N. M. Le, Ananya S Iyyangar, Youngran Kim, Mohammad Rauf Chaudhry, S. Salazar‐Marioni, R. Abdelkhaleq, A. Niktabe, A. Ballekere, Hussain M Azeem, Sandi Shaw, Peri Smith, Mallory Cowan, Isabel Gonzales, Louise D McCullough, Luca Giancardo, Sunil A. Sheth
Accelerating door‐in‐door‐out (DIDO) times at primary stroke centers (PSCs) for patients with large vessel occlusion (LVO) acute ischemic stroke transferred for possible endovascular stroke therapy (EVT) is important to optimize outcomes. Here, we assess whether automated LVO detection coupled with secure communication at non‐EVT performing PSCs improves DIDO time and increases the proportion of patients receiving EVT after transfer. From our prospectively collected multicenter registry, we identified patients with LVO acute ischemic stroke that presented to one of 7 PSCs in the Greater Houston area from January 1, 2021, to February 27, 2022. Noncontrast computed tomography and computed tomographic angiography were performed in all patients at the time of presentation, per standard of care. A machine learning (artificial intelligence [AI]) algorithm trained to detect LVO (Viz.AI) from computed tomographic angiography was implemented at all 7 hospitals. The primary outcome of the study was DIDO at the PSCs and was determined using multivariable linear regression adjusted for sex and on/off hours. Secondary outcomes included likelihood of receiving EVT post‐transfer. Among 115 patients who met inclusion criteria, 80 were evaluated pre‐AI and 35 post‐AI. The most common occlusion locations were middle cerebral artery (51.3%) and internal carotid artery (25.2%). There were no substantial differences in demographics or presentation characteristics between the 2 groups. Median time from onset to PSC arrival was 117 minutes (interquartile range, 54–521 minutes). In univariable analysis, patients evaluated at the PSCs after AI implementation had a shorter DIDO time (median difference, 77 minutes; P <0.001). In multivariable linear regression, patients evaluated with automated LVO detection AI software were associated with a 106‐minute (95% CI, −165 to −48 minutes) reduction in DIDO time but no difference in likelihood of EVT post‐transfer (odd ratio, 2.13 [95% CI, 0.88–5.13). Implementation of a machine learning method for automated LVO detection coupled with secure communication resulted in a substantial decrease in DIDO time at non‐EVT performing PSCs.
{"title":"Machine Learning–Enabled Automated Large Vessel Occlusion Detection Improves Transfer Times at Primary Stroke Centers","authors":"N. M. Le, Ananya S Iyyangar, Youngran Kim, Mohammad Rauf Chaudhry, S. Salazar‐Marioni, R. Abdelkhaleq, A. Niktabe, A. Ballekere, Hussain M Azeem, Sandi Shaw, Peri Smith, Mallory Cowan, Isabel Gonzales, Louise D McCullough, Luca Giancardo, Sunil A. Sheth","doi":"10.1161/svin.123.001119","DOIUrl":"https://doi.org/10.1161/svin.123.001119","url":null,"abstract":"\u0000 \u0000 Accelerating door‐in‐door‐out (DIDO) times at primary stroke centers (PSCs) for patients with large vessel occlusion (LVO) acute ischemic stroke transferred for possible endovascular stroke therapy (EVT) is important to optimize outcomes. Here, we assess whether automated LVO detection coupled with secure communication at non‐EVT performing PSCs improves DIDO time and increases the proportion of patients receiving EVT after transfer.\u0000 \u0000 \u0000 \u0000 From our prospectively collected multicenter registry, we identified patients with LVO acute ischemic stroke that presented to one of 7 PSCs in the Greater Houston area from January 1, 2021, to February 27, 2022. Noncontrast computed tomography and computed tomographic angiography were performed in all patients at the time of presentation, per standard of care. A machine learning (artificial intelligence [AI]) algorithm trained to detect LVO (Viz.AI) from computed tomographic angiography was implemented at all 7 hospitals. The primary outcome of the study was DIDO at the PSCs and was determined using multivariable linear regression adjusted for sex and on/off hours. Secondary outcomes included likelihood of receiving EVT post‐transfer.\u0000 \u0000 \u0000 \u0000 \u0000 Among 115 patients who met inclusion criteria, 80 were evaluated pre‐AI and 35 post‐AI. The most common occlusion locations were middle cerebral artery (51.3%) and internal carotid artery (25.2%). There were no substantial differences in demographics or presentation characteristics between the 2 groups. Median time from onset to PSC arrival was 117 minutes (interquartile range, 54–521 minutes). In univariable analysis, patients evaluated at the PSCs after AI implementation had a shorter DIDO time (median difference, 77 minutes;\u0000 P\u0000 <0.001). In multivariable linear regression, patients evaluated with automated LVO detection AI software were associated with a 106‐minute (95% CI, −165 to −48 minutes) reduction in DIDO time but no difference in likelihood of EVT post‐transfer (odd ratio, 2.13 [95% CI, 0.88–5.13).\u0000 \u0000 \u0000 \u0000 \u0000 Implementation of a machine learning method for automated LVO detection coupled with secure communication resulted in a substantial decrease in DIDO time at non‐EVT performing PSCs.\u0000","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"32 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-03-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140365649","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Yingjie Xu, Miaomiao Hu, Pan Zhang, LuLu Xiao, Yanan Lu, Dezhi Liu, Yongkun Li, A. Alexandre, A. Pedicelli, A. Broccolini, L. Scarcia, Hao Chen, Wen Sun
Vertebrobasilar artery occlusion (VBAO) is a severe type of stroke. Multiple prediction models for outcome and symptomatic intracranial hemorrhage (sICH) of patients with acute ischemic stroke treated with endovascular treatment have been developed to improve patient management, but few are based on VBAO. This study aimed to provide an overview of published models to predict functional outcome and sICH as well as to validate their ability in patients with acute VBAO treated with endovascular treatment. We performed a systematic search to identify models either developed or validated to predict functional outcomes or sICH after endovascular treatment. Models were externally validated in the Posterior Circulation Ischemic Stroke Registry (PERSIST) study (n = 2422). Outcome measures included the modified Rankin Scale (mRS) score at 90 days and sICH. Model performance was evaluated with discrimination (c‐statistic) and calibration (slope and intercept). A total of 65 models were included in overview. The most frequently used predictors were baseline National Institutes of Health Stroke Scale score (n = 57), age (n = 45), and glucose (n = 32). In the external validation cohort, 777 of 2353 patients (33.0%) achieved mRS score 0–2 at 90 days, 1061 of 2353 patients (45.1%) patients achieved mRS score 0–3 at 90 days, and sICH occurred in 170 of 2422 patients (7.0%). Finally, 27 models were included in external validation. For functional outcome models focusing on mRS score 0–2/3–6, discrimination ranged from 0.63 to 0.66 and best calibrated model was SC (Stroke Checkerboard) (intercept, −0.13 [95% CI, −0.27 to 0.01]; slope, 0.92 [95% CI, 0.67–1.17]). For functional outcome models focusing on mRS score 0–3/4–6, discrimination ranged from 0.64 to 0.74 and best calibrated model was modified Houston Intra‐Arterial Therapy 2 (mHIAT2) (intercept, −0.12 [95% CI, −0.31 to 0.07]; slope, 0.85 [95% CI, 0.65–1.04]). For sICH models, discrimination ranged from 0.53 to 0.83 and best calibrated model was Thrombolysis in Cerebral Infarction score, Alberta Stroke Program Early CT Score, and glucose (TAG) (intercept, 0.13 [95% CI, −0.25 to 0.51]; slope, 0.93 [95% CI, 0.63–1.23]). The currently published models are inadequate for predicting functional outcomes and sICH in patients with acute VBAO undergoing endovascular treatment and, therefore, there is a need for more effective models specifically developed for VBAO conditions.
{"title":"Functional Outcomes and Symptomatic Intracranial Hemorrhage After Endovascular Treatment in Acute Vertebrobasilar Artery Occlusions: External Validation of Prediction Models","authors":"Yingjie Xu, Miaomiao Hu, Pan Zhang, LuLu Xiao, Yanan Lu, Dezhi Liu, Yongkun Li, A. Alexandre, A. Pedicelli, A. Broccolini, L. Scarcia, Hao Chen, Wen Sun","doi":"10.1161/svin.123.001284","DOIUrl":"https://doi.org/10.1161/svin.123.001284","url":null,"abstract":"\u0000 \u0000 Vertebrobasilar artery occlusion (VBAO) is a severe type of stroke. Multiple prediction models for outcome and symptomatic intracranial hemorrhage (sICH) of patients with acute ischemic stroke treated with endovascular treatment have been developed to improve patient management, but few are based on VBAO. This study aimed to provide an overview of published models to predict functional outcome and sICH as well as to validate their ability in patients with acute VBAO treated with endovascular treatment.\u0000 \u0000 \u0000 \u0000 We performed a systematic search to identify models either developed or validated to predict functional outcomes or sICH after endovascular treatment. Models were externally validated in the Posterior Circulation Ischemic Stroke Registry (PERSIST) study (n = 2422). Outcome measures included the modified Rankin Scale (mRS) score at 90 days and sICH. Model performance was evaluated with discrimination (c‐statistic) and calibration (slope and intercept).\u0000 \u0000 \u0000 \u0000 A total of 65 models were included in overview. The most frequently used predictors were baseline National Institutes of Health Stroke Scale score (n = 57), age (n = 45), and glucose (n = 32). In the external validation cohort, 777 of 2353 patients (33.0%) achieved mRS score 0–2 at 90 days, 1061 of 2353 patients (45.1%) patients achieved mRS score 0–3 at 90 days, and sICH occurred in 170 of 2422 patients (7.0%). Finally, 27 models were included in external validation. For functional outcome models focusing on mRS score 0–2/3–6, discrimination ranged from 0.63 to 0.66 and best calibrated model was SC (Stroke Checkerboard) (intercept, −0.13 [95% CI, −0.27 to 0.01]; slope, 0.92 [95% CI, 0.67–1.17]). For functional outcome models focusing on mRS score 0–3/4–6, discrimination ranged from 0.64 to 0.74 and best calibrated model was modified Houston Intra‐Arterial Therapy 2 (mHIAT2) (intercept, −0.12 [95% CI, −0.31 to 0.07]; slope, 0.85 [95% CI, 0.65–1.04]). For sICH models, discrimination ranged from 0.53 to 0.83 and best calibrated model was Thrombolysis in Cerebral Infarction score, Alberta Stroke Program Early CT Score, and glucose (TAG) (intercept, 0.13 [95% CI, −0.25 to 0.51]; slope, 0.93 [95% CI, 0.63–1.23]).\u0000 \u0000 \u0000 \u0000 The currently published models are inadequate for predicting functional outcomes and sICH in patients with acute VBAO undergoing endovascular treatment and, therefore, there is a need for more effective models specifically developed for VBAO conditions.\u0000","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"30 10","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140378224","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Leslie Morrison, Juan Gutierrez, C. Ayata, Miguel Lopez-Toledano, E. Carrazana, I. Awad, A. Rabinowicz, Helen Kim
Cerebral cavernous malformations (CCMs) are vascular lesions associated with seizures, hemorrhage, and neurologic deficits. The familial form of CCM constitutes ≈20% of cases and presents with multifocal lesions in the brain and spinal cord, whereas the more common sporadic form typically involves a single lesion. Treatments of CCM include surgical resection and stereotactic radiosurgery, as well as management of symptoms (eg, seizures). Surgical resection or irradiation of lesions in eloquent areas requires careful consideration because of the potential for morbidity and mortality, and these treatments are not advised for asymptomatic lesions. The purpose of this narrative review is to describe the current state of treatments for CCM, with an emphasis on potential clinically relevant pharmacologic treatments aimed at targeting aberrant molecular signaling associated with CCM. Literature was identified through PubMed using search terms related to treatments of CCMs. In endothelial cells, overactivation of RhoA/Rho‐associated kinase contributes to disruption of cell‐cell junctions and a shift to a senescence‐associated secretory phenotype, which leads to inflammation, migration, and invasiveness of mutant endothelial cells. Specific (NRL‐1049) and nonspecific (fasudil, statins) inhibition of Rho‐associated kinase has shown effectiveness to reduce lesion burden in mouse models of CCM. A phase 1/2 clinical trial is currently underway to investigate the efficacy of atorvastatin in patients with CCM, and a first‐in‐human clinical trial to evaluate safety, tolerability, and pharmacokinetic parameters of NRL‐1049 began in 2023. The β‐blocker propranolol and the superoxide dismutase mimetic REC‐994 have also shown effectiveness in attenuating lesion burden in preclinical studies. Results from a pilot phase 2 clinical trial of propranolol support further investigation in an adequately powered trial, and the safety, pharmacokinetics, and potential efficacy of REC‐994 are currently being evaluated in a phase 2 clinical trial. Additional agents have been used solely in preclinical models and require clinical evaluation.
{"title":"Current and Future Treatment Options for Cerebral Cavernous Malformations","authors":"Leslie Morrison, Juan Gutierrez, C. Ayata, Miguel Lopez-Toledano, E. Carrazana, I. Awad, A. Rabinowicz, Helen Kim","doi":"10.1161/svin.123.001140","DOIUrl":"https://doi.org/10.1161/svin.123.001140","url":null,"abstract":"Cerebral cavernous malformations (CCMs) are vascular lesions associated with seizures, hemorrhage, and neurologic deficits. The familial form of CCM constitutes ≈20% of cases and presents with multifocal lesions in the brain and spinal cord, whereas the more common sporadic form typically involves a single lesion. Treatments of CCM include surgical resection and stereotactic radiosurgery, as well as management of symptoms (eg, seizures). Surgical resection or irradiation of lesions in eloquent areas requires careful consideration because of the potential for morbidity and mortality, and these treatments are not advised for asymptomatic lesions. The purpose of this narrative review is to describe the current state of treatments for CCM, with an emphasis on potential clinically relevant pharmacologic treatments aimed at targeting aberrant molecular signaling associated with CCM. Literature was identified through PubMed using search terms related to treatments of CCMs. In endothelial cells, overactivation of RhoA/Rho‐associated kinase contributes to disruption of cell‐cell junctions and a shift to a senescence‐associated secretory phenotype, which leads to inflammation, migration, and invasiveness of mutant endothelial cells. Specific (NRL‐1049) and nonspecific (fasudil, statins) inhibition of Rho‐associated kinase has shown effectiveness to reduce lesion burden in mouse models of CCM. A phase 1/2 clinical trial is currently underway to investigate the efficacy of atorvastatin in patients with CCM, and a first‐in‐human clinical trial to evaluate safety, tolerability, and pharmacokinetic parameters of NRL‐1049 began in 2023. The β‐blocker propranolol and the superoxide dismutase mimetic REC‐994 have also shown effectiveness in attenuating lesion burden in preclinical studies. Results from a pilot phase 2 clinical trial of propranolol support further investigation in an adequately powered trial, and the safety, pharmacokinetics, and potential efficacy of REC‐994 are currently being evaluated in a phase 2 clinical trial. Additional agents have been used solely in preclinical models and require clinical evaluation.","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"97 4","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-03-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140223371","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Vivek S. Yedavalli, M. Koneru, M. Hoseinyazdi, E. Marsh, R. Llinas, Victor C Urrutia, Richard Leigh, L. F. Gonzalez, Risheng Xu, Justin M Caplan, Judy Huang, Hanzhang Lu, Max Wintermark, A. Dmytriw, A. Guenego, Gregory W Albers, Licia Luna, J. Heit, K. Nael, Argye E. Hillis
Hemorrhagic transformation (HT) is a major complication in patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy. However, HT in patients with AIS due to medium‐vessel occlusions has still not been well researched. In large‐vessel occlusions, collateral status is an important determinant of postprocedural HT, and the cerebral blood volume (CBV) index is a reliable surrogate of collateral status. The aim of our study is to identify an optimal CBV index threshold associated with HT in patients with AIS due to medium‐vessel occlusion and evaluate additional parameters that are independently associated with HT in this group. This retrospective analysis of our prospectively collected database from 2 comprehensive stroke centers consisted of patients presenting with AIS due to medium‐vessel occlusion from 2019 to 2023. The primary outcome was the presence of HT on follow‐up imaging. Optimal CBV index cutoff for HT was derived from a univariate logistic regression analysis. Multivariable logistic regression analysis for HT was derived from the dichotomized CBV index and other covariates. The receiver operator characteristic curve yielded area under the curve. Statistical significance was P ≤ $ le $ 0.05. Of 111 patients (median age, 70 years; 43.2% women) included, 26 (23.4%) patients had HT. The optimal CBV index cutoff was 0.7. From multivariable regression analysis, significant variables included prior stroke (adjusted odds ratio [aOR], 7.18 [95% CI, 1.60–32.16]; P = 0.01), endovascular thrombectomy attempt (aOR, 7.86 [95% CI, 1.78–34.68]; P = 0.01), and CBV index ( ≤ $ le $ 0.7; aOR, 4.23 [95% CI, 1.02–17.59]; P = 0.04). The area under the curve was 0.82 (95% CI, 0.69–0.91). A CBV index ≤ $ le $ 0.7 was independently associated with HT in patients with AIS due to medium‐vessel occlusion. Endovascular thrombectomy attempt and prior stroke history were also independently associated with HT in this population.
{"title":"Low Cerebral Blood Volume Index, Thrombectomy, and Prior Stroke Are Independently Associated With Hemorrhagic Transformation in Medium‐Vessel Occlusion Ischemic Stroke","authors":"Vivek S. Yedavalli, M. Koneru, M. Hoseinyazdi, E. Marsh, R. Llinas, Victor C Urrutia, Richard Leigh, L. F. Gonzalez, Risheng Xu, Justin M Caplan, Judy Huang, Hanzhang Lu, Max Wintermark, A. Dmytriw, A. Guenego, Gregory W Albers, Licia Luna, J. Heit, K. Nael, Argye E. Hillis","doi":"10.1161/svin.123.001250","DOIUrl":"https://doi.org/10.1161/svin.123.001250","url":null,"abstract":"\u0000 \u0000 Hemorrhagic transformation (HT) is a major complication in patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy. However, HT in patients with AIS due to medium‐vessel occlusions has still not been well researched. In large‐vessel occlusions, collateral status is an important determinant of postprocedural HT, and the cerebral blood volume (CBV) index is a reliable surrogate of collateral status. The aim of our study is to identify an optimal CBV index threshold associated with HT in patients with AIS due to medium‐vessel occlusion and evaluate additional parameters that are independently associated with HT in this group.\u0000 \u0000 \u0000 \u0000 \u0000 This retrospective analysis of our prospectively collected database from 2 comprehensive stroke centers consisted of patients presenting with AIS due to medium‐vessel occlusion from 2019 to 2023. The primary outcome was the presence of HT on follow‐up imaging. Optimal CBV index cutoff for HT was derived from a univariate logistic regression analysis. Multivariable logistic regression analysis for HT was derived from the dichotomized CBV index and other covariates. The receiver operator characteristic curve yielded area under the curve. Statistical significance was\u0000 P\u0000 \u0000 \u0000 ≤\u0000 $ le $\u0000 \u0000 \u0000 0.05.\u0000 \u0000 \u0000 \u0000 \u0000 \u0000 Of 111 patients (median age, 70 years; 43.2% women) included, 26 (23.4%) patients had HT. The optimal CBV index cutoff was 0.7. From multivariable regression analysis, significant variables included prior stroke (adjusted odds ratio [aOR], 7.18 [95% CI, 1.60–32.16];\u0000 P\u0000 = 0.01), endovascular thrombectomy attempt (aOR, 7.86 [95% CI, 1.78–34.68];\u0000 P\u0000 = 0.01), and CBV index (\u0000 \u0000 \u0000 ≤\u0000 $ le $\u0000 \u0000 \u0000 0.7; aOR, 4.23 [95% CI, 1.02–17.59];\u0000 P\u0000 = 0.04). The area under the curve was 0.82 (95% CI, 0.69–0.91).\u0000 \u0000 \u0000 \u0000 \u0000 \u0000 A CBV index\u0000 \u0000 \u0000 ≤\u0000 $ le $\u0000 \u0000 \u0000 0.7 was independently associated with HT in patients with AIS due to medium‐vessel occlusion. Endovascular thrombectomy attempt and prior stroke history were also independently associated with HT in this population.\u0000 \u0000","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"131 5","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-03-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140223561","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Correction of: Mechanical Thrombectomy in the Late Presentation of Anterior Circulation Large Vessel Occlusion Stroke: A Guideline From the Society of Vascular and Interventional Neurology Guidelines and Practice Standards Committee","authors":"","doi":"10.1161/svi2.12893","DOIUrl":"https://doi.org/10.1161/svi2.12893","url":null,"abstract":"","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"162 3","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-03-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140235613","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Hamidreza Saber, G. Colby, N. Mueller-Kronast, M. A. Aziz-Sultan, R. Klucznik, J. Saver, N. Sanossian, Frank R Hellinger, Dileep R. Yavagal, Tom L Yao, Reza Jahan, Diogo C. Haussen, Raul G Nogueira, M. Froehler, Osama O. Zaidat, David S. Liebeskind
Subarachnoid hemorrhage (SAH) associated with vessel injury during endovascular therapy for acute ischemic stroke is a known complication. Arterial anatomy may predispose to increased risk of SAH and technical safety, yet factors such as clot location, arterial size, and tortuosity have not been explored. We examined these anatomic factors with respect to SAH during thrombectomy. Arterial anatomy at the site of occlusion and mechanical thrombectomy during device deployment was detailed by the STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) core laboratory. Luminal diameters, arterial branching, and segmental tortuosity were measured. Arterial tortuosity was quantified using the distance factor metric. Statistical analyses included descriptive variables of arterial anatomy, with univariable and multivariable modeling to predict SAH. Arterial tortuosity in each segment from the proximal cerebral arteries to the site of occlusion was quantified in 790 subjects treated with mechanical thrombectomy in STRATIS. Cumulative arterial tortuosity to the site of vessel occlusion was greater in distal lesions. SAH was clearly linked with more distal thrombectomy ( P = 0.02), occurring in 19.0% of distal M2, 16.7% of M3, 7.3% of distal M1, 5.8% of proximal M2, 2.4% of distal internal carotid artery, and 2.1% of proximal M1. In multivariable analysis after adjusting for arterial diameter at the site of occlusion, arterial tortuosity was a significant predictor of SAH (upper tertile versus 1: odds ratio, 3.08 [95% CI, 1.04–9.09]; P = 0.04), while arterial diameter was unrelated to SAH ( P = 0.30) when accounting for tortuosity. This novel analysis of arterial tortuosity and angiographic anatomy during mechanical thrombectomy establishes tortuosity as a determinant of SAH, providing insight for future techniques and innovative device designs.
{"title":"Arterial Tortuosity Is a Potent Determinant of Safety in Endovascular Therapy for Acute Ischemic Stroke","authors":"Hamidreza Saber, G. Colby, N. Mueller-Kronast, M. A. Aziz-Sultan, R. Klucznik, J. Saver, N. Sanossian, Frank R Hellinger, Dileep R. Yavagal, Tom L Yao, Reza Jahan, Diogo C. Haussen, Raul G Nogueira, M. Froehler, Osama O. Zaidat, David S. Liebeskind","doi":"10.1161/svin.123.001178","DOIUrl":"https://doi.org/10.1161/svin.123.001178","url":null,"abstract":"\u0000 \u0000 Subarachnoid hemorrhage (SAH) associated with vessel injury during endovascular therapy for acute ischemic stroke is a known complication. Arterial anatomy may predispose to increased risk of SAH and technical safety, yet factors such as clot location, arterial size, and tortuosity have not been explored. We examined these anatomic factors with respect to SAH during thrombectomy.\u0000 \u0000 \u0000 \u0000 Arterial anatomy at the site of occlusion and mechanical thrombectomy during device deployment was detailed by the STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) core laboratory. Luminal diameters, arterial branching, and segmental tortuosity were measured. Arterial tortuosity was quantified using the distance factor metric. Statistical analyses included descriptive variables of arterial anatomy, with univariable and multivariable modeling to predict SAH.\u0000 \u0000 \u0000 \u0000 \u0000 Arterial tortuosity in each segment from the proximal cerebral arteries to the site of occlusion was quantified in 790 subjects treated with mechanical thrombectomy in STRATIS. Cumulative arterial tortuosity to the site of vessel occlusion was greater in distal lesions. SAH was clearly linked with more distal thrombectomy (\u0000 P \u0000 = 0.02), occurring in 19.0% of distal M2, 16.7% of M3, 7.3% of distal M1, 5.8% of proximal M2, 2.4% of distal internal carotid artery, and 2.1% of proximal M1. In multivariable analysis after adjusting for arterial diameter at the site of occlusion, arterial tortuosity was a significant predictor of SAH (upper tertile versus 1: odds ratio, 3.08 [95% CI, 1.04–9.09];\u0000 P \u0000 = 0.04), while arterial diameter was unrelated to SAH (\u0000 P \u0000 = 0.30) when accounting for tortuosity.\u0000 \u0000 \u0000 \u0000 \u0000 This novel analysis of arterial tortuosity and angiographic anatomy during mechanical thrombectomy establishes tortuosity as a determinant of SAH, providing insight for future techniques and innovative device designs.\u0000","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"33 3","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-03-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140235358","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
M. Olivé-Gadea, M. Rodrigo-Gisbert, Á. García‐Tornel, S. Rudilosso, Alejandro Rodríguez, A. Doncel-Moriano, Mariano Facundo Werner, A. Renú, M. Muchada, M. Requena, Federica Rizzo, N. P. de la Ossa, S. Abilleira, Marc Ribó, Xabi Urra
The optimal strategy for transferring patients to specialized acute stroke care remains controversial. This substudy of the Effect of Direct Transportation to Thrombectomy‐Capable Center vs Local Stroke Center on Neurological Outcomes in Patients with suspected Large‐Vessel Occlusion Stroke in Nonurban Areas (RACECAT) trial aims to investigate the impact of local hospital characteristics and performance on the optimal transport strategy and stroke outcomes. This was a secondary post hoc analysis of the RACECAT trial, evaluating factors potentially associated with functional outcomes among patients initially evaluated at a local stroke center (Local‐SC) versus a thrombectomy‐capable center. The primary outcome was the shift in the 90‐day modified Rankin Scale score in the target population of the RACECAT trial. Door‐to‐needle time, level of care of the Local‐SC (telestroke versus primary stroke center), the specialty of the physician involved with therapeutic decisions, and Local‐SC case volume were assessed for subgroup analyses. Of the 1367 patients included in the analysis, 903 had acute ischemic strokes (modified intention to treat). The 90‐day modified Rankin Scale score was associated with door‐to‐needle time in the entire modified intention‐to‐treat cohort ( P = 0.026) and in patients initially evaluated in a Local‐SC ( P = 0.063), and with local hospital level of care (telestroke versus primary stroke center; P = 0.10). There was a trend favoring direct transport to thrombectomy‐capable center for patients whose assigned Local‐SC was a telestroke center (adjusted odds ratio [OR], 1.47 [95% CI, 0.93–2.33] versus 0.94 [95% CI, 0.71–1.24]; P interaction = 0.08) or had door‐to‐needle time over the global median (adjusted OR, 1.52 [95% CI, 0.97–2.40] versus 0.94 [95% CI, 0.71–1.25]; P interaction = 0.06). In patients with confirmed large‐vessel occlusion, the benefit of direct transport to thrombectomy‐capable centers when the Local‐SC was a telestroke center ( P interaction = 0.04) or had longer door‐to‐needle time ( P interaction = 0.07) was more evident. Direct transport to thrombectomy‐capable centers may be preferable in areas primarily covered by telestroke or Local‐SCs with poorer performance, especially in patients with large‐vessel occlusion. These findings can contribute to refining prehospital triage strategies and optimizing stroke systems of care.
{"title":"Evaluating Transport Strategies and Local Hospital Impact on Stroke Outcomes: A RACECAT Trial Substudy","authors":"M. Olivé-Gadea, M. Rodrigo-Gisbert, Á. García‐Tornel, S. Rudilosso, Alejandro Rodríguez, A. Doncel-Moriano, Mariano Facundo Werner, A. Renú, M. Muchada, M. Requena, Federica Rizzo, N. P. de la Ossa, S. Abilleira, Marc Ribó, Xabi Urra","doi":"10.1161/svin.123.001213","DOIUrl":"https://doi.org/10.1161/svin.123.001213","url":null,"abstract":"\u0000 \u0000 The optimal strategy for transferring patients to specialized acute stroke care remains controversial. This substudy of the Effect of Direct Transportation to Thrombectomy‐Capable Center vs Local Stroke Center on Neurological Outcomes in Patients with suspected Large‐Vessel Occlusion Stroke in Nonurban Areas (RACECAT) trial aims to investigate the impact of local hospital characteristics and performance on the optimal transport strategy and stroke outcomes.\u0000 \u0000 \u0000 \u0000 This was a secondary post hoc analysis of the RACECAT trial, evaluating factors potentially associated with functional outcomes among patients initially evaluated at a local stroke center (Local‐SC) versus a thrombectomy‐capable center. The primary outcome was the shift in the 90‐day modified Rankin Scale score in the target population of the RACECAT trial. Door‐to‐needle time, level of care of the Local‐SC (telestroke versus primary stroke center), the specialty of the physician involved with therapeutic decisions, and Local‐SC case volume were assessed for subgroup analyses.\u0000 \u0000 \u0000 \u0000 \u0000 Of the 1367 patients included in the analysis, 903 had acute ischemic strokes (modified intention to treat). The 90‐day modified Rankin Scale score was associated with door‐to‐needle time in the entire modified intention‐to‐treat cohort (\u0000 P\u0000 = 0.026) and in patients initially evaluated in a Local‐SC (\u0000 P\u0000 = 0.063), and with local hospital level of care (telestroke versus primary stroke center;\u0000 P\u0000 = 0.10). There was a trend favoring direct transport to thrombectomy‐capable center for patients whose assigned Local‐SC was a telestroke center (adjusted odds ratio [OR], 1.47 [95% CI, 0.93–2.33] versus 0.94 [95% CI, 0.71–1.24];\u0000 P\u0000 interaction\u0000 = 0.08) or had door‐to‐needle time over the global median (adjusted OR, 1.52 [95% CI, 0.97–2.40] versus 0.94 [95% CI, 0.71–1.25];\u0000 P\u0000 interaction\u0000 = 0.06). In patients with confirmed large‐vessel occlusion, the benefit of direct transport to thrombectomy‐capable centers when the Local‐SC was a telestroke center (\u0000 P\u0000 interaction\u0000 = 0.04) or had longer door‐to‐needle time (\u0000 P\u0000 interaction\u0000 = 0.07) was more evident.\u0000 \u0000 \u0000 \u0000 \u0000 Direct transport to thrombectomy‐capable centers may be preferable in areas primarily covered by telestroke or Local‐SCs with poorer performance, especially in patients with large‐vessel occlusion. These findings can contribute to refining prehospital triage strategies and optimizing stroke systems of care.\u0000","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"192 3","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-03-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140247137","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Gillian Gordon Perue, Esmeralda Segura, Domini Crandon, Francene Gayle, Jude Charles, Nycole Joseph, G. S. Saint Croix, Ryna Then, V. Inoa
Low‐ to middle‐income countries have limited access to thrombolytic therapy. To our knowledge, there is no validated tool available to objectively measure access to thrombolytic agents or barriers to routine clinical use. We developed the 17‐item tissue plasminogen activator Spot Check tool to assess usage of acute stroke thrombolysis regarding local experience, financial constraints, and perceived barriers to care; evaluating the current state of clinical practices in the Mission Thrombectomy 2020+ Caribbean region. The survey was disseminated via an online link, and the information was collected and analyzed via SPSS. The tool was validated by 3 international experts with an Average Content Validity Index of 1 and a Universal Agreement Index of 1 across 3 domains: local experience, financial constraints, and barriers to usage. The participant survey response rate was 64%, representing 15 of 44 Mission Thrombectomy 2020+ Caribbean countries. There was limited or no access to thrombolytic agents in 40% of countries surveyed. Among cases treated with thrombolytics, 43% of patients had to pay out of pocket before treatment was provided, and l<10% were covered by insurance/government. Among 51% of countries surveyed, no acute thrombolytic treatment was provided for acute stroke in the 2021 calendar year. Only 1 center treated >100 cases per year. Most respondents (88%) agreed there were barriers to acute stroke thrombolysis in the region. The tissue plasminogen activator Spot Check tool was able to identify barriers impacting the number of cases per year, including absence of stroke protocol ( P <0.001), upfront cost of alteplase ( P = 0.003), restricted the amount of thrombolytics ( P = 0.002), neurology intensive care unit or stroke unit monitoring of patients following thrombolytics ( P = 0.017), cost of thrombolytic agents to the hospital ( P = 0.042), and access to computed tomography scan ( P = 0.03). This survey brings light to an enormous disparity in the care of stroke patients around the world, specifically in the Mission Thrombectomy 2020+ Caribbean region.
{"title":"Current Status of Stroke Thrombolysis in the Mission Thrombectomy 2020+ Caribbean Region","authors":"Gillian Gordon Perue, Esmeralda Segura, Domini Crandon, Francene Gayle, Jude Charles, Nycole Joseph, G. S. Saint Croix, Ryna Then, V. Inoa","doi":"10.1161/svin.123.001161","DOIUrl":"https://doi.org/10.1161/svin.123.001161","url":null,"abstract":"\u0000 \u0000 Low‐ to middle‐income countries have limited access to thrombolytic therapy. To our knowledge, there is no validated tool available to objectively measure access to thrombolytic agents or barriers to routine clinical use.\u0000 \u0000 \u0000 \u0000 We developed the 17‐item tissue plasminogen activator Spot Check tool to assess usage of acute stroke thrombolysis regarding local experience, financial constraints, and perceived barriers to care; evaluating the current state of clinical practices in the Mission Thrombectomy 2020+ Caribbean region. The survey was disseminated via an online link, and the information was collected and analyzed via SPSS.\u0000 \u0000 \u0000 \u0000 \u0000 The tool was validated by 3 international experts with an Average Content Validity Index of 1 and a Universal Agreement Index of 1 across 3 domains: local experience, financial constraints, and barriers to usage. The participant survey response rate was 64%, representing 15 of 44 Mission Thrombectomy 2020+ Caribbean countries. There was limited or no access to thrombolytic agents in 40% of countries surveyed. Among cases treated with thrombolytics, 43% of patients had to pay out of pocket before treatment was provided, and l<10% were covered by insurance/government. Among 51% of countries surveyed, no acute thrombolytic treatment was provided for acute stroke in the 2021 calendar year. Only 1 center treated >100 cases per year. Most respondents (88%) agreed there were barriers to acute stroke thrombolysis in the region. The tissue plasminogen activator Spot Check tool was able to identify barriers impacting the number of cases per year, including absence of stroke protocol (\u0000 P\u0000 <0.001), upfront cost of alteplase (\u0000 P\u0000 = 0.003), restricted the amount of thrombolytics (\u0000 P\u0000 = 0.002), neurology intensive care unit or stroke unit monitoring of patients following thrombolytics (\u0000 P\u0000 = 0.017), cost of thrombolytic agents to the hospital (\u0000 P\u0000 = 0.042), and access to computed tomography scan (\u0000 P\u0000 = 0.03).\u0000 \u0000 \u0000 \u0000 \u0000 This survey brings light to an enormous disparity in the care of stroke patients around the world, specifically in the Mission Thrombectomy 2020+ Caribbean region.\u0000","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"182 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-03-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140256207","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Emma Frost, Mary Penckofer, Linda Zhang, Kenyon W. Sprankle, N. Vigilante, Omnea Elgendy, Jiyoun Ackerman, Abyson Kalladanthyil, Manisha Koneru, Zixin Yi, Jane Khalife, Taryn Hester, Hermann Schumacher, James Bonner, Christopher J. Love, James E. Siegler
Artificial intelligence platforms, like Viz.ai with large vessel occlusion detection, have been used for disease detection and interprovider communication. Whether this software expedites patient transfer and evaluation for treatment needs further exploration. A single‐center retrospective registry was queried for patients with acute large vessel occlusion of the intracranial internal carotid, middle cerebral M1 or M2 segments, or basilar artery treated in a comprehensive stroke network (8 spokes, 1 hub) for 6 months pre‐ and post‐implementation of the Viz large vessel occlusion platform (excluding a 1‐month “washout” period). Robust regression was used to summarize time from initial hospital contact to arterial puncture (primary outcome) between periods, with prespecified subgroup analyses, which were assessed using interaction terms. Of the 132 patients (n = 58 preintervention), there were nonsignificantly fewer patients undergoing endovascular therapy in the postintervention period (86.2% preintervention versus 73.0% postintervention; P = 0.07). Among patients who underwent endovascular therapy (n = 50 preintervention, n = 54 postintervention), there was a nonsignificant reduction in time from first contact to arterial puncture (median 155 minute preintervention versus 116 minute postintervention; P = 0.10); however, this became significant in adjusted robust regression accounting for stroke severity, age, Alberta Stroke Program Early Computed Tomography Scale score, daytime versus nighttime and weekend versus weekday arrival, and use of perfusion imaging (β −20.9 [95% CI, −40.5 to −1.4)]. There was also a significant interaction observed for the association between spoke versus hub arrival and the Viz large vessel occlusion period, with shorter intervals observed for transferred patients (n = 32 preintervention with a median of 169 versus 142 minutes for n = 33 postintervention; P interaction <0.01). Implementation of the artificial intelligence platform was not associated with shorter intervals between initial hospital contact and neurointervention among all‐comers. A meaningful difference in time to treatment was observed among transferred patients. Larger data sets are needed to validate these observations.
人工智能平台，如具有大血管闭塞检测功能的 Viz.ai，已被用于疾病检测和医护人员之间的交流。这种软件是否能加快患者的转院和治疗评估还需要进一步探讨。 在一个综合性卒中网络（8 个辐条，1 个枢纽）中，对实施 Viz 大血管闭塞平台前后 6 个月（不包括 1 个月的 "清洗期"）接受治疗的颅内颈内动脉、大脑中动脉 M1 或 M2 段或基底动脉急性大血管闭塞患者进行了单中心回顾性登记查询。采用稳健回归法总结了不同时期从初次接触医院到动脉穿刺（主要结果）的时间，并使用交互项评估了预设的亚组分析。 在 132 名患者（干预前为 58 人）中，干预后接受血管内治疗的患者人数明显减少（干预前为 86.2%，干预后为 73.0%；P = 0.07）。在接受血管内治疗的患者中（干预前 n = 50，干预后 n = 54），从首次接触到动脉穿刺的时间缩短了（干预前中位时间为 155 分钟，干预后为 116 分钟；P = 0.10）；然而，考虑到中风严重程度、年龄、阿尔伯塔省中风计划早期计算机断层扫描量表评分、白天与夜间、周末与平日到达，以及使用灌注成像（β -20.9 [95% CI, -40.5 to -1.4)]，调整后的稳健回归结果显示，这一时间显著缩短。在轮辐式到达与枢纽式到达和 Viz 大血管闭塞时间之间也观察到了明显的交互作用，转运患者的时间间隔更短（干预前 n = 32，中位数为 169 分钟，干预后 n = 33，中位数为 142 分钟；P 交互作用 <0.01）。 在所有患者中，实施人工智能平台与缩短首次医院接触和神经干预之间的时间间隔无关。在转院患者中，治疗时间出现了有意义的差异。需要更大的数据集来验证这些观察结果。
{"title":"Door to Puncture in Large Vessel Occlusions Pre‐ and Postimplementation of an Automated Image Interpretation and Communication Platform: A Single Center Study","authors":"Emma Frost, Mary Penckofer, Linda Zhang, Kenyon W. Sprankle, N. Vigilante, Omnea Elgendy, Jiyoun Ackerman, Abyson Kalladanthyil, Manisha Koneru, Zixin Yi, Jane Khalife, Taryn Hester, Hermann Schumacher, James Bonner, Christopher J. Love, James E. Siegler","doi":"10.1161/svin.123.001306","DOIUrl":"https://doi.org/10.1161/svin.123.001306","url":null,"abstract":"\u0000 \u0000 Artificial intelligence platforms, like Viz.ai with large vessel occlusion detection, have been used for disease detection and interprovider communication. Whether this software expedites patient transfer and evaluation for treatment needs further exploration.\u0000 \u0000 \u0000 \u0000 A single‐center retrospective registry was queried for patients with acute large vessel occlusion of the intracranial internal carotid, middle cerebral M1 or M2 segments, or basilar artery treated in a comprehensive stroke network (8 spokes, 1 hub) for 6 months pre‐ and post‐implementation of the Viz large vessel occlusion platform (excluding a 1‐month “washout” period). Robust regression was used to summarize time from initial hospital contact to arterial puncture (primary outcome) between periods, with prespecified subgroup analyses, which were assessed using interaction terms.\u0000 \u0000 \u0000 \u0000 \u0000 Of the 132 patients (n = 58 preintervention), there were nonsignificantly fewer patients undergoing endovascular therapy in the postintervention period (86.2% preintervention versus 73.0% postintervention;\u0000 P\u0000 = 0.07). Among patients who underwent endovascular therapy (n = 50 preintervention, n = 54 postintervention), there was a nonsignificant reduction in time from first contact to arterial puncture (median 155 minute preintervention versus 116 minute postintervention;\u0000 P\u0000 = 0.10); however, this became significant in adjusted robust regression accounting for stroke severity, age, Alberta Stroke Program Early Computed Tomography Scale score, daytime versus nighttime and weekend versus weekday arrival, and use of perfusion imaging (β −20.9 [95% CI, −40.5 to −1.4)]. There was also a significant interaction observed for the association between spoke versus hub arrival and the Viz large vessel occlusion period, with shorter intervals observed for transferred patients (n = 32 preintervention with a median of 169 versus 142 minutes for n = 33 postintervention;\u0000 P\u0000 interaction\u0000 <0.01).\u0000 \u0000 \u0000 \u0000 \u0000 Implementation of the artificial intelligence platform was not associated with shorter intervals between initial hospital contact and neurointervention among all‐comers. A meaningful difference in time to treatment was observed among transferred patients. Larger data sets are needed to validate these observations.\u0000","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"248 6","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-03-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140255777","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Hubert Lee, Uzair Ahmed, Teresa E. Bell-Stephens, Gary K. Steinberg
Hypertension is often codiagnosed in patients with moyamoya disease (MMD), a progressive intracranial steno‐occlusive vasculopathy; this has principally been attributed to renal artery stenosis (up to 10%). Susceptibility MMD genes, including ring finger protein 213/mysterin and GUCY1A3 , have also been linked to extracranial vascular disease and increased systolic blood pressure. We aimed to define the prevalence of systemic hypertension in MMD patients and characterize its evolution after cerebral revascularization. Patients with MMD treated with extracranial‐intracranial bypass from 2014 to 2018 were retrospectively enrolled. Blood pressure measurements and antihypertensive agent use were recorded pre‐ and postoperatively. Hypertension was defined according to the 2020 International Society of Hypertension Guidelines (adults) and 2017 American Academy of Pediatrics Guidelines (children). Multivariate logistic regression was performed for clinical and radiographic predictors of hypertension. A total of 242 adult and 51 pediatric patients underwent revascularization. Preoperatively, 146 adult and 20 pediatric patients met the diagnostic criteria for hypertension resulting in prevalences of 60.3% and 39.2% respectively. In adults, this was significantly associated with age (odds ratio [OR] 1.05 [95% CI, 1.02–1.09]), body mass index (OR, 1.08 [95% CI, 1.03–1.13]), hyperlipidemia (OR, 2.57 [95% CI, 1.09–6.04]), kidney disease (OR, 18.98 [95% CI, 1.80–200.47]), and symptomatic presentation (OR, 8.88 [95% CI, 1.16–68.06]). After a mean follow‐up of 34.3±18.1 months in adults (33.8±14.9 months – children), patients with hypertension decreased by 15.3% (1.9% – pediatrics) and 31.8% (17.7% – children) experienced improvement in hypertensive status with normalization of blood pressure or reduced need for antihypertensive agents. Posterior circulation involvement was a negative predictor for response of hypertensive status to revascularization (OR, 0.10 [95% CI, 0.01–0.79]). Hypertension is prevalent among adult and pediatric patients with MMD with contributions from known vascular risk factors. Its association with symptomatic presentation and observed improvement following revascularization suggests blood pressure changes, in part, are a compensatory physiological response to increased intracranial vascular resistance.
{"title":"Prevalence of Systemic Hypertension and the Effects of Cerebral Revascularization in Patients With Moyamoya Disease","authors":"Hubert Lee, Uzair Ahmed, Teresa E. Bell-Stephens, Gary K. Steinberg","doi":"10.1161/svin.123.001176","DOIUrl":"https://doi.org/10.1161/svin.123.001176","url":null,"abstract":"\u0000 \u0000 \u0000 Hypertension is often codiagnosed in patients with moyamoya disease (MMD), a progressive intracranial steno‐occlusive vasculopathy; this has principally been attributed to renal artery stenosis (up to 10%). Susceptibility MMD genes, including ring finger protein 213/mysterin and\u0000 GUCY1A3\u0000 , have also been linked to extracranial vascular disease and increased systolic blood pressure. We aimed to define the prevalence of systemic hypertension in MMD patients and characterize its evolution after cerebral revascularization.\u0000 \u0000 \u0000 \u0000 \u0000 Patients with MMD treated with extracranial‐intracranial bypass from 2014 to 2018 were retrospectively enrolled. Blood pressure measurements and antihypertensive agent use were recorded pre‐ and postoperatively. Hypertension was defined according to the 2020 International Society of Hypertension Guidelines (adults) and 2017 American Academy of Pediatrics Guidelines (children). Multivariate logistic regression was performed for clinical and radiographic predictors of hypertension.\u0000 \u0000 \u0000 \u0000 A total of 242 adult and 51 pediatric patients underwent revascularization. Preoperatively, 146 adult and 20 pediatric patients met the diagnostic criteria for hypertension resulting in prevalences of 60.3% and 39.2% respectively. In adults, this was significantly associated with age (odds ratio [OR] 1.05 [95% CI, 1.02–1.09]), body mass index (OR, 1.08 [95% CI, 1.03–1.13]), hyperlipidemia (OR, 2.57 [95% CI, 1.09–6.04]), kidney disease (OR, 18.98 [95% CI, 1.80–200.47]), and symptomatic presentation (OR, 8.88 [95% CI, 1.16–68.06]). After a mean follow‐up of 34.3±18.1 months in adults (33.8±14.9 months – children), patients with hypertension decreased by 15.3% (1.9% – pediatrics) and 31.8% (17.7% – children) experienced improvement in hypertensive status with normalization of blood pressure or reduced need for antihypertensive agents. Posterior circulation involvement was a negative predictor for response of hypertensive status to revascularization (OR, 0.10 [95% CI, 0.01–0.79]).\u0000 \u0000 \u0000 \u0000 Hypertension is prevalent among adult and pediatric patients with MMD with contributions from known vascular risk factors. Its association with symptomatic presentation and observed improvement following revascularization suggests blood pressure changes, in part, are a compensatory physiological response to increased intracranial vascular resistance.\u0000","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"22 100","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-03-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140260231","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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