Cerebrovascular Diseases Extra最新文献

Introduction: The data on focal cerebral arteriopathy (FCA) in young adults are limited to very few series, and the role of high-resolution magnetic resonance vessel wall imaging (MRVWI) has not been adequately explored.

Methods: FCA was defined as unilateral, unifocal nonprogressive stenosis/irregularity of the distal internal carotid artery (ICA) or its proximal branches. All young patients aged 18-55 years admitted to our institute between 2010 and 2022 were retrospectively reviewed, and functional outcomes were quantified using the modified Rankin scale.

Results: We identified 10 patients (9 males) with FCA giving an incidence rate of 2.8 per 1,000 person-years. Nine patients had an ischemic presentation (transient ischemic attacks = 5, minor strokes = 3, and major stroke = 1), while 1 patient had a cortical subarachnoid hemorrhage. The supraclinoid ICA and proximal middle cerebral artery (MCA) were the most common segments involved. Nine patients were treated with antiplatelets, and 3 received additional steroids. All cases underwent MRVWI, with concentric wall enhancement noted in most (80%). Follow-up imaging showed improvement in stenosis in 2 patients and a reduction in vessel wall enhancement in 3 patients. Except for the patient with a major stroke, all others had excellent short- and long-term outcomes with no recurrence of ischemic events. The presence of vessel wall enhancement did not predict short- or long-term outcomes.

Conclusion: FCA is a rare cause of young stroke that preferentially involves the supraclinoid ICA and proximal MCA with excellent outcomes. MRVWI can be useful in ruling out mimics, but the presence of contrast enhancement did not predict outcome.

Introduction: Venous thromboembolism (VTE) is an important complication after spontaneous intracerebral hemorrhage (ICH). However, it remains a clinical challenge to identify individuals at high risk for VTE in a population with ICH. This study aimed to develop a model integrating cardiac biomarkers with clinical-radiological factors for predicting VTE risk in patients with spontaneous ICH.

Methods: ICH patients were retrospectively enrolled between October 2019 and December 2022. Baseline clinical characteristics, laboratory data, and radiological features were collected. Patients with pulmonary embolism (PE) and deep vein thrombosis were classified into the VTE group. Cox regression analysis was used to identify independent predictors of in-hospital VTE. A nomogram was developed based on the multivariate model, and its performance was evaluated using the concordance index (C-index), decision curve analysis, and net reclassification improvement.

Results: A total of 170 patients (mean age: 54.66 ± 13.6 years, 125 [73.5%] males) with ICH were included in the analysis. Thirty-six (21.2%) patients were assigned to the VTE group. Multivariate Cox analysis identified age (HR = 1.032, 95% CI: 1.002-1.062, p = 0.033), baseline edema volume (HR = 1.034, 95% CI: 1.012-1.056, p = 0.002), intraventricular hemorrhage (HR = 3.268, 95% CI: 1.635-6.530, p < 0.001), myoglobin (Myo; HR = 1.002, 95% CI: 1.000-1.003, p = 0.010), and B-type natriuretic peptide (BNP; HR = 1.003, 95% CI: 1.001-1.006, p = 0.007) as independent predictors. The combined model showed better predictive performance than the clinical-radiological model alone (C-index: 0.791 vs. 0.749). The nomogram demonstrated good calibration and clinical utility across a wide risk threshold range.

Conclusion: Myo and BNP provide incremental predictive value for VTE risk stratification in ICH patients beyond traditional factors. The developed nomogram offers a practical tool for individualized risk assessment, potentially guiding optimized VTE prophylaxis strategies.

Introduction: Trousseau syndrome (TS) represents a significant vascular thromboembolic event in cancer patients and has progressively gained attention as a critical clinical concern in recent years. The aim of this study was to investigate the survival status and prognostic factors in patients with TS whose initial clinical manifestation was acute ischemic stroke (AIS).

Methods: A retrospective analysis was conducted on 24 TS patients hospitalized at the Affiliated Hospital of Jiangsu University between 2018 and 2024. Data collected included demographic characteristics, tumor staging, complete blood count, C-reactive protein, coagulation function, blood biochemistry analyses, tumor markers, National Institutes of Health Stroke Scale scores, modified Rankin Scale, and treatment regimen. Based on the temporal sequence of AIS onset relative to tumor diagnosis, patients were categorized into two groups: the AIS-TS (AIS as an initial symptom with TS, n = 9) group and the NAIS-TS (AIS was not as an initial symptom with TS, n = 15) group. Survival follow-up was performed via outpatient visits and telephone interviews. Kaplan-Meier survival analysis was used to compare survival rates between the two groups with log-rank tests for statistical comparisons. Univariate Cox regression analysis was initially conducted to screen potential prognostic factors, followed by multivariate Cox regression analysis for variables with p < 0.1.

Results: Kaplan-Meier survival analysis revealed that the overall survival rate of the AIS-TS group was significantly lower than that of the NAIS-TS group (log-rank χ2 = 5.07, p = 0.024). Multivariate Cox regression analysis indicated that after adjusting for confounding factors, D-dimer index (DDI) (HR = 1.17, 95% CI: 1.05-1.31, p = 0.004), carcinoembryonic antigen (CEA) (HR = 1.04, 95% CI: 1.02-1.06, p = 0.001), and female sex (HR = 4.80, 95% CI: 1.42-16.23, p = 0.012) were independent risk factors for all-cause mortality in TS patients.

Conclusion: TS patients presenting with AIS as the initial symptom exhibited shorter survival time and poorer prognoses. Female sex, elevated DDI, and elevated CEA levels were identified as significant prognostic indicators influencing poor survival and prognosis in TS patients, potentially establishing a foundation for future prognostic evaluations in TS 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.

Background: Cerebrovascular radiation-related vasculopathies can involve vessels of all sizes. Of these, extracranial carotid and vertebral artery (VA) radiation-induced atherosclerosis are the most commonly encountered radiation vasculopathy in Asia. This is because of the high incidence of oro-nasopharyngeal cancers in this region, where radiation therapy (RT) is the mainstay treatment.

Summary: Radiation exposure induces the early and rapid development of atherosclerosis in the extracranial arteries. In retrospective studies, significant changes were demonstrated as early as 1 year after RT, using carotid intima media thickness measurements. Plaque development continued at an accelerated rate, with a four times increased risk compared to those without radiation exposure, and regardless of the presence or absence of traditional risk factors. In addition, radiation-induced plaques were often extensive, involving all cranial arteries exposed to radiation. They often have high-risk features, which included echolucent plaques with ulcerations, mobile components, and/or intraplaque hypoechoic foci. The risk of both ischaemic and haemorrhagic strokes are increased, with the highest risk seen in patients younger than 40 years old. Carotid blowout is a rare and potentially deadly complication, which could involve the common, internal or external carotid arteries. Both carotid endarterectomy and carotid artery stenting have been performed, but there is a preference for stenting because of a "hostile neck," from underlying radiation dermopathy and fibrosis, or scarring from prior surgeries, both contributing to poor wound healing and difficult CEA. Favourable outcomes have been reported with transcarotid artery revascularisation, compared against CEA. Other radiation-related vasculopathies, intracranial aneurysms, intracranial disease or moyamoya syndrome, cavernomas, and microbleeds were less common and rarely encountered in Asian populations. Of this, radiation-related intracranial aneurysm has been described in <1% of Chinese patients who had head and neck radiation, with a long latency periods after radiation exposure, ranging from median lag time of 6-20 years.

Key messages: Cerebrovascular radiation vasculopathies have a diverse phenotypic range, from small vessel to large vessel involvement, from extracranial to intracranial disease, intracranial aneurysms, cavernomas and microbleeds. In Asia, extracranial carotid and VA radiation-induced atherosclerosis was most commonly encountered and reported, due to the prevalence of oro-nasopharyngeal cancers in many parts of this region. Complications include atherosclerosis, stroke, and increased risk of carotid blowout syndrome.

Introduction: Methamphetamine is an established risk factor for intracerebral hemorrhage (ICH). Despite growing concerns over its abuse, particularly in the Philippines, region-specific data on its neurological consequences remain lacking. This study aimed to investigate the temporal trends in the frequency of methamphetamine-associated ICH (Meth-ICH) in the Philippines.

Methods: Consecutive patients presenting with ICH at the Philippine National Specialty Center for Brain and Spine Care between 2018 and 2024 were retrospectively included. Meth-ICH cases were identified through positive urine toxicology tests at the time of admission. Frequency counts of total ICH and Meth-ICH cases were used to calculate the proportion of Meth-ICH cases for each year. Temporal trends were assessed using the two-sided Cochrane-Armitage test for trend, and by analyzing absolute and relative changes in proportions.

Results: Of the 1,652 ICH patients included, 116 (7.02%) tested positive for methamphetamine. The proportion of Meth-ICH cases increased 11.82-fold over the 7-year study period, rising from 1.49% (4/268, 95% confidence interval [CI]: 1.15%-1.83%) in 2018 to 17.58% (74/421, 95% CI: 14.04%-21.12%) in 2024. Between 2018 and 2021, no significant changes were observed in the number and proportion of Meth-ICH cases. A nonsignificant upward trend was noted between 2021 and 2022, with a relative change in proportion of 67.30% (95% CI: -86.57% to 231.17%; p = 0.635). A significant increase in the proportion of Meth-ICH cases was seen between 2022 and 2024, with relative changes in proportion of 310.70% (95% CI: 213.70%-407.70%; p = 0.003) from 2022 to 2023, and 100.80% (95% CI: 5.89%-207.69%; p = 0.001) from 2023 to 2024.

Conclusion: There was an increasing trend in the frequency of Meth-ICH cases in the Philippines from 2018 to 2024, with a significant and sustained surge beginning in 2022. Comprehensive evidence-based public health strategies are urgently needed, particularly in regions with high rates of methamphetamine use.

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.

Background: Stroke related to infections represents a less common but significant cause, particularly in low- and middle-income countries. This review examines the pathophysiology of stroke from infections, involving both direct and indirect mechanisms.

Summary: Bacterial infections such as tuberculous meningitis and infective endocarditis can directly cause strokes through local inflammation, arteritis, and septic embolism. Viral infections like Varicella zoster virus and HIV increase stroke risk through chronic immune activation, vasculopathy, and endothelial dysfunction. Parasitic infections, particularly malaria and neurocysticercosis, can cause strokes via vascular occlusion and inflammatory responses. Fungal infections like aspergillosis and mucormycosis can lead to strokes through vasculitis and direct invasion of the CNS.

Key messages: Understanding the mechanisms by which various infectious agents contribute to stroke pathogenesis is essential for developing targeted therapeutic strategies and improving patient outcomes. Further research is needed to establish effective prevention and treatment for infection-related strokes, especially in low- and middle-income countries.

Introduction: Intracranial artery stenosis (ICAS) is a significant contributor to cortical infarcts, and studies have also shown associations between ICAS and structural brain changes, such as lacunes, white matter hyperintensities (WMHs), and brain atrophy. We aimed to assess the associations between ICAS and cortical infarcts, lacunes, WMHs, and brain parenchymal fraction (BPF) in a general population.

Methods: We included 1,842 participants (981 women and 861 men) aged 40-84 years who participated in a cross-sectional population-based study. Three-dimensional time-of-flight magnetic resonance angiography was used for the assessment of ICAS, while 3D T2-fluid-attenuated inversion recovery sequences, 3D T1-weighted sequences, and susceptibility-weighted images were used for evaluation of brain structure. ICAS was defined as a ≥50% focal narrowing of the intracranial arterial flow diameter. WMHs were assessed by the Fazekas score and automated volumetric measurements. BPF was used as a proxy for brain atrophy.

Results: The 111 participants (6.0%) with ICAS had significantly more cortical infarcts (23.4% vs. 5.5%, p < 0.001) and lacunes (27.0% vs. 7.7%, p < 0.001) compared to participants without ICAS (1,731). Multivariable-adjusted analysis showed an independent association between ICAS and cortical infarcts (OR: 2.23, 95% CI: 1.27 to 3.90, p = 0.005) and lacunes (OR 2.05, 95% CI: 1.24 to 3.41, p = 0.005), mainly driven by lacunes in the posterior circulation (OR: 4.76, 95% CI: 1.75 to 12.97, p = 0.002). ICAS was independently associated with moderate-to-severe periventricular Fazekas score (OR 2.04, 95% CI: 1.26 to 3.28) and BPF (β-coefficient -0.0131, 95% CI: -0.0232 to -0.0030). There was no significant association between ICAS and deep moderate-to-severe Fazekas score or WMH volumes.

Conclusion: ICAS was associated with both cortical infarcts in the anterior and posterior circulation and with lacunes in the posterior circulation. The results also indicate a relationship between ICAS and periventricular WMHs and brain atrophy.

Introduction: Timely thrombolytic therapy improves outcomes in acute ischemic stroke. Manual chart review to screen for thrombolysis contraindications may be time-consuming and prone to errors. We developed and tested a large language model (LLM)-based tool to identify thrombolysis contraindications from clinical notes using synthetic data in a proof-of-concept study.

Methods: We generated 150 synthetic clinical notes containing randomly assigned thrombolysis contraindications using LLMs. We then used Llama 3.1 405B with a custom prompt to generate a list of thrombolysis contraindications from each note. Performance was evaluated using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and F1 score.

Results: A total of 150 synthetic notes were generated using five different models: ChatGPT-4o, Llama 3.1 405B, Llama 3.1 70B, ChatGPT-4o mini, and Gemini 1.5 Flash. On average, each note contained 241.6 words (SD 110.7; range 80-549) and included 1.5 contraindications (SD 1.1; range 0-5). Our tool achieved a sensitivity of 90.9% (95% CI: 86.3%-94.3%), specificity of 99.2% (95% CI: 98.8%-99.5%), PPV of 87.7% (95% CI: 82.7%-91.7%), NPV of 99.4% (95% CI: 99.1%-99.6%), accuracy of 98.7% (95% CI: 98.2%-99.0%), and an F1 score of 0.892. Among the false positives, 24 (86%) were due to the inclusion of irrelevant contraindications, and 4 (14%) resulted from repetitive information. No hallucinations were observed.

Conclusion: Our LLM-based tool may identify stroke thrombolysis contraindications from synthetic clinical notes with high sensitivity and PPV. Future studies will validate its performance using real EMR data and integrate it into acute stroke workflows to facilitate faster and safer thrombolysis decision-making.