Cerebrovascular Diseases Extra最新文献

Introduction: Pure arterial malformations (PAMs) are rare vascular abnormalities defined as dilated, tortuous arterial loops without any associated venous compartment. PAMs are thought to be benign developmental anomalies that can be safely managed conservatively.

Methods: We present a case of life-threatening hemorrhage in a patient with a PAM associated with two aneurysms and review the literature describing hemorrhages associated with PAMs.

Results: A 65-year-old female presented with subarachnoid and intraventricular hemorrhage. A digital subtraction angiography revealed a posterior inferior cerebellar artery PAM associated with two saccular aneurysms, which were subsequently microsurgically clipped. At the 1-year follow-up, the patient was neurologically intact. In our literature review, we identified 21 papers describing a total of 37 PAMs. Patients were predominantly female (64.9%) and their median age was 35 years. Almost half (48.6%) of PAMs were associated with aneurysms. In the group of PAMs that were not associated with an aneurysm, the intracranial hemorrhage rate was 15.8%, while in cases of coexisting PAM and aneurysm it was 44.4% (p = 0.0789).

Conclusions: PAM natural history remains unknown, particularly in cases of coexistence with aneurysms. Patients so affected require careful observation. The description of PAMs as benign vascular malformations should be revised. Surgical management of hemorrhagic PAMs coexisting with aneurysms is possible and should be considered.

Background: Patient selection for reperfusion therapies requires significant expertise in neuroimaging. Increasingly, machine learning-based analysis is used for faster and standardized patient selection. However, there is little information on how such software influences real-world patient management.

Aims: We evaluated changes in thrombolysis and thrombectomy delivery following implementation of automated analysis at a high volume primary stroke centre.

Methods: We retrospectively collected data on consecutive stroke patients admitted to a large university stroke centre from two identical 7-month periods in 2017 and 2018 between which the e-Stroke Suite (Brainomix, Oxford, UK) was implemented to analyse non-contrast CT and CT angiography results. Delivery of stroke care was otherwise unchanged. Patients were transferred to a hub for thrombectomy. We collected the number of patients receiving intravenous thrombolysis and/or thrombectomy, the time to treatment; and outcome at 90 days for thrombectomy.

Results: 399 patients from 2017 and 398 from 2018 were included in the study. From 2017 to 2018, thrombolysis rates increased from 11.5% to 18.1% with a similar trend for thrombectomy (2.8-4.8%). There was a trend towards shorter door-to-needle times (44-42 min) and CT-to-groin puncture times (174-145 min). There was a non-significant trend towards improved outcomes with thrombectomy. Qualitatively, physician feedback suggested that e-Stroke Suite increased decision-making confidence and improved patient flow.

Conclusions: Use of artificial intelligence decision support in a hyperacute stroke pathway facilitates decision-making and can improve rate and time of reperfusion therapies in a hub-and-spoke system of care.

Introduction: This study investigates gender differences among stroke patients treated in the telestroke network using specific risk factors that contribute to stroke severity.

Methods: We examined gender differences in stroke severity among 454 patients hospitalized with acute ischemic stroke (AIS). The logistic regression model was used to predict clinical risk factors associated with stroke severity in men and women AIS patients.

Results: In the adjusted analysis among women patients, increasing age (odds ratio [OR] = 1.05, 95% CI: 1.017-1.085, p = 0.003) and higher heart rate (OR = 1.031, 95% CI: 1.005-1.058, p = 0.021) were associated with worsening neurological functions, while direct admission (OR = 0.191, 95% CI: 0.079-0.465, p < 0.001) was associated with improving neurologic functions. Among men, hypertension (OR = 3.077, 95% CI: 1.060-8.931, p = 0.039) and higher international normalized ratio (INR) (OR = 21.959, 95% CI: 1.489-323.912, p = 0.024) were associated with worsening neurologic functions, while Caucasian (OR = 0.181, 95% CI: 0.062-0.526, p = 0.002) and obesity (OR = 0.449, 95% CI: 0.203-0.99, p = 0.047) were associated with neurologic improvement.

Conclusion: Increasing age and heart rate in women, hypertension and greater INR in men contribute to worsening neurologic functions. There is a need to develop strategies to improve the care of both men and women in the telestroke network.

Introduction: Diabetes mellitus (DM) is known to influence outcomes in the short term following stroke. However, the impact of DM on long-term functional outcomes after stroke is unclear. We compared functional outcomes periodically over 7 years between diabetic and nondiabetic ischemic stroke patients, and investigated the impact of DM on the long-term trajectory of post-stroke functional outcomes. We also studied the influence of age on the diabetes-functional outcome association.

Methods: This is a longitudinal observational cohort study of 802 acute ischemic stroke patients admitted to the Singapore General Hospital from 2005 to 2007. Functional outcomes were assessed using the modified Rankin Scale (mRS) with poor functional outcome defined as mRS ≥3. Follow-up data were determined at 6 months and at median follow-up durations of 29 and 86 months.

Results: Among the 802 ischemic stroke patients studied (mean age 64 ± 12 years, male 63%), 42% had DM. In regression analyses adjusting for covariates, diabetic patients were more likely to have poor functional outcomes at 6 months (OR = 2.12, 95% CI: 1.23-3.67) and at median follow-up durations of 29 months (OR = 1.96, 95% CI: 1.37-2.81) and 86 months (OR = 2.27, 95% CI: 1.58-3.25). In addition, age modulated the effect of DM, with younger stroke patients (≤65 years) more likely to have long-term poor functional outcome at the 29-month (p = 0.0179) and 86-month (p = 0.0144) time points.

Conclusions: DM was associated with poor functional outcomes following ischemic stroke in the long term, with the effect remaining consistent throughout the 7-year follow-up period. Age modified the effect of DM in the long term, with an observed increase in risk in the ≤65 age-group but not in the >65 age-group.

Introduction: Early assessment and management of patients with mild stroke and transient ischemic attack (TIA) by specialists were recommended. This study aimed to evaluate the outcomes of these patients and identify the predictive factors of clinical progression, unfavorable outcomes, and recurrent stroke.

Methods: Patients with mild ischemic stroke (NIHSS ≤5) and high-risk TIA were studied. All patients were managed by stroke specialists within 24 h of stroke onset. The outcomes of the patients at 3 months and final follow-up were studied. Predictive factors of clinical progression, unfavorable outcomes, and recurrent stroke were analyzed.

Results: 254 patients were studied. Thirty-eight patients (15%) had clinical progression during admission. Large artery atherosclerosis (OR 2.49, 95% CI: 1.06-5.81), cardioembolism (OR 3.34, 95% CI: 1.26-8.87), and brainstem stroke (OR 2.78, 95% CI: 1.28-6.01) were associated with clinical progression. At the final follow-up, median 22 months, 81 patients (32%) had unfavorable outcomes. Previous disability (OR 1.81, 95% CI: 3.31-100), moderate to severe white matter lesions (OR 2.90, 95% CI: 1.44-5.84), clinical progression (OR 12.5, 95% CI: 5.08-31.25), and recurrent stroke (OR 8.47, 95% CI: 3.21-22.72) were related to unfavorable outcomes. Eleven patients (4%) had recurrent stroke within 3 months and 31 patients (12%) at the final follow-up. Older age (OR 6.68, 95% CI: 2.35-19.02), diabetes mellitus (OR 2.59, 95% CI: 1.07-6.27), and smoking (OR 4.26, 95% CI: 1.52-11.95) were related to recurrent stroke.

Conclusion: Implementation of the up-to-date standard care in clinical practice would bring good clinical outcomes to the patients with mild stroke and high-risk TIA.

Introduction: Prealbumin is a marker of malnutrition and inflammation. It has been associated with poor prognosis in cardiovascular disease, but less is known in stroke patients. Our objective was to evaluate the association of prealbumin levels at admission with prognosis in patients with stroke treated with mechanical thrombectomy.

Methods: Retrospective study of a prospective database of consecutive patients treated with mechanical thrombectomy. Clinical, radiological, and blood parameters including serum prealbumin, and prognostic variables such as respiratory infection, in-hospital mortality, and the modified Rankin scale at 3 months were collected.

Results: We included 319 patients between 2018 and 2019. Prealbumin levels were significantly lower in patients older than 80 years, women, patients with a prestroke Rankin score >2, a glomerular filtrate rate <60 mL/min, and in those with atrial fibrillation. Regarding prognostic variables, prealbumin levels were not associated with respiratory infection. Low prealbumin levels were associated with poor functional prognosis (Rankin score >2), in-hospital mortality, and 3-month mortality. In multivariate analysis, prealbumin was an independent risk factor associated with mortality at 3 months, OR 0.92 [0.86-0.98], p = 0.019.

Conclusion: Lower prealbumin levels at admission behaved as an independent predictor of long-term mortality in patients treated with mechanical thrombectomy. These results should be replicated in other cohorts.

Stroke is a major cause of death and disability in Indonesia. Stroke requires high-quality, fast, and precise management to prevent and avoid disability and death. Stroke can be prevented by adequately controlling the risk factors and encouraging healthy lifestyles. Efforts are needed to organize health promotion programs at the community level. More and a better distribution of neurologists and neurointerventionalists is needed. All hospitals should have a CT scan machine and stroke units. Telemedicine for stroke patients is a very promising endeavor for an integrated acute stroke management system.