</p>","PeriodicalId":17135,"journal":{"name":"Journal of Stroke","volume":"25 3","pages":"388-398"},"PeriodicalIF":8.2,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/68/c2/jos-2023-01641.PMC10574299.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41182937","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-05-01Epub Date: 2023-05-30DOI: 10.5853/jos.2023.00185
Saurav Das, Liqi Shu, Rebecca J Morgan, Asghar Shah, Fayez H Fayad, Eric D Goldstein, Dalia Chahien, Benton Maglinger, Satish Kumar Bokka, Cory Owens, Mehdi Abbasi, Alexandra Kvernland, James E Siegler, Brian Mac Grory, Thanh N Nguyen, Karen Furie, Pooja Khatri, Eva Mistry, Shyam Prabhakaran, David S Liebeskind, Jose G Romano, Adam de Havenon, Lina Palaiodimou, Georgios Tsivgoulis, Shadi Yaghi
Background and purpose: Intracranial arterial stenosis (ICAS)-related stroke occurs due to three primary mechanisms with distinct infarct patterns: (1) borderzone infarcts (BZI) due to impaired distal perfusion, (2) territorial infarcts due to distal plaque/thrombus embolization, and (3) plaque progression occluding perforators. The objective of the systematic review is to determine whether BZI secondary to ICAS is associated with a higher risk of recurrent stroke or neurological deterioration.
Methods: As part of this registered systematic review (CRD42021265230), a comprehensive search was performed to identify relevant papers and conference abstracts (with ≥20 patients) reporting initial infarct patterns and recurrence rates in patients with symptomatic ICAS. Subgroup analyses were performed for studies including any BZI versus isolated BZI and those excluding posterior circulation stroke. The study outcome included neurological deterioration or recurrent stroke during follow-up. For all outcome events, corresponding risk ratios (RRs) and 95% confidence intervals (95% CI) were calculated.
Results: A literature search yielded 4,478 records with 32 selected during the title/abstract triage for full text; 11 met inclusion criteria and 8 studies were included in the analysis (n=1,219 patients; 341 with BZI). The meta-analysis demonstrated that the RR of outcome in the BZI group compared to the no BZI group was 2.10 (95% CI 1.52-2.90). Limiting the analysis to studies including any BZI, the RR was 2.10 (95% CI 1.38-3.18). For isolated BZI, RR was 2.59 (95% CI 1.24-5.41). RR was 2.96 (95% CI 1.71-5.12) for studies only including anterior circulation stroke patients.
Conclusion: This systematic review and meta-analysis suggests that the presence of BZI secondary to ICAS may be an imaging biomarker that predicts neurological deterioration and/or stroke recurrence.
{"title":"Borderzone Infarcts and Recurrent Cerebrovascular Events in Symptomatic Intracranial Arterial Stenosis: A Systematic Review and Meta-Analysis.","authors":"Saurav Das, Liqi Shu, Rebecca J Morgan, Asghar Shah, Fayez H Fayad, Eric D Goldstein, Dalia Chahien, Benton Maglinger, Satish Kumar Bokka, Cory Owens, Mehdi Abbasi, Alexandra Kvernland, James E Siegler, Brian Mac Grory, Thanh N Nguyen, Karen Furie, Pooja Khatri, Eva Mistry, Shyam Prabhakaran, David S Liebeskind, Jose G Romano, Adam de Havenon, Lina Palaiodimou, Georgios Tsivgoulis, Shadi Yaghi","doi":"10.5853/jos.2023.00185","DOIUrl":"10.5853/jos.2023.00185","url":null,"abstract":"<p><strong>Background and purpose: </strong>Intracranial arterial stenosis (ICAS)-related stroke occurs due to three primary mechanisms with distinct infarct patterns: (1) borderzone infarcts (BZI) due to impaired distal perfusion, (2) territorial infarcts due to distal plaque/thrombus embolization, and (3) plaque progression occluding perforators. The objective of the systematic review is to determine whether BZI secondary to ICAS is associated with a higher risk of recurrent stroke or neurological deterioration.</p><p><strong>Methods: </strong>As part of this registered systematic review (CRD42021265230), a comprehensive search was performed to identify relevant papers and conference abstracts (with ≥20 patients) reporting initial infarct patterns and recurrence rates in patients with symptomatic ICAS. Subgroup analyses were performed for studies including any BZI versus isolated BZI and those excluding posterior circulation stroke. The study outcome included neurological deterioration or recurrent stroke during follow-up. For all outcome events, corresponding risk ratios (RRs) and 95% confidence intervals (95% CI) were calculated.</p><p><strong>Results: </strong>A literature search yielded 4,478 records with 32 selected during the title/abstract triage for full text; 11 met inclusion criteria and 8 studies were included in the analysis (n=1,219 patients; 341 with BZI). The meta-analysis demonstrated that the RR of outcome in the BZI group compared to the no BZI group was 2.10 (95% CI 1.52-2.90). Limiting the analysis to studies including any BZI, the RR was 2.10 (95% CI 1.38-3.18). For isolated BZI, RR was 2.59 (95% CI 1.24-5.41). RR was 2.96 (95% CI 1.71-5.12) for studies only including anterior circulation stroke patients.</p><p><strong>Conclusion: </strong>This systematic review and meta-analysis suggests that the presence of BZI secondary to ICAS may be an imaging biomarker that predicts neurological deterioration and/or stroke recurrence.</p>","PeriodicalId":17135,"journal":{"name":"Journal of Stroke","volume":"25 2","pages":"223-232"},"PeriodicalIF":8.2,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/36/a3/jos-2023-00185.PMC10250880.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9599861","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Yan Zhang, Guangchen He, Jing Lu, Guihua Miao, Da Liang, Jiangliang Wang, Liming Wei, Jiangshan Deng, Yueqi Zhu
Background and purpose: To evaluate whether the thrombus enhancement sign (TES) can be used to differentiate embolic large vessel occlusion (LVO) from in situ intracranial atherosclerotic stenosis (ICAS)-related LVO in the anterior circulation of patients with acute ischemic stroke (AIS).
Methods: Patients with LVO in the anterior circulation who underwent both non-contrast computed tomography (CT) and CT angiography and mechanical thrombectomy were retrospectively enrolled. Both embolic LVO (embo-LVO) and in situ ICAS-related LVO (ICAS-LVO) were confirmed by two neurointerventional radiologists after reviewing the medical and imaging data. TES was assessed to predict embo-LVO or ICAS-LVO. The associations between occlusion type and TES, along with clinical and interventional parameters, were investigated using logistic regression analysis and a receiver operating characteristic curve.
Results: A total of 288 patients with AIS were included and divided into an embo-LVO group (n=235) and an ICAS-LVO group (n=53). TES was identified in 205 (71.2%) patients and was more frequently observed in those with embo-LVO, with a sensitivity of 83.8%, specificity of 84.9%, and area under the curve (AUC) of 0.844. Multivariate analysis showed that TES (odds ratio [OR], 22.2; 95% confidence interval [CI], 9.4-53.8; P<0.001) and atrial fibrillation (OR, 6.6; 95% CI, 2.8-15.8; P<0.001) were independent predictors of embolic occlusion. A predictive model that included both TES and atrial fibrillation yielded a higher diagnostic ability for embo-LVO, with an AUC of 0.899.
Conclusion: TES is an imaging marker with high predictive value for identifying embo- and ICAS-LVO in AIS and provides guidance for endovascular reperfusion therapy.
{"title":"Thrombus Enhancement Sign May Differentiate Embolism From Arteriosclerosis-Related Large Vessel Occlusion.","authors":"Yan Zhang, Guangchen He, Jing Lu, Guihua Miao, Da Liang, Jiangliang Wang, Liming Wei, Jiangshan Deng, Yueqi Zhu","doi":"10.5853/jos.2022.03489","DOIUrl":"https://doi.org/10.5853/jos.2022.03489","url":null,"abstract":"<p><strong>Background and purpose: </strong>To evaluate whether the thrombus enhancement sign (TES) can be used to differentiate embolic large vessel occlusion (LVO) from in situ intracranial atherosclerotic stenosis (ICAS)-related LVO in the anterior circulation of patients with acute ischemic stroke (AIS).</p><p><strong>Methods: </strong>Patients with LVO in the anterior circulation who underwent both non-contrast computed tomography (CT) and CT angiography and mechanical thrombectomy were retrospectively enrolled. Both embolic LVO (embo-LVO) and in situ ICAS-related LVO (ICAS-LVO) were confirmed by two neurointerventional radiologists after reviewing the medical and imaging data. TES was assessed to predict embo-LVO or ICAS-LVO. The associations between occlusion type and TES, along with clinical and interventional parameters, were investigated using logistic regression analysis and a receiver operating characteristic curve.</p><p><strong>Results: </strong>A total of 288 patients with AIS were included and divided into an embo-LVO group (n=235) and an ICAS-LVO group (n=53). TES was identified in 205 (71.2%) patients and was more frequently observed in those with embo-LVO, with a sensitivity of 83.8%, specificity of 84.9%, and area under the curve (AUC) of 0.844. Multivariate analysis showed that TES (odds ratio [OR], 22.2; 95% confidence interval [CI], 9.4-53.8; P<0.001) and atrial fibrillation (OR, 6.6; 95% CI, 2.8-15.8; P<0.001) were independent predictors of embolic occlusion. A predictive model that included both TES and atrial fibrillation yielded a higher diagnostic ability for embo-LVO, with an AUC of 0.899.</p><p><strong>Conclusion: </strong>TES is an imaging marker with high predictive value for identifying embo- and ICAS-LVO in AIS and provides guidance for endovascular reperfusion therapy.</p>","PeriodicalId":17135,"journal":{"name":"Journal of Stroke","volume":"25 2","pages":"233-241"},"PeriodicalIF":8.2,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/bd/ac/jos-2022-03489.PMC10250882.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9956027","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Ghada A Mohamed, Raul G Nogueira, Muhammed Amir Essibayi, Hassan Aboul-Nour, Mahmoud Mohammaden, Diogo C Haussen, Aldo Mendez Ruiz, Bradley A Gross, Okkes Kuybu, Mohamed M Salem, Jan-Karl Burkhardt, Brian Jankowitz, James E Siegler, Pratit Patel, Taryn Hester, Santiago Ortega-Gutierrez, Mudassir Farooqui, Milagros Galecio-Castillo, Thanh N Nguyen, Mohamad Abdalkader, Piers Klein, Jude H Charles, Vasu Saini, Dileep R Yavagal, Ammar Jumah, Ali Alaraj, Sophia Peng, Muhammad Hafeez, Omar Tanweer, Peter Kan, Jacopo Scaggiante, Stavros Matsoukas, Johanna T Fifi, Stephan A Mayer, Alex B Chebl
Background and purpose: Randomized trials proved the benefits of mechanical thrombectomy (MT) for select patients with large vessel occlusion (LVO) within 24 hours of last-known-well (LKW). Recent data suggest that LVO patients may benefit from MT beyond 24 hours. This study reports the safety and outcomes of MT beyond 24 hours of LKW compared to standard medical therapy (SMT).
Methods: This is a retrospective analysis of LVO patients presented to 11 comprehensive stroke centers in the United States beyond 24 hours from LKW between January 2015 and December 2021. We assessed 90-day outcomes using the modified Rankin Scale (mRS).
Results: Of 334 patients presented with LVO beyond 24 hours, 64% received MT and 36% received SMT only. Patients who received MT were older (67±15 vs. 64±15 years, P=0.047) and had a higher baseline National Institutes of Health Stroke Scale (NIHSS; 16±7 vs.10±9, P<0.001). Successful recanalization (modified thrombolysis in cerebral infarction score 2b-3) was achieved in 83%, and 5.6% had symptomatic intracranial hemorrhage compared to 2.5% in the SMT group (P=0.19). MT was associated with mRS 0-2 at 90 days (adjusted odds ratio [aOR] 5.73, P=0.026), less mortality (34% vs. 63%, P<0.001), and better discharge NIHSS (P<0.001) compared to SMT in patients with baseline NIHSS ≥6. This treatment benefit remained after matching both groups. Age (aOR 0.94, P<0.001), baseline NIHSS (aOR 0.91, P=0.017), Alberta Stroke Program Early Computed Tomography (ASPECTS) score ≥8 (aOR 3.06, P=0.041), and collaterals scores (aOR 1.41, P=0.027) were associated with 90-day functional independence.
Conclusion: In patients with salvageable brain tissue, MT for LVO beyond 24 hours appears to improve outcomes compared to SMT, especially in patients with severe strokes. Patients' age, ASPECTS, collaterals, and baseline NIHSS score should be considered before discounting MT merely based on LKW.
{"title":"Tissue Clock Beyond Time Clock: Endovascular Thrombectomy for Patients With Large Vessel Occlusion Stroke Beyond 24 Hours.","authors":"Ghada A Mohamed, Raul G Nogueira, Muhammed Amir Essibayi, Hassan Aboul-Nour, Mahmoud Mohammaden, Diogo C Haussen, Aldo Mendez Ruiz, Bradley A Gross, Okkes Kuybu, Mohamed M Salem, Jan-Karl Burkhardt, Brian Jankowitz, James E Siegler, Pratit Patel, Taryn Hester, Santiago Ortega-Gutierrez, Mudassir Farooqui, Milagros Galecio-Castillo, Thanh N Nguyen, Mohamad Abdalkader, Piers Klein, Jude H Charles, Vasu Saini, Dileep R Yavagal, Ammar Jumah, Ali Alaraj, Sophia Peng, Muhammad Hafeez, Omar Tanweer, Peter Kan, Jacopo Scaggiante, Stavros Matsoukas, Johanna T Fifi, Stephan A Mayer, Alex B Chebl","doi":"10.5853/jos.2023.00017","DOIUrl":"https://doi.org/10.5853/jos.2023.00017","url":null,"abstract":"<p><strong>Background and purpose: </strong>Randomized trials proved the benefits of mechanical thrombectomy (MT) for select patients with large vessel occlusion (LVO) within 24 hours of last-known-well (LKW). Recent data suggest that LVO patients may benefit from MT beyond 24 hours. This study reports the safety and outcomes of MT beyond 24 hours of LKW compared to standard medical therapy (SMT).</p><p><strong>Methods: </strong>This is a retrospective analysis of LVO patients presented to 11 comprehensive stroke centers in the United States beyond 24 hours from LKW between January 2015 and December 2021. We assessed 90-day outcomes using the modified Rankin Scale (mRS).</p><p><strong>Results: </strong>Of 334 patients presented with LVO beyond 24 hours, 64% received MT and 36% received SMT only. Patients who received MT were older (67±15 vs. 64±15 years, P=0.047) and had a higher baseline National Institutes of Health Stroke Scale (NIHSS; 16±7 vs.10±9, P<0.001). Successful recanalization (modified thrombolysis in cerebral infarction score 2b-3) was achieved in 83%, and 5.6% had symptomatic intracranial hemorrhage compared to 2.5% in the SMT group (P=0.19). MT was associated with mRS 0-2 at 90 days (adjusted odds ratio [aOR] 5.73, P=0.026), less mortality (34% vs. 63%, P<0.001), and better discharge NIHSS (P<0.001) compared to SMT in patients with baseline NIHSS ≥6. This treatment benefit remained after matching both groups. Age (aOR 0.94, P<0.001), baseline NIHSS (aOR 0.91, P=0.017), Alberta Stroke Program Early Computed Tomography (ASPECTS) score ≥8 (aOR 3.06, P=0.041), and collaterals scores (aOR 1.41, P=0.027) were associated with 90-day functional independence.</p><p><strong>Conclusion: </strong>In patients with salvageable brain tissue, MT for LVO beyond 24 hours appears to improve outcomes compared to SMT, especially in patients with severe strokes. Patients' age, ASPECTS, collaterals, and baseline NIHSS score should be considered before discounting MT merely based on LKW.</p>","PeriodicalId":17135,"journal":{"name":"Journal of Stroke","volume":"25 2","pages":"282-290"},"PeriodicalIF":8.2,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/33/d4/jos-2023-00017.PMC10250878.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9599863","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-05-01Epub Date: 2023-05-30DOI: 10.5853/jos.2023.00213
Setareh Salehi Omran, Liqi Shu, Allison Chang, Neal S Parikh, Adeel S Zubair, Alexis N Simpkins, Mirjam R Heldner, Arsany Hakim, Sami Al Kasab, Thanh Nguyen, Piers Klein, Eric D Goldstein, Maria Cristina Vedovati, Maurizio Paciaroni, David S Liebeskind, Shadi Yaghi, Shawna Cutting
Background and purpose: Vessel recanalization after cerebral venous thrombosis (CVT) is associated with favorable outcomes and lower mortality. Several studies examined the timing and predictors of recanalization after CVT with mixed results. We aimed to investigate predictors and timing of recanalization after CVT.
Methods: We used data from the multicenter, international AntiCoagulaTION in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT) study of consecutive patients with CVT from January 2015 to December 2020. Our analysis included patients that had undergone repeat venous neuroimaging more than 30 days after initiation of anticoagulation treatment. Prespecified variables were included in univariate and multivariable analyses to identify independent predictors of failure to recanalize.
Results: Among the 551 patients (mean age, 44.4±16.2 years, 66.2% women) that met inclusion criteria, 486 (88.2%) had complete or partial, and 65 (11.8%) had no recanalization. The median time to first follow-up imaging study was 110 days (interquartile range, 60-187). In multivariable analysis, older age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03-1.07), male sex (OR, 0.44; 95% CI, 0.24-0.80), and lack of parenchymal changes on baseline imaging (OR, 0.53; 95% CI, 0.29-0.96) were associated with no recanalization. The majority of improvement in recanalization (71.1%) occurred before 3 months from initial diagnosis. A high percentage of complete recanalization (59.0%) took place within the first 3 months after CVT diagnosis.
Conclusion: Older age, male sex, and lack of parenchymal changes were associated with no recanalization after CVT. The majority recanalization occurred early in the disease course suggesting limited further recanalization with anticoagulation beyond 3 months. Large prospective studies are needed to confirm our findings.
{"title":"Timing and Predictors of Recanalization After Anticoagulation in Cerebral Venous Thrombosis.","authors":"Setareh Salehi Omran, Liqi Shu, Allison Chang, Neal S Parikh, Adeel S Zubair, Alexis N Simpkins, Mirjam R Heldner, Arsany Hakim, Sami Al Kasab, Thanh Nguyen, Piers Klein, Eric D Goldstein, Maria Cristina Vedovati, Maurizio Paciaroni, David S Liebeskind, Shadi Yaghi, Shawna Cutting","doi":"10.5853/jos.2023.00213","DOIUrl":"10.5853/jos.2023.00213","url":null,"abstract":"<p><strong>Background and purpose: </strong>Vessel recanalization after cerebral venous thrombosis (CVT) is associated with favorable outcomes and lower mortality. Several studies examined the timing and predictors of recanalization after CVT with mixed results. We aimed to investigate predictors and timing of recanalization after CVT.</p><p><strong>Methods: </strong>We used data from the multicenter, international AntiCoagulaTION in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT) study of consecutive patients with CVT from January 2015 to December 2020. Our analysis included patients that had undergone repeat venous neuroimaging more than 30 days after initiation of anticoagulation treatment. Prespecified variables were included in univariate and multivariable analyses to identify independent predictors of failure to recanalize.</p><p><strong>Results: </strong>Among the 551 patients (mean age, 44.4±16.2 years, 66.2% women) that met inclusion criteria, 486 (88.2%) had complete or partial, and 65 (11.8%) had no recanalization. The median time to first follow-up imaging study was 110 days (interquartile range, 60-187). In multivariable analysis, older age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03-1.07), male sex (OR, 0.44; 95% CI, 0.24-0.80), and lack of parenchymal changes on baseline imaging (OR, 0.53; 95% CI, 0.29-0.96) were associated with no recanalization. The majority of improvement in recanalization (71.1%) occurred before 3 months from initial diagnosis. A high percentage of complete recanalization (59.0%) took place within the first 3 months after CVT diagnosis.</p><p><strong>Conclusion: </strong>Older age, male sex, and lack of parenchymal changes were associated with no recanalization after CVT. The majority recanalization occurred early in the disease course suggesting limited further recanalization with anticoagulation beyond 3 months. Large prospective studies are needed to confirm our findings.</p>","PeriodicalId":17135,"journal":{"name":"Journal of Stroke","volume":"25 2","pages":"291-298"},"PeriodicalIF":8.2,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/e8/30/jos-2023-00213.PMC10250867.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9602145","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Keun-Sik Hong, Oh Young Bang, Jong-Ho Park, Jin-Man Jung, Sang-Hun Lee, Tae-Jin Song, Hyo Suk Nam, Hee-Kwon Park, Keun-Hwa Jung, Sung Hyuk Heo, Jaseong Koo, Kyung-Ho Yu, Kwang-Yeol Park, Chi Kyung Kim, Hong-Kyun Park, Jiyoon Lee, Juneyoung Lee, Woo-Keun Seo
Background and purpose: Moderate-intensity statin plus ezetimibe versus high-intensity statin alone may provide a greater low-density lipoprotein cholesterol (LDL-C) reduction in patients with recent ischemic stroke.
Methods: This randomized, open-label, controlled trial assigned patients with recent ischemic stroke <90 days to rosuvastatin/ezetimibe 10/10 mg once daily (ROS10/EZT10) or to rosuvastatin 20 mg once daily (ROS20). The primary endpoint was LDL-C reduction ≥50% from baseline at 90 days. Key secondary endpoints were LDL-C <70 mg/dL and multiple lipid goal achievement, and composite of major vascular events.
Results: Of 584 randomized, 530 were included in the modified intention-to-treat analysis. The baseline LDL-C level was 130.2±34.7 mg/dL in the ROS10/EZT10 group and 131.0±33.9 mg/dL in the ROS20 group. The primary endpoint was achieved in 198 patients (72.5%) in the ROS10/EZT10 group and 148 (57.6%) in the ROS20 group (odds ratio [95% confidence interval], 1.944 [1.352-2.795]; P= 0.0003). LDL-C level <70 mg/dL was achieved in 80.2% and 65.4% in the ROS10/EZT10 and ROS20 groups (P=0.0001). Multiple lipid goal achievement rate was 71.1% and 53.7% in the ROS10/EZT10 and ROS20 groups (P<0.0001). Major vascular events occurred in 1 patient in the ROS10/EZT10 group and 9 in the ROS20 group (P=0.0091). The adverse event rates did not differ between the two groups.
Conclusion: Moderate-intensity rosuvastatin plus ezetimibe was superior to high-intensity rosuvastatin alone for intensive LDL-C reduction in patients with recent ischemic stroke. With the combination therapy, more than 70% of patients achieved LDL-C reduction ≥50% and 80% had an LDL-C <70 mg/dL at 90 days.
{"title":"Moderate-Intensity Rosuvastatin Plus Ezetimibe Versus High-Intensity Rosuvastatin for Target Low-Density Lipoprotein Cholesterol Goal Achievement in Patients With Recent Ischemic Stroke: A Randomized Controlled Trial.","authors":"Keun-Sik Hong, Oh Young Bang, Jong-Ho Park, Jin-Man Jung, Sang-Hun Lee, Tae-Jin Song, Hyo Suk Nam, Hee-Kwon Park, Keun-Hwa Jung, Sung Hyuk Heo, Jaseong Koo, Kyung-Ho Yu, Kwang-Yeol Park, Chi Kyung Kim, Hong-Kyun Park, Jiyoon Lee, Juneyoung Lee, Woo-Keun Seo","doi":"10.5853/jos.2022.02957","DOIUrl":"https://doi.org/10.5853/jos.2022.02957","url":null,"abstract":"<p><strong>Background and purpose: </strong>Moderate-intensity statin plus ezetimibe versus high-intensity statin alone may provide a greater low-density lipoprotein cholesterol (LDL-C) reduction in patients with recent ischemic stroke.</p><p><strong>Methods: </strong>This randomized, open-label, controlled trial assigned patients with recent ischemic stroke <90 days to rosuvastatin/ezetimibe 10/10 mg once daily (ROS10/EZT10) or to rosuvastatin 20 mg once daily (ROS20). The primary endpoint was LDL-C reduction ≥50% from baseline at 90 days. Key secondary endpoints were LDL-C <70 mg/dL and multiple lipid goal achievement, and composite of major vascular events.</p><p><strong>Results: </strong>Of 584 randomized, 530 were included in the modified intention-to-treat analysis. The baseline LDL-C level was 130.2±34.7 mg/dL in the ROS10/EZT10 group and 131.0±33.9 mg/dL in the ROS20 group. The primary endpoint was achieved in 198 patients (72.5%) in the ROS10/EZT10 group and 148 (57.6%) in the ROS20 group (odds ratio [95% confidence interval], 1.944 [1.352-2.795]; P= 0.0003). LDL-C level <70 mg/dL was achieved in 80.2% and 65.4% in the ROS10/EZT10 and ROS20 groups (P=0.0001). Multiple lipid goal achievement rate was 71.1% and 53.7% in the ROS10/EZT10 and ROS20 groups (P<0.0001). Major vascular events occurred in 1 patient in the ROS10/EZT10 group and 9 in the ROS20 group (P=0.0091). The adverse event rates did not differ between the two groups.</p><p><strong>Conclusion: </strong>Moderate-intensity rosuvastatin plus ezetimibe was superior to high-intensity rosuvastatin alone for intensive LDL-C reduction in patients with recent ischemic stroke. With the combination therapy, more than 70% of patients achieved LDL-C reduction ≥50% and 80% had an LDL-C <70 mg/dL at 90 days.</p>","PeriodicalId":17135,"journal":{"name":"Journal of Stroke","volume":"25 2","pages":"242-250"},"PeriodicalIF":8.2,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/1d/55/jos-2022-02957.PMC10250871.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9603106","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The collateral circulation plays a crucial role in maintaining perfusion to brain tissue in ischemic stroke, which prolongs the time window for effective therapies to be provided and ultimately avoids irreversible damage that may lead to worse clinical outcomes. The understanding of this complex vascular bypass system has advanced greatly in the past few years, yet effective treatments for its potentiation as a therapeutic target remain a challenge. The assessment of the collateral circulation is now part of the routine neuroimaging protocols for acute ischemic stroke, which provides a more complete pathophysiological picture in each patient that allows for a better selection for acute reperfusion therapies and a more accurate prognostication of outcomes, among other potential uses. In this review, we aim to provide a structured and updated approach to the collateral circulation while highlighting ongoing research areas with promising future clinical applications.
{"title":"Collateral Circulation in Ischemic Stroke: An Updated Review.","authors":"Gino Maguida, Ashfaq Shuaib","doi":"10.5853/jos.2022.02936","DOIUrl":"https://doi.org/10.5853/jos.2022.02936","url":null,"abstract":"<p><p>The collateral circulation plays a crucial role in maintaining perfusion to brain tissue in ischemic stroke, which prolongs the time window for effective therapies to be provided and ultimately avoids irreversible damage that may lead to worse clinical outcomes. The understanding of this complex vascular bypass system has advanced greatly in the past few years, yet effective treatments for its potentiation as a therapeutic target remain a challenge. The assessment of the collateral circulation is now part of the routine neuroimaging protocols for acute ischemic stroke, which provides a more complete pathophysiological picture in each patient that allows for a better selection for acute reperfusion therapies and a more accurate prognostication of outcomes, among other potential uses. In this review, we aim to provide a structured and updated approach to the collateral circulation while highlighting ongoing research areas with promising future clinical applications.</p>","PeriodicalId":17135,"journal":{"name":"Journal of Stroke","volume":"25 2","pages":"179-198"},"PeriodicalIF":8.2,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/88/83/jos-2022-02936.PMC10250877.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9604002","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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