European Stroke Journal最新文献

Introduction: We examined the prevalence and the characteristics of vessel wall (VW) lesions in young stroke patients and their relation to recurrent vascular events. We hypothesize that having VW lesions is associated with an increased risk on recurrent vascular events.

Patients and methods: Single-center prospective study of participants aged 18-50 years, with a transient ischemic attack (TIA) or ischemic stroke, who underwent high-resolution 3T magnetic resonance imaging (HR-MRI) with VW imaging. We included 10 controls with symptoms diagnosed as stroke mimics. The HR-MRI scans were reviewed by two neuroradiologists blinded for clinical information. Follow-up was conducted via telephone interviews. Recurrent vascular events were defined as TIA, cerebral stroke, myocardial infarctions, revascularization procedures, or vascular death.

Results: We included 158 participants (median age: 41.5 years, IQR 33.0-46.4); 75 (47.5%) of whom were women. Of these, 44 (27.8%) participants had 81 VW lesions, primarily characterized by VW enhancement (74.1%). 86.4% of VW lesions were located in the corresponding ischemic territory, and 48.6% showed no MRA abnormalities. Almost half of the VW lesions were found in the rare causes subgroup, while 13.6% of the "cryptogenic" subgroup showed VW enhancement. VW lesions were not significantly associated with an increased risk of recurrent vascular events (HR 2.2, 95% CI: 0.7-6.6).

Conclusion: One in four young stroke patients have VW lesions, which were not related to an increased risk of recurrent vascular events. VW lesions were seen across all TOAST categories and were not specific to one stroke cause. Further research is needed to investigate the diagnostic and prognostic value of VW lesions in young stroke patients.

Introduction: The superficial temporal artery-middle cerebral artery (STA-MCA) flow augmentation bypass is effective for treating Moyamoya vasculopathy and selected cases of atherosclerotic large vessel disease. Recently, blood oxygen level-dependent cerebrovascular reactivity (BOLD-CVR) has emerged as a novel tool to assess hemodynamic impairment for patient selection and monitoring. This study investigates whether preoperative BOLD-CVR in the affected vascular territory (i.e. middle cerebral artery (MCA) territory) correlates with intraoperative bypass flow and whether intraoperative bypass flow serves as a predictor of postoperative hemodynamic improvement.

Patients and methods: We prospectively included patients with symptomatic cerebrovascular steno-occlusive disease who underwent STA-MCA bypass with pre- and postoperative BOLD-CVR imaging and intraoperative bypass flow measurements. Pearson correlation and multivariable regression models assessed the relationships between preoperative hemodynamic status (i.e. preoperative BOLD-CVR), intraoperative bypass flow, and postoperative BOLD-CVR improvement, adjusting for confounders (type of steno-occlusive disease, age, and cerebrovascular risk factors).

Results: Forty-three patients (three receiving bilateral bypass) were included. Despite lack of association (p = 0.08) at univariable analysis, multivariable regression analysis revealed that, after correction for known confounders, preoperative CVR in the affected MCA territory was inversely associated with intraoperative bypass flow. For each 0.1 unit (percentage BOLD signal change/mmHg CO2) decrease in preoperative MCA territory CVR, the predicted bypass flow increased by 14.61 mL/min. Preoperative CVR was also the only significant predictor of postoperative CVR, with higher preoperative BOLD-CVR values linked to greater hemodynamic improvement.

Conclusion: The severity of preoperative hemodynamic impairment in the affected MCA territory correlates with the increased need for bypass flow, serving as a potential predictor for intraoperative quantitative bypass flow demand once relevant covariates are accounted for. The STA-MCA bypass appears to deliver optimal flow when the cerebrovascular reserve capacity is not fully exhausted.

Introduction: The impact of intra-arterial thrombolysis (IAT) following successful endovascular thrombectomy (EVT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) remains uncertain. This study aims to assess the efficacy and safety of IAT as an adjunct to EVT in patients with AIS-LVO.

Patients and methods: We searched PubMed, Embase, and Cochrane databases to identify randomized controlled trials (RCTs) that compared EVT + IAT with EVT-only for AIS-LVO. The primary outcome was an excellent functional outcome, defined as a modified Rankin Scale (mRS) score of 0-1 at 90 days. Secondary outcomes included functional independence (mRS 0-2), symptomatic intracranial hemorrhage (sICH), and mortality. The pooled data were analyzed using random-effects models.

Discussion and conclusion: A total of four RCTs, involving 1395 patients, were included in the analysis. The results showed that patients who received EVT + IAT had a significantly higher likelihood of achieving an excellent functional outcome at 90 days compared to those who received EVT-only (risk ratio [RR], 1.16; 95% confidence interval [CI], 1.03-1.31). No statistically significant differences were observed between the EVT + IAT and EVT-only groups in terms of 90-day functional independence (RR, 1.03; 95% CI, 0.94-1.13), sICH (RR, 1.30; 95% CI, 0.80-2.13), or 90-day mortality (RR, 0.94; 95% CI, 0.76-1.17).

Conclusions: Among patients with AIS-LVO who have undergone successful EVT, the use of adjunct IAT, compared to no additional treatment, was associated with a greater likelihood of achieving an excellent functional outcome at 90 days.

Systematic review registration: CRD42024602099.

Background: Accurate diagnosis of cerebral amyloid angiopathy (CAA) in surviving patients is indispensable for making treatment decisions and conducting clinical trials. We aimed to evaluate the diagnostic value and clinical utility of the simplified Edinburgh computed tomography (CT) criteria for CAA-related hemorrhage in Chinese patients.

Methods: We analyzed 212 patients with lobar hemorrhage who underwent brain CT and magnetic resonance imaging (MRI) from a multicentre cohort. Using the Boston criteria version 2.0 (v2.0) as the gold standard, we assessed the application value of the simplified Edinburgh CT criteria, and investigated whether the Edinburgh CT criteria predict patient outcomes.

Results: Patients with probable CAA accounted for 36.6% according to the Boston criteria v2.0. The Edinburgh CT criteria indicated an area under the receiver operating characteristic curves (AUC) of 0.735 for the diagnosis of probable CAA, and it performed better when there was a high-risk threshold of CAA in the decision curve analysis. Patients with a high risk of CAA based on the Edinburgh CT criteria had poorer outcomes at 90-day after adjusting for confounding factors (p = 0.034). Finger-like projections in the Edinburgh CT criteria were associated with lobar microbleeds, cortical superficial siderosis, and multispot white matter hyperintensity according to the Boston criteria.

Conclusions: Taking the Boston criteria v2.0 as the gold standard, the Edinburgh CT criteria demonstrated good diagnostic value and predicted outcomes well at 90-day in Chinese patients with lobar hemorrhage. Further studies with larger sample sizes are required to confirm these findings.

Background: Despite international recognition of stroke as a significant health priority, discrepancies persist between the target values for stroke quality measures and the actual values that are achieved in clinical practice, referred to as gaps. This study aimed to reach consensus among international experts on prioritizing gaps in stroke care.

Methods: A two-round Delphi process was conducted, surveying an international expert panel in the field of stroke care and cerebrovascular medicine, including patient representatives, healthcare professionals, researchers, policymakers, and medical directors. Experts scored the importance and required effort to close 13 gaps throughout the stroke care continuum and proposed potential solutions. Data were analyzed using descriptive statistics and qualitative analysis methods.

Results: In the first and second Delphi rounds, 35 and 30 experts participated, respectively. Expert consensus was reached on the high importance of closing 11 out of 13 gaps. Two out of 13 gaps were considered moderately important to close, with expert consensus for one of these two gaps. Expert consensus indicated that only one gap, related to the prevention of complications after stroke, requires moderate effort to close, whereas the others were considered to require high effort to close. Key focus areas for potential solutions included: "Care infrastructure," "Geographic disparities," "Interdisciplinary collaboration," and "Advocacy and funding."

Conclusions: While closing gaps in stroke care primarily requires high effort and substantial resources, targeted interventions in the identified key focus areas may provide feasible and clinically meaningful improvements.

Introduction: Endovascular thrombectomy (EVT) procedures and workflow have evolved over the years. We examined trends in patient characteristics, EVT techniques and outcomes over 5 years in the Netherlands.

Patients and methods: Data from the MR CLEAN Registry (2014-2018) were analysed, including patients treated with EVT for anterior circulation acute ischaemic stroke (AIS). Patients were grouped by year of inclusion except for the linear regression analysis where the inclusion date was used. Baseline predicted probability of poor outcome (modified Rankin Scale (mRS) score 3-6) was calculated using a validated prediction model. Primary outcome was mRS score at 90 days. Secondary outcomes included workflow times, EVT techniques, successful reperfusion (eTICI ⩾ 2B) and symptomatic intracranial haemorrhage (sICH). Time trends were analysed using multivariable regression models (adjusted common odds ratios (acOR) per year).

Results: 5193 patients were included. Median age increased (from 66 in 2014 to 74 years in 2018 [p < 0.001]). Proportion of patients with pre-stroke dependence (mRS ⩾ 3) increased from 2014 through 2018 (9% to 16%, p < 0.001). Baseline predicted probability of poor outcome did not change (60% vs 66%, p = 0.06). Over time, functional outcomes improved (acOR 1.14 per year, 95%CI: 1.09-1.20); mortality decreased (aOR 0.88 per year, 95%CI: 0.83-0.94). EVT under local anaesthesia increased (from 46% in 2014 to 70% in 2018; aOR 1.15, 95%CI: 1.10-1.22), as did use of direct aspiration (13%-36%; aOR 1.43, 95%CI: 1.35-1.53). Successful reperfusion became more frequent (aOR 1.32 per year, 95%CI: 1.25-1.40), despite needing more attempts (1 in 2014 vs 2 in 2018, aOR 0.93 per year, 95%CI: 0.89-0.98). Incidence of sICH remained unchanged (5% vs 5%, aOR 0.99 per year, 95%CI: 0.89-1.09). Time from emergency room to groin puncture reduced by 7 min per year (95%CI: 5-8).

Discussion and conclusion: Enhanced workflow and increased EVT experience may have led to shorter time to treatment and more frequent successful reperfusion, with better functional outcomes over 5 years, despite treating older, more dependent patients.