Cerebrovascular Diseases Extra最新文献

Introduction: Prehospital stroke scales have been developed to identify anterior large vessel occlusion (LVO) in acute ischemic stroke (AIS) patients for direct transport to thrombectomy-capable hospitals. However, its performance in a Vietnamese population remains unknown. We aimed to evaluate the predictive value of the Rapid Arterial oCclusion Evaluation (RACE) scale for LVO detection in patients with ischemic stroke presenting within 24 h in Vietnam.

Methods: This was a prospective study of patients with AIS admitted at People's 115 Hospital between May 2022 and October 2022. All patients were assessed with the RACE scale with five items: facial palsy (scored 0-2), arm motor function (0-2), leg motor function (0-2), gaze (0-1), and aphasia or agnosia (0-2). LVO was diagnosed by CTA or MRA. Receiver operating characteristic curve, sensitivity, specificity, and accuracy of the RACE scale were analyzed to evaluate its predictive value for LVO.

Results: There were 318 patients included. LVO was detected in 121/318 patients (37.6%). The higher the RACE score, the higher the proportion of patients with LVO (p < 0.001). Receiver operating characteristic curves showed capacity to predict LVO of the RACE scale with an area under the curve (AUC) of 0.767. The optimal RACE cutoff was ≥5 with sensitivity = 0.68, specificity = 0.79, positive predictive value = 0.67, negative predictive value = 0.80, and overall accuracy = 0.75. RACE ≥5 had higher sensitivity and same specificity for detecting LVO in AIS patients within 6-h versus 6-24-h window (AUC = 0.79 vs. 0.75, sensitivity = 0.74 vs. 0.65, specificity = 0.79 vs. 0.80, accuracy = 0.77 vs. 0.74).

Conclusions: The RACE scale is a simple tool that can accurately identify AIS patients with LVO. This tool may be useful for early detection of LVO patients and should be validated in the prehospital setting in Vietnam.

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.

Introduction: The recently proposed cerebral small vessel disease (CSVD) score system may help 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 magnetic resonance imaging (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.

Introduction: Recent trials have demonstrated the remarkable benefit of endovascular treatment (EVT) up to 24 h in patients with large vessel occlusion (LVO) and target mismatch profiles; however, benefits of late-window EVT in Vietnamese population remain poorly understood. This study aims to evaluate the real-world outcomes of EVT in acute ischemic stroke (AIS) patients selected using perfusion imaging within the 6-24-h window.

Methods: This is a prospective study of consecutive patients with anterior circulation LVO stroke who underwent EVT within 6-24 h after last known well between August 2022 and March 2024. Patients were selected based on the DAWN/DEFUSE-3 criteria (Perfusion-RAPID, iSchemaView). The primary outcome was the proportion of patients with functional independence at 90 days (modified Rankin Scale score of 0-2). The secondary outcomes were successful reperfusion defined by thrombolysis in cerebral infarction (TICI) ≥2b on the final procedure and subgroup analysis between good (hypoperfusion intensity ratio [HIR] <0.4) and poor collaterals (HIR ≥0.4) groups. Safety outcomes were mortality rate and symptomatic intracranial hemorrhage (sICH).

Results: Of 122 enrolled patients, 68% met inclusion criteria of DEFUSE-3 trial, 61% met DAWN trial criteria. Mean age was 66 years, median baseline NIHSS was 13, median time from stroke onset to hospital arrival was 12.55 h (9.50-16.48), and median infarct volume was 11.5 mL. The rate of functional independence at 90 days was 45.9%. Successful reperfusion (TICI score of ≥2b) was achieved by 83.6% of cases. The 90-day mortality rate was 10.7%; sICH was reported in 8 patients (6.6%). Patients with good collaterals had better functional outcome.

Conclusions: This real-world observational study suggests that late-window EVT may be safe and effective in eligible Vietnamese patients selected based on perfusion imaging, thus supporting its practical use in this patient population. HIR is a robust indicator of collateral status and could made it a valuable addition to stroke imaging workup in clinical setting.

Background: Postoperative hyperperfusion syndrome (PHS) is a well-known complication following superficial temporal artery (STA)-middle cerebral artery (MCA) bypass for moyamoya disease (MMD). The early detection of postoperative radiological hyperperfusion (PRH), characterized by a transient increase in local cerebral blood flow (CBF), is crucial for the early diagnosis of PHS. This study aimed to investigate the effectiveness of waveform analysis for early PRH detection.

Methods: We reviewed 52 consecutive patients who underwent STA-MCA bypass for MMD. Patients were divided into PRH and non-PRH groups based on the postoperative/preoperative CBF ratio. We collected the intraoperative bypass graft waveform and bypass flow data using a flowmeter. The pulsatile index (PI), an indicator of peripheral vascular resistance (PVR), was calculated from bypass flow data. Next, the newly proposed index of PVR, the ratio of the time from peak to 50% decay and to 100% decay (RT50), was calculated through waveform analysis. The values were then compared between the PRH and non-PRH groups.

Results: Twenty-seven of the 52 patients met the inclusion criteria. Fourteen of these 27 patients showed PRH. The RT50, but not the PI, was significantly higher in the PRH group. Linear regression analysis revealed a significant correlation between the RT50 and PI. In the receiver operating characteristic for predicting PRH, the area under the curve of RT50 was 0.750, with a cutoff value of 0.255, a sensitivity of 0.928, and a specificity of 0.500.

Conclusions: The RT50 obtained from waveform analysis is associated with PVR and can be useful for the early detection of PRH in patients with MMD.

Introduction: Enlarged perivascular spaces (EPVS) are considered early manifestations of impaired clearance mechanisms in the brain; however, it is unclear whether EPVS they are associated with the development of malignant cerebral edema (MCE) after large hemispheric infarction (LHI). Therefore, we investigated the predictive value of EPVS in predicting MCE in LHI.

Methods: Patients suffering from acute LHI were consecutively enrolled. EPVS were rated after the stroke with validated rating scales from magnetic resonance imagess. Patients were divided into two groups according to the occurrence of MCE. Logistic regression was used to analyze the relationship between EPVS and MCE in the basal ganglia (BG) and centrum semiovale (CS) regions. Receiver operating characteristic (ROC) curves assessed the ability of EPVS individually and with other factors in predicting MCE.

Results: We included a total of 255 patients, of whom 98 were MCE patients (58 [59.2%] males, aged 70 [range=61.75-78] years) and found that atrial fibrillation, National Institutes of Health Stroke Scale score, infarct volume, neutrophil-lymphocyte ratio, and moderate-to-severe CS-EPVS were positively associated with MCE. After adjusting for confounds, moderate-to-severe CS-EPVS remained independent risk factor of MCE (odds ratio=16.212, p＜0.001). According to the ROC analysis, MCE was highly suspected when CS-EPVS > 14 (sensitivity=0.82, specificity=0.48), and the guiding value were higher when CS-EPVS combined with other MCE predictors (area under the curve=0.90, sensitivity=0.74, specificity=0.90).

Conclusion: CS-EPVS were important risk factor for MEC in patients with acute LHI and can help identify patients at risk for MCE.

Introduction: Revascularization surgery is recommended for all pediatric patients with moyamoya disease (MMD) with ischemic symptoms because the brains of such patients are still developing. By contrast, no clear guidelines for selective revascularization surgery in adult patients (30 years or more) with ischemic presentation have been established. Regarding the age of initial onset of ischemic MMD, patients in their 20s are at the bottom of the distribution and this age group may share features with both adult and pediatric patients. The present prospective study aimed to clarify the clinical features and treatment outcomes of patients in their 20s (younger patients) with ischemic MMD compared with patients aged 30-60 years (older patients).

Methods: While patients with misery perfusion in the symptomatic cerebral hemisphere on 15O-positron emission tomography underwent combined surgery including direct and indirect revascularizations in the first study period and indirect revascularization alone in the second study period, patients without misery perfusion in that hemisphere received pharmacotherapy alone through the two study periods. Cerebral angiography via arterial catheterization and neuropsychological testing were performed before and after surgery.

Results: During 12 years, 12 younger patients were included and comprised 6% of all adult patients (194 patients). The incidence of misery perfusion in the affected hemisphere was significantly higher in younger (12/12 [100%]) than in older patients (57/182 [31%]) (p < 0.0001). No difference in the incidence of cerebral hyperperfusion syndrome and postoperatively declined cognition was seen between younger (2/5 [40%] and 2/5 [40%], respectively) and older (11/36 [31%] and 15/36 [42%], respectively) cerebral hemispheres undergoing combined revascularization surgery. No difference in the incidence of postoperatively formed collateral flows feeding more than one-third of the middle cerebral artery cortical territory on angiograms and postoperatively improved cognition was seen between younger (9/10 [90%] and 6/10 [60%], respectively) and older (18/22 [83%] and 14/22 [64%], respectively) cerebral hemispheres undergoing indirect revascularization surgery alone.

Conclusion: Patients in their 20s with ischemic MMD always exhibit misery perfusion in the affected hemisphere, unlike older patients, and sometimes develop cerebral hyperperfusion syndrome after combined revascularization surgery, leading to cognitive decline, similar to older patients. Moreover, indirect revascularization surgery alone forms sufficient collateral circulation and restores cognitive function in patients in their 20s, similar to older patients.

Introduction: In emergency rooms (ERs), 5% of patients experiencing an acute ischemic stroke (AIS) receive an alternative diagnosis; these cases are known as stroke chameleons (SC). The percentage of SC treated with intravenous thrombolysis (IVT) and the characteristics have not been well described. We aimed at investigating the variables associated with the probability receiving IVT.

Methods: In this prospective study, we included consecutive patients with SC admitted at the ER of Clínica Alemana between September 2014 and October 2023.

Results: Among 1,193 stroke patients; sixty-three (5.2%) corresponded to SC. Ten of these cases (15.8%, 95% CI: 8.8-26.8) were treated with IVT, mean door-to-needle (DTN) time of 85.7 (SD 35) min, median of 73.5 (IQR 62-113) min. SCs who underwent IVT were younger (p = 0.01), with higher NIHSS (p = 0.05). They presented more frequently with altered level of consciousness in the NIHSS (p = 0.01), language abnormities (p = 0.001), and dysarthria (p = 0.01). In multivariate analysis, none of the variables were significantly associated with IVT. A secondary analysis showed that only time to brain imaging was significantly associated with IVT (OR: 0.99; 95% CI: 0.98-0.99; p = 0.01).

Conclusions: Almost 1 out of every 7 SC could be treated with IVT but with a prolonged DTN time; the chance of being treated is associated with time to brain imaging.

Introduction: In emergency rooms (ERs), 5% of patients experiencing an acute ischemic stroke (AIS) receive an alternative diagnosis; these cases are known as stroke chameleons (SC). The percentage of SC treated with intravenous thrombolysis (IVT) and the characteristics have not been well described. We aimed at investigating the variables associated with the probability receiving IVT.

Methods: In this prospective study, we included consecutive patients with SC admitted at the ER of Clínica Alemana between September 2014 and October 2023.

Results: Among 1,193 stroke patients; sixty-three (5.2%) corresponded to SC. Ten of these cases (15.8%, 95% CI: 8.8-26.8) were treated with IVT, mean door-to-needle (DTN) time of 85.7 (SD 35) min, median of 73.5 (IQR 62-113) min. SCs who underwent IVT were younger (p = 0.01), with higher NIHSS (p = 0.05). They presented more frequently with altered level of consciousness in the NIHSS (p = 0.01), language abnormities (p = 0.001), and dysarthria (p = 0.01). In multivariate analysis, none of the variables were significantly associated with IVT. A secondary analysis showed that only time to brain imaging was significantly associated with IVT (OR: 0.99; 95% CI: 0.98-0.99; p = 0.01).

Conclusions: Almost 1 out of every 7 SC could be treated with IVT but with a prolonged DTN time; the chance of being treated is associated with time to brain imaging.