Cerebrovascular Diseases Extra最新文献

Introduction: This study sought to investigate the severity of intracranial artery calcification (IAC) in relation to white matter hyperintensities (WMHs), and whether the association was mediated by cerebral autoregulation (CA).

Methods: A total of 144 patients with cerebral small vessel disease were included in this study. The severity of WMH was assessed using Fazekas scores in FLAIR-magnetic resonance imaging images. On non-contrast head computed tomography images, the severity of IAC was measured by IAC scores and further classified as intimal or medial calcification. As proxy of CA, critical closing pressure (CrCP) was determined by analyzing blood pressure-flow velocity relationships in the middle cerebral artery. Mediation analyses were conducted examine the proportion of mediation of CrCP on the association between IAC and WMH.

Results: IAC scores were found to be associated with WMH scores (β 0.364; 95% confidence interval [CI], 0.133-0.409; p < 0.001). After multivariable adjustment, a statistically significant association was observed between IAC scores and higher CrCP values (β, 0.329; 95% CI, 0.129-0.528; p = 0.001). Mediation analyses revealed that CrCP partially mediated (10.3%) the association between higher IAC scores and increased WMH severity. The proportion of mediation was driven by a medial calcification pattern (13.9%).

Conclusion: This hospital-based study demonstrated the association between higher IAC scores and the severity of WMH in patients with cerebral small vessel disease, which can be partially mediated by CA as indicated by CrCP, especially for the patients with predominantly medial calcification.

Post-stroke atrial fibrillation (AFib) is a frequent yet undetected complication, particularly in resource-limited settings, where systematic screening remains challenging. Timely identification is essential for guiding anticoagulation strategies and reducing recurrent stroke risk. This scoping review synthesizes evidence on predictive strategies integrating artificial intelligence, circulating biomarkers, and advanced rhythm-monitoring modalities in adults with ischemic stroke or transient ischemic attack without known AFib. Predictive variables from conventional clinical scores and modern AI-based models were harmonized into a unified framework, highlighting incremental contributions from natriuretic peptides, imaging radiomics, and electronic health record-derived laboratory parameters. A novel analytical construct-area under the curve (AUC)-cost-feasibility mapping-was introduced to compare diagnostic strategies, including risk scores, handheld and patch electrocardiography, smartwatch-based photoplethysmography (with ECG confirmation required for diagnosis), and implantable loop recorders, with explicit consideration of scalability in low- and middle-income countries. Based on this synthesis, a tiered diagnostic pathway is proposed, combining clinical risk stratification with biomarker-guided triage (particularly NT-proBNP and MR-proANP) to inform allocation of extended monitoring resources, thereby optimizing diagnostic yield and cost-effectiveness. Persistent knowledge gaps include the absence of standardized biomarker thresholds, limited head-to-head evaluations of AI-enabled workflow in post-stroke populations, insufficient external validation in diverse populations, and a lack of prospective cost-effectiveness analyses. By integrating predictive domains, quantifying performance-cost trade-offs, and outlining an implementation-oriented, risk-stratified strategy, this review aims to inform AFib screening after stroke from theoretical innovation toward context-adapted clinical application, offering a structured framework to guide both research and practice in diverse healthcare environments.

Stroke in Young Adults in Asia Background Stroke in young adults is a worldwide problem with long term physical and socioeconomic implications. The largest burden of disease is expected to impact Asia. Stroke in young adults is defined broadly as strokes occurring between the ages of 18-49 and include ischaemic stroke and intracerebral haemorrhage. The objective of this review is to focus on the important aspects of epidemiology, risk factors, genetic contributions as well as evaluation, management and outcome of stroke in young adults within the Asian context. Summary This publication is an overview of recent literature from many countries in Asia. Population and hospital level data offer insight into common and unique aetiologies of pre-mature ischaemic stroke and intracerebral haemorrhage in young adults. In young adults, prognosis and outcomes were worse in intracerebral haemorrhage compared to ischaemic stroke. Stroke prevention should be emphasized while rapid access to acute stroke reperfusion and interventional therapies can benefit younger patients. More research should be performed in young adults with stroke in order to reduce the short and long term mortality in both stroke subtypes, improve primary as well as secondary prevention and define further the role of next generation sequencing for cryptogenic stroke. Key Messages Stroke in young adults in Asia reveal the interplay between complex genetic factors, traditional risk factors and unique aetiologies. Socioeconomic status and healthcare access are other important factors affecting the care of these patients.

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: We aimed to determine whether relative hypotension, defined as a systolic blood pressure (SBP) threshold of <140 mm Hg or 160 mm Hg at the time of neuroimaging, was associated with rapid infarct progressor phenotype, as defined by a high hypoperfusion intensity ratio on MISTAR imaging software (DT6/DT2 >0.318) during anterior circulation large-vessel occlusion (LVO) acute ischaemic stroke (AIS).

Methods: In a retrospective cohort study, consecutive patients admitted to a metropolitan comprehensive stroke centre within South Australia between January 2017 and January 2024 with anterior circulation LVO AIS were included. LVO was defined as either carotid terminus or M1 occlusion. Univariable and multivariable logistic regressions were performed.

Results: A total of 477 patients were included (253 [53.0%] female), of whom 163 (34.2%) had an elevated hypoperfusion intensity ratio (HIR). Hypotension, as defined by either SBP of <160 mm Hg (odds ratio [OR]: 1.2, 95% CI: 0.8-1.8) or SBP of <140 mm Hg (OR 1.7, 95% CI 0.8-1.7), was not associated with elevated HIR. Insular cortex ischaemia (OR: 6.1, 95% CI: 1.7-38.9) and ischaemic heart disease (OR: 2.0, 95% CI: 1.3-3.1) were associated with elevated HIR. Smoking history (OR: 0.5, 95% CI: 0.3-0.9) and obesity (OR: 0.4, 95% CI: 0.2-0.8) were associated with lower HIR.

Conclusion: Relative hypotension was not significantly associated with rapid infarct progressor phenotype in anterior circulation LVO AIS. Insular cortex ischaemia and ischaemic heart disease were associated with rapid progression phenotype, whilst smoking history and obesity were associated with slower progression phenotype. Further mechanistic studies to elucidate how systemic comorbidities and regional brain vulnerability contribute to infarct evolution are needed.

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.

Introduction: Stroke is a leading cause of morbidity and mortality globally, with Africa bearing a disproportionately high burden of poor outcomes. In sub-Saharan Africa, acute stroke care remains inconsistent, with organized stroke units being either absent or rarely available, contributing to the high stroke mortality rates in the region. To address this issue, the Tanzania Stroke Project (TSP) was launched, aimed at establishing acute stroke services at two of the largest tertiary care centers in collaboration with the Tanzanian Ministry of Health, the World Stroke Organization, and Hospital Directorates.

Methods: TSP utilized a three-tier implementation approach to establish a more organized stroke care system in two large academic hospitals. Here, we detail the process of this initiative, which took place between August 2023 and August 2024. The three-tier approach included (1) the establishment of stroke registries; (2) the training of healthcare workers (HCWs); and (3) the development of acute stroke protocols and establishment of stroke units at Muhimbili National Hospital-Mloganzila and Bugando Medical Center in Tanzania.

Results: In tier one (stroke registry), two comprehensive stroke registries were established, including 460 adults (mean age 60 ± 15 years). Hemorrhagic stroke was the most common subtype, accounting for 59% of cases (n = 269). Premorbid hypertension was the most prevalent risk factor, affecting 81% (n = 373) of the patients. More than half of patients (58%, n = 171) arrived at the hospital after 24 h from stroke symptoms. Only 11% (n = 50/452) had documented swallowing screenings, and among patients with intracerebral hemorrhage, 11% (n = 28/251) achieved the target for blood pressure control, while 47% (n = 99/213) met blood glucose control targets. The in-hospital mortality rate was 27% (n = 93/340). In tier two (training of HCWs), extensive evidence-based mentorship training was provided with higher participation rates among HCWs at Bugando Medical Center compared to Muhimbili National Hospital-Mloganzila (57% [29/51] vs. 23% [7/31], p = 0.002). In tier three (stroke unit protocols), stroke protocols were developed based on the training and current evidence, leading to the establishment of dedicated stroke units at each facility, with a minimum of 8 beds per unit. The full impact of these implementations has yet to be fully assessed.

Conclusion: This was the first initiative to implement stroke services at two large tertiary healthcare centers in Tanzania. Our findings highlight the importance of multilevel stakeholder engagement through a 3-tier approach in countries starting to establish stroke services and the need for ongoing quality-of-care monitoring and continuous efforts to sensitize both HCWs and the broader community.

Background: 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 the Asian population. ICAS should be distinguished from extracranial atherosclerotic stenosis (ECAS) due to differences in pathophysiology. Understanding the mechanisms of ICAS is crucial for stroke prevention in the Asian population. Traditional vascular risk factors and the degree of the stenosis play an important role in predicting stroke occurrence.

Summary: In East Asia, non-atherosclerotic vasculopathies are also often observed in ischemic stroke patients caused by large artery disease, highlighting the importance of identifying the specific etiologies of intracranial artery stenosis. Advances in diagnostic neuroimaging, such as high-resolution MRI (HR-MRI), can be helpful in distinguishing between them. For stroke prevention in patients with both asymptomatic and symptomatic ICAS, intensive management, including strict control of modifiable risk factors and appropriate antiplatelet therapies, is essential. There are no clear guidelines regarding the duration and combination of antiplatelet therapies. However, current recommendations suggest short-term dual antiplatelet therapies for 90 days to reduce the recurrence of stroke in symptomatic severe ICAS (70-99%). Cilostazol is also proposed as a good second-line treatment option, following clopidogrel, which remains the most widely used. In addition, endovascular or surgical interventions could be considered alternatives for a limited subset of symptomatic severe ICAS cases that are hemodynamically unstable.

Key messages: The key messages are as follows: (1) ICAS is a major cause of ischemic stroke, especially in Asian populations. Its distinct pathophysiology, compared to ECAS, requires different treatment strategies for secondary prevention; (2) differentiation of intracranial artery stenosis etiology is essential, and HR-MRI would be a valuable diagnostic tool; (3) stroke prevention includes strict vascular risk factor control and the use of antiplatelet therapies, with short-term DAPT recommended for symptomatic severe ICAS; (4) cilostazol may serve as an effective second-line option for preventing ischemic stroke, while endovascular or surgical interventions may be limited to hemodynamically unstable cases.

Background: 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 the Asian population. ICAS should be distinguished from extracranial atherosclerotic stenosis (ECAS) due to differences in pathophysiology. Understanding the mechanisms of ICAS is crucial for stroke prevention in the Asian population. Tr

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: 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 6,069 patients in our analysis. Cerebrovascular disease was diagnosed in 85.2% (2,576/3,022) of women and 88.0% (2,681/3,047) 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 acknowledgment 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.