Cerebrovascular Diseases Extra最新文献

Introduction: Tenecteplase (TNK) has demonstrated to be non-inferior to Alteplase (ALT) for intravenous thrombolysis (IVT) in acute ischemic stroke (AIS). There are potential workflow benefits associated with TNK use, aiming to reduce patient length of stay in the emergency department. Our aim was to investigate whether the routine use of TNK during the COVID-19 pandemic influenced workflow times compared to historical use of ALT, while maintaining non-inferior clinical outcomes in a non-drip and ship scenario of a comprehensive stroke center.

Methods: We included patients with AIS admitted from September 2019 to September 2022 and compared those treated with TNK during the COVID-19 pandemic to those treated with ALT in the period immediately before. We compared emergency department length of stay (EDLOS), door-to-needle time (DTN), door-to-groin puncture time (DTG), clinical and safety outcomes with adjusted general linear regression models.

Results: 110 patients treated with TNK and 111 with ALT were included in this study. Mean EDLOS was 251 (SD=164) minutes for TNK users versus 240 (SD=148) minutes for ALT (p=0.62). Mean DTN was 43 (SD=25) minutes for TNK versus 46 (SD=27) minutes for ALT users (p=0.39). Mean DTN under 60 minutes was achieved in 86 (78.2%) patients and in 85 (76.5%) patients of the TNK and ALT groups respectively (p=1.0). DTN under 45 minutes was achieved in 65.4% and 58.6% (p=0.65) of the TNK and ALT groups respectively. DTG time was 114 (SD=43) minutes for TNK versus 111 (58=SD) minutes in the ALT group (p=0.88). DTG under 90 minutes was achieved in 32% of the TNK group and 35% of the ALT group (p=0.69). There were no differences in any of the clinical or safety outcomes between groups at 90 days.

Conclusions: The adoption of TNK during COVID 19 pandemic did not result in a change in EDLOS, DTN or DTG times when compared to ALT in this cohort. Safety and clinical outcomes were similar between groups. Probably a greater benefit could have been seen in a drip and ship thrombolysis setting. Further research is needed to assess the potential advantages of TNK in drip and ship scenarios of IVT.

Introduction This case report illustrates the complexities of arrhythmogenic right ventricular cardiomyopathy (ARVC) and its thromboembolic complications resulting in top-of-basilar artery syndrome. We discuss the case of a 37-year-old male with ARVC who presented with acute onset of dizziness, imbalance, and vomiting, leading to the diagnosis of a top-of-basilar artery occlusion which was successfully treated. Case presentation This case highlights the diagnostic and acute treatment challenges in basilar artery occlusion (BAO) due to its non-specific symptoms and emphasizes the critical role of CT angiography in detecting occlusive thrombi for timely intervention. With prompt endovascular thrombectomy and bridging intravenous thrombolysis, complete recanalization was achieved and the patient was discharged with modified Rankin Scale (mRS) of 1. Effective management strategies involve assessing ventricular function, detecting arrhythmias, identifying intracardiac thrombi, and implementing individualized stroke prevention measures, such as using direct oral anticoagulants(DOACs). Conclusion: This study illustrates the necessity of a multidisciplinary approach in optimizing patient outcomes in acute stroke care. Focusing on the rare condition of ARVC and the specific challenge of top-of-basilar artery occlusions in this case underscores the intricate interplay between cardiovascular and cerebrovascular pathology leading to improved understanding and management of these conditions.

Background Stroke is a major cause of death and disability globally, with different stroke burdens in different regions. This paper reviews the epidemiology of stroke in Asia. Summary There is a wide range in age and sex-standardised stroke incidence, highest in China, lowest in Bhutan. Geographically, incidence is highest in East Asia, lowest in South Asia. Stroke mortality is highest in Papua New Guinea, lowest in Singapore. There are variations in mortality within regions - in East Asia, it is higher in Mongolia and North Korea, lowest in Japan; in South Asia, it is higher in Bangladesh and Pakistan, lowest in Sri Lanka; in South-East Asia, it is higher in Papua New Guinea and Indonesia, lowest in Singapore. Stroke Disability Adjusted Life-Years lost (DALYs) is highest in Papua New Guinea, lowest in Singapore. There is intra-regional variation - in East Asia, it is higher in Mongolia and North Korea, lowest in Japan; in South Asia, higher in Bangladesh and Pakistan, lowest in Sri Lanka; in South-East Asia, it is highest in Papua New Guinea, lowest in Singapore. Among the stroke subtypes, ischaemic stroke (IS) has the highest incidence, intracerebral haemorrhage (ICH) second, subarachnoid haemorrhage (SAH) third. IS incidence is highest in China, lowest in Bhutan. The burden due to ICH is highest in Mongolia; ICH incidence is lowest in Sri Lanka, mortality and DALYs are lowest in Japan. SAH has a high incidence in Japan, Singapore, Brunei and Republic of Korea. In hospital-based registries, the frequency of ICH was highest in Myanmar, low in Mongolia. Among IS, based on the Trial of Org 10,172 in Acute Stroke Treatment classification, large artery atherosclerosis (LAA) is more frequent in some countries (eg China, India, Indonesia, Pakistan, Republic of Korea), but small artery occlusion (SAO) in most others (Bangladesh, Japan, Nepal, Singapore, Sri Lanka, Taiwan, Thailand, Vietnam); cardioembolism is third. Of the stroke risk factors, hypertension is the most frequent, diabetes mellitus (DM) is usually second, with varying positions for hyperlipidaemia, smoking and prior stroke or transient ischaemic attacks, obesity and insufficient physical activity. Key Messages Asis carries a particularly heavy burden of stroke, higher in some countries. IS is the most common subtype. Among IS, the more common mechanisms are LAA and SAO. Hypertension and DM are the more common risk factors. A greater understanding of stroke epidemiology and risk factors will help in healthcare planning for the prevention and management of stroke.

Introduction During carotid artery stenting (CAS), safe navigation of the guiding catheter (GC) is essential for the success of procedures. However, in cases where stenosis or floating thrombi are located in the common carotid artery (CCA), especially for proximal lesions, advancing the GC without touching the lesions is often difficult. We describe a preliminary experience of the "no-touch" technique for navigating the GC to the CCA using an inner catheter with a specifically designed shape and stiffness optimized to overcome tortuous anatomy. Methods We retrospectively reviewed CAS procedures involving the "no-touch" technique for treating stenotic lesions in the CCA. A 4-Fr Newton-shaped stiff catheter was positioned in the CCA. Given its high stiffness and dedicated shape, contact with the lesser curvature of the aortic arch absorbed kickback force. Then, a 6-Fr intermediate catheter and an 8- or 9-Fr balloon guiding catheter were coaxially advanced in sequence to the target position without guidewire support, ensuring "no-touch" with the plaques. Patient characteristics, aortic arch type, lesion location, and periprocedural complications were recorded. Results The technique was applied to eight procedures (six left-sided lesions) in seven patients (median age, 76 years; six men) among 53 CAS procedures performed on 49 patients. Lesions were located at the proximal CCA (four procedures) or the carotid bifurcation (four procedures). Three patients had floating thrombi, and four had type III aortic arches. GCs were successfully navigated without touching the lesions in all cases, with no periprocedural complications. Conclusion The "no-touch" technique with a Newton-shaped stiff catheter is useful and feasible for navigating the GC in treating stenotic lesions in the CCA, particularly with tortuous anatomy, proximal lesions, and vulnerable plaques.

Ischemic stroke is a significant global health problem associated with mortality and disability. Intracranial atherosclerotic stenosis (ICAS) is a leading cause of stroke and contributes to recurrent stroke, especially in Asian population. Because of the different pathophysiology and mechanisms of ICAS resulting in ischemic stroke compared to extracranial atherosclerotic stenosis (ECAS), treatment strategies for secondary prevention would be different. It is associated with traditional vascular risk factors and the degree of the stenosis is one of the important predictors for the occurrence of stroke. Because non-atherosclerotic vasculopathies are frequently observed in ischemic stroke patients caused by large artery disease in East Asia, it is important to differentiate the specific etiologies of intracranial artery stenoses. Recently developed diagnostic neuroimaging techniques, such as high-resolution MRI (HR-MRI) would be helpful in differentiating them. For stroke prevention in patients with both asymptomatic and symptomatic intracranial artery stenosis, the intensive management, including strict control of modifiable risk factors and antiplatelet therapies is essential. There have been no clear guidelines about the duration and combination of antiplatelet therapies. Nowadays, short-term dual antiplatelet therapies for 90 days are recommended to reduce the recurrence of stroke in symptomatic severe ICAS (70-99%). Cilostazol is also suggested as a good choice for the second-line therapy, following the most widely used clopidogrel. In addition, endovascular or surgical interventions could be considered as alternatives for limited cases of symptomatic severe ICAS that is hemodynamically unstable.

Introduction: Combination of clopidogrel and aspirin has been proven beneficial in treating symptomatic intracranial stenosis. The CYP2C19 polymorphism (CYP2C19*1, CYP2C19*2, CYP2C19*3, and CYP2C19*17 alleles) affects the efficacy of clopidogrel. Although epidemiologic studies of CYP2C19 polymorphism have been conducted in the Thai population, data on the frequency of allelic variants of CYP2C19 in Thai patients with symptomatic intracranial stenosis are lacking. This study aims to determine the prevalence of CYP2C19 polymorphism in patients with symptomatic intracranial stenosis.

Methods: The study included 100 Thai patients with symptomatic intracranial stenosis. Genotyping of CYP2C19 alleles (CYP2C19*1, CYP2C19*2, CYP2C19*3, and CYP2C19*17) was performed using the Real-time Polymerase Chain Reaction (rt-PCR) technique.

Results: The allele frequencies of CYP2C19*1, CYP2C19*2, CYP2C19*3, and CYP2C19*17 were 70.5%, 26%, 2.5%, and 1%, respectively. The results indicated that 53% of patients with symptomatic intracranial stenosis were normal metabolizers, while 36% were intermediate metabolizers and 10% were poor metabolizers.

Conclusion: Almost half of the Thai patients with symptomatic intracranial stenosis were intermediate or poor metabolizers. The combination of aspirin and clopidogrel might not be effective in this group of patients.

Introduction: The recently proposed cerebral small vessel disease (CSVD) score system may help to capture the overall burden of CSVD. This study aimed to investigate the associations between carotid artery ultrasound features and the burden score and cognitive performance of CSVD patients.

Methods: This is a cross-sectional analysis of an ongoing prospective study. From May 2019 to October 2023, 287 patients with at least one neuroimaging marker of CSVD were recruited and underwent carotid ultrasound examination, brain MRI scans, and neuropsychological assessment. Carotid artery properties, including carotid plaque, intima-media thickness (IMT), β stiffness index (β-index), Peterson's elastic modulus (PEM), and pulse wave velocity-β (PWV-β), were calculated. The CSVD score was graded according to MRI evaluation. Participants were classified as having cognitive impairment (CI) or normal cognitive function (NCF) according to Montreal Cognitive Assessment (MoCA) scale.

Results: A total of 209 eligible patients were included in the final analysis. A significant difference was revealed regarding the CSVD score between CI and NCF participants (P<0.001). After adjusted for covariates, increased IMT (OR=1.11, 95% CI 1.04-1.37, P=0.030) and PWV-β (OR=1.24, 95% CI 1.09-1.51, P=0.006) were both associated with the presence of CI. IMT and PWV-β were also associated with worse performance on attention and processing speed (IMT: β=-0.13, P=0.011; PWV-β: β=-0.21, P=0.011), and executive function (IMT: β=-0.20, P=0.024; PWV-β: β=-0.33, P=0.008). Additionally, PEM was negatively associated with executive function (β=-0.20, P=0.009). Furthermore, binary logistic regression indicated that IMT (OR=1.45, 95% CI 1.18-2.01, P=0.006), β-index (OR=1.30, 95% CI 1.10-1.64, P=0.008) and PWV-β (OR=1.23, 95% CI 1.01-1.89, P=0.047) were independently related to a moderate to severe CSVD burden score.

Conclusions: Carotid artery atherosclerosis and stiffness are associated with the burden score and cognitive performance of CSVD patients. Noninvasive ultrasound parameters of the carotid artery are capable of discriminating high-risk individuals with CSVD.

Background: Compared to ischemic stroke, intracerebral hemorrhage (ICH) has higher mortality and more severe disability. Asian such as Chinese and Japanese and Mexican Americans, Latin Americans, African Americans, Native Americans has higher incidences than do white Americans. So, ICH is an important cerebrovascular disease in Asia.

Summary: ICH accounts for approximately 10-20% of all strokes. The incidence of ICH is higher in low- and middle-income than high-income countries and is estimated 8-15% in western countries like USA, UK, and Australia, and 18-24% in Japan, Taiwan, and Korea. The ICH incidence increases exponentially with age, and old age especially over 80 years is a major predictor of mortality independent of ICH severity. Females are older at the onset of ICH and have higher clinical severity than males. Modifiable risk factors include blood pressure, smoking, alcohol consumption, lipid profiles, use of anticoagulants, antiplatelet agents, and sympathomimetic drugs. Non-modifiable risk factors constitute old age, male gender, Asian ethnicity, cerebral amyloid angiopathy, cerebral microbleed, and chronic kidney disease. Blood pressure is the most important risk factor of ICH. Imaging markers may help predict ICH outcome, which include black hole sign, blend sign, iodine sign, island sign, leakage sign, satellite sign, spot sign, spot-tail sign, swirl sign, and hypodensities. ICH prognostic scoring system such as ICH scoring system and ICH grading scale scoring system in Chinese and Osaka prognostic score and Naples prognostic score has been used to predict ICH outcome. Early minimally invasive removal of ICH can be recommended for lobar ICH of 30-80 mL within 24 h after onset. Decompressive craniectomy without clot evacuation might benefit ICH patients aged 18-75 years with 30-100 mL at basal ganglia or thalamus. However, clinical studies are needed to investigate the effect of surgery on patients with smaller or larger ICH, ICH in non-lobar locations, and for older patients or patients with preexisting disability. Surgical treatment is usually associated with neurological sequels if survived. For medical treatment, blood pressure lowering should be careful titrated to secure continuous smooth and sustained control and avoid peaks and large variability in systolic blood pressure. Stroke and cancer are the most common causes of death in Asian ICH patients, compared to stroke and cardiac disease in non-Asian patients.

Key messages: The incidence and outcome are different between Asian and non-Asian patients, and more clinical studies are needed to investigate the best management for Asian ICH patients.

Introduction: Acute and late inflammatory markers including high-sensitivity C-reactive protein (hsCRP) and interleukin-6 (IL-6) are associated with future vascular events after stroke. However, few longitudinal studies exist examining the intra-individual reproducibility of inflammatory biomarker measures at different timepoints after atherosclerotic stroke. We sought to examine the reproducibility of hsCRP and IL-6 in a cohort of patients with minor stroke or transient ischaemic attack (TIA) caused by ipsilateral carotid atherosclerosis.

Methods: Two observational cohort studies (DUCASS and BIOVASC) were pooled. Included patients had non-severe ischaemic stroke and ipsilateral internal carotid artery stenosis (≥50%). Patients had bloods drawn within 2 weeks of their index stroke/TIA event which was stored for later analysis. All patients included were followed up at 5 years, and repeat phlebotomy was performed. Bloods were analysed for hsCRP and IL-6 using high-throughput immunochemiluminescence. Difference between baseline and follow-up blood levels and intraclass correlation (ICC) was calculated.

Results: Ninety-five participants were included, median age 69 (IQR: 63-77), and 51 (53.7%) had TIA as their presenting event. When biomarkers were dichotomised (for hsCRP <2 mg/L or ≥2 mg/L, and for IL-6 <7.5 pg/mL [median] or ≥7.5 pg/mL), 68.4% (IL-6) and 65.2% (hsCRP) of participants remained in the same risk category (high or low) over time. However, when analysed as a continuous variable, ICC coefficients were low: ICC for IL-6 0.14 (95% CI: -0.06 to 0.33), ICC for hsCRP 0.05 (95% CI: -0.14 to 0.25). ICC increased after removing outliers. Clinical characteristics and treatment were not associated with observed variability.

Conclusion: Our results suggest that concordance between early- and late-phase inflammatory marker risk categories is modest, and absolute levels are not highly correlated at early and late timepoints, despite associations at both times with future vascular risk. Investigators should standardise timing of phlebotomy and analysis protocols in future studies of inflammatory biomarkers.

Introduction: Intracranial large artery atherosclerosis (ICAS) is a common cause of stroke in Asia. Prior epidemiological publications on ICAS have largely been single-country reports. This collaborative study involving several Asian countries aims to investigate the characteristics and outcomes of patients with stroke attributable to ICAS.

Methods: This is an international, multicenter, observational, prospective cohort study of patients admitted with acute ischemic stroke secondary to ICAS to stroke centers in six Asian countries. Stroke due to ICAS was diagnosed when there was a ≥50% intracranial large artery stenosis ipslateral to a non-lacunar infarct, without significant ipsilateral extracranial stenosis, cardiac cause or other mechanism found for the stroke. Data were collected on patient demographics, vascular risk factors, stroke location, and severity. Outcomes of interest were stroke recurrence and mortality at 12-month follow-up.

Results: A total of 356 patients were recruited. Mean age was 62.7 ± 13.8 years, and 39.9% were females. Mean NIHSS on admission was 9 ± 8, with majority of patients having mild (39.3%) or moderate (37.9%) strokes. Stroke recurrence was 6.7% (95% CI: 4.4-9.9%) while mortality rate was 13.2% (95% CI: 9.9-17.2%) within 1 year. The risk of stroke recurrence was associated with increasing age (odds ratio [OR]: 1.04, 95% CI: 1-1.06, p = 0.05) and hypertension (OR: 3.23, 95% CI: 1.09-9.61, p = 0.035). Mortality was associated with age (OR: 1.05, 95% CI: 1.01-1.08, p = 0.006) and NIHSS (OR: 1.12, 95% CI: 1.07-1.17, p < 0.001).

Conclusions: This multicenter Asian study demonstrates a high risk of stroke recurrence and mortality among patients with acute stroke due to ICAS. They are associated with age (both), as well as hypertension (for recurrence) and NIHSS (for mortality). Better treatment modalities are needed to reduce the frequency of adverse outcomes in symptomatic ICAS.