Cerebrovascular Diseases Extra最新文献

Introduction: Understanding sex differences in the clinical presentation of patients with suspected stroke is important to reduce sex-related disparities and improve care. We aimed to characterize presenting symptoms in women and men with suspected stroke evaluated at our comprehensive stroke center.

Methods: This was a retrospective analysis of consecutive patients with suspected stroke treated at the University Hospital Essen between January 2017 and December 2021. Patient characteristics, signs and symptoms as well as final diagnoses in women and men were compared. Logistic regression analysis was performed to assess the association of individual symptoms with a diagnosis of cerebrovascular disease.

Results: We included 6069 patients in our analysis. Cerebrovascular disease was diagnosed in 85.2% (2576/3022) of women and 88.0% (2681/3047) of men (p = 0.002). Aphasia (31.4% vs. 27.7%, p = 0.002), neglect (15.5% vs. 12.8%, p = 0.003), gaze deviation (21.0% vs. 18.8%, p = 0.034), as well as nonfocal symptoms including impairments in consciousness (17.0% vs 14.6%, p = 0.012), orientation (42.5 vs. 36.4%, p < 0.001) and completion of tasks (31.2% vs. 26.0%, p < 0.001) were more common among women. Limb ataxia (8.1% vs. 11.2%, p < 0.001) and dysarthria (44.0% vs. 46.8%, p = 0.030) were less frequent in women. Neglect and gaze deviation were independent positive predictors of cerebrovascular disease in women but not in men.

Conclusion: Although clinical presentation was similar in both sexes, cortical and nonfocal symptoms were more common among women with suspected stroke. Awareness of sex differences and acknowledgement of the full clinical picture are important to ensure optimal management for women and men with suspected stroke. Our findings might serve as a target for educational programs in order to improve preclinical stroke detection in patients with predominantly nonfocal or subtle symptoms.

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: Parenteral heparin is widely used as bridging therapy while optimizing oral anticoagulation (OAC). Newer direct-acting OACs (DOACs) attain therapeutic effect very quickly. We report the use of dabigatran as bridging therapy during warfarin optimization for cardioembolic stroke in two patients who opted to receive warfarin for long-term anticoagulation for secondary stroke prevention.

Case presentations: Patient A was a 60-year-old man with hypertension, hyperlipidaemia, and gout who was admitted with a sudden onset of left-sided weakness. Clinically, he was alert but had right gaze preference and left-sided hemiplegia. The clinical diagnosis was of a right cortical stroke. He underwent intravenous tPA augmented with sonothrombolysis - the National Institute of Health Stroke Scale (NIHSS) score fell from 7 to 0. Repeat brain scan showed infarcts in the right frontal and parietal lobes. He was found to have atrial fibrillation (AF) and advised anticoagulation. He opted for warfarin with dabigatran bridging which was started on day 2 of his hospital admission. His International Normalized Ratio (INR) exceeded 2 by day 6 of anticoagulation, at which time the bridging dabigatran was stopped, fixed-dose warfarin was continued, and he was discharged well. On subsequent reviews in the clinic, his INR was in the therapeutic range of 2.0-3.0. He had no bleeding or recurrent ischaemic events during follow-up. Patient B was a 78-year-old man with a hypertension, hyperlipidaemia, and diabetes mellitus. He was admitted after he developed difficulty talking and mild right-sided weakness. Clinically, he was alert but had expressive aphasia and mild right-sided upper limb weakness (NIHSS 6). The clinical diagnosis was of a left cortical stroke. The brain scan showed a left posterior frontal and parietal infarct. He was out of the time window for recanalization therapy and was treated conservatively. He was found to have AF and advised anticoagulation. He opted for warfarin with dabigatran bridging which was started on day 1 of his hospital admission. His INR was almost 2 by day 5 of anticoagulation, at which time the bridging dabigatran was stopped and fixed-dose warfarin continued. He declined daily blood taking - his INR 4 days later was in the therapeutic range of 2.0-3.0. He had no bleeding or recurrent ischaemic events. He underwent rehabilitation uneventfully and was discharged well.

Conclusions: The use of DOACs such as dabigatran as bridging therapy during optimization of OAC is feasible. Compared to heparin as bridging therapy, DOAC has the advantage of oral administration, lower cost, and possibly lower bleeding risks. This novel practice may be applicable in thrombosis in arterial and venous circulations, e.g., ischaemic stroke, deep venous thrombosis, pulmonary embolism.

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 GC 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 7 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.

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: Clopidogrel and aspirin were proved to have benefit in symptomatic intracranial stenosis. CYP2C19 polymorphism (CYP2C19*1, CYP2C19*2, CYP2C19*3, and CYP2C19*17 alleles) affects efficacy of clopidogrel. Epidemiologic study of CYP2C19 polymorphism has been conducted in Thai population. There was no data showed the frequency of allelic variants of CYP2C19 in Thai symptomatic intracranial stenosis patients. The aim of this study was to determine the prevalence of CYP2C19 polymorphism in symptomatic intracranial stenosis patients.

Methods: The study group included 100 Thai symptomatic intracranial stenosis patients. Genotyping of CYP2C19 alleles (CYP2C19*1, CYP2C19*2, CYP2C19*3, and CYP2C19*17 alleles) was carried out by real-time polymerase chain reaction (rt-PCR) technique.

Results: The allele frequency of CYP2C19*1, CYP2C19*2, CYP2C19*3, and CYP2C19*17 were 70.5%, 26%, 2.5%, and 1%, respectively. The result showed that 53% of symptomatic intracranial stenosis patients are normal metabolizers, while intermediate and poor metabolizer were 36 and 10 percent, respectively.

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

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 Southeast Asia, it is higher in Papua New Guinea and Indonesia, lowest in Singapore. Stroke disability-adjusted life years (DALYs) lost 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 Southeast 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) is second, subarachnoid haemorrhage (SAH) is 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 (e.g., China, India, Indonesia, Japan, Pakistan, and Republic of Korea), but small artery occlusion (SAO) in most others (Bangladesh, Nepal, Singapore, Sri Lanka, Taiwan, Thailand, and 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: Asia 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: 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.