European Stroke Journal最新文献

Introduction: Patients with a CTA spot sign could benefit more from interventions to limit ICH expansion. We evaluated whether its presence modifies the association between systolic blood pressure (SBP) reduction and ICH outcomes.

Patients and methods: A prospective study of patients with ICH < 6 hours and SBP ≥ 150 mmHg at 2 Comprehensive Stroke Centers in Barcelona over 4.5 years. Patients underwent multiphase CTA (arterial, peak venous and late venous phases) and received treatment targeting SBP ≤ 140 mmHg ≤ 60 minutes. We assessed independent associations and interaction of achieving SBP target ≤ 60 minutes and spot sign status (arterial, or secondarily any phase) with hematoma expansion (>6 mL or > 33%) at 24 hours (primary outcome) and 90-day mRS.

Results: Among 207 patients (mean age 71 ± 13.2 years, 134 [64.7%] male), 67 (32.4%) presented an arterial spot sign and 122 (58.9%) achieved SBP target ≤ 60 minutes. Target rates were similar with and without arterial spot sign (38 [56.7%] vs 84 [60.0%], P = .653). Hematoma expansion occurred in 46/177 (26.0%), and median 90-day mRS was 4 (2-5). Arterial spot sign and SBP target ≤ 60 minutes were independently associated with hematoma expansion (adjusted odds ratio [aOR] 4.07; 95% CI, 1.74-9.89 and aOR 0.27; 95% CI, 0.11-0.64) and 90-day mRS (aOR 2.23; 95% CI, 1.23-4.07 and aOR 0.43; 95% CI, 0.24-0.76), with no interaction between them (P = .575 and P = .187, respectively). Similar results were observed considering spot sign in any multiphase CTA phase.

Conclusion: The association between rapidly achieving SBP reduction and ICH outcomes appears neither dependent on nor modified by spot sign status.

Introduction: Randomised controlled trials comparing endovascular thrombectomy (EVT) to medical treatment in patients with medium vessel occlusion (MeVO) suggested neutrality or futility of EVT. We studied whether the size difference between thrombectomy device and the occluded vessel influenced MeVO outcomes.

Patients and methods: This was a retrospective single-centre observational study comprising EVT-treated patients with occlusion of the M2 branch of the middle cerebral artery on digital subtraction angiography. The diameter of the occluded M2 was measured and compared to the manufacturer's recommendation for the minimal vessel size. Based on this device-to-vessel size ratio, we divided the patients into three groups: A) ratio ⩽1.0 (device smaller or equals the vessel size), B) 1.0 < ratio ⩽ 1.2 (device larger, difference ⩽20%), and C) ratio >1.2 (device larger, significant difference >20%). The primary outcomes were futility (3-month modified Rankin scale 5 or 6) and symptomatic intracranial haemorrhage (sICH).

Results: In the cohort of 146 patients (median age 73; 47.3% women), 58.9% were in group A, 13.7% in group B and 27.4% in group C. Patients in group C had more frequently sICH (20.0%) compared to group A (7.0%) and group B (5.0%), and the highest futility rate (34.2% vs 17.3% vs 25.0%, respectively). In the adjusted analyses, belonging to the group C was associated with sICH (OR 3.32 [1.04-10.64]) and mRS 5-6 (OR 2.84 [1.09-7.37]).

Discussion and conclusions: The size of the thrombectomy device relative to the size of the occluded vessel is associated with haemorrhagic complications and futile outcomes.

Introduction: In Acute Ischemic Stroke (AIS), mismatch between Diffusion-Weighted Imaging (DWI) and Fluid-Attenuated Inversion-Recovery (FLAIR) helps identify patients who can benefit from thrombolysis when stroke onset time is unknown (15% of AIS). However, visual assessment has suboptimal observer agreement. Our study aims to develop and validate a Deep-Learning model for predicting DWI-FLAIR mismatch using solely DWI data.

Patients and methods: This retrospective study included AIS patients from ETIS registry (derivation cohort, 2018-2024) and WAKE-UP trial (validation cohort, 2012-2017). DWI-FLAIR mismatch was rated visually. We trained a model to predict manually-labeled FLAIR visible areas (FVA) matching the DWI lesion on baseline and early follow-up MRIs, using only DWI as input. FVA-index was defined as the volume of predicted regions. Area under the ROC curve (AUC) and optimal FVA-index cutoff to predict DWI-FLAIR mismatch in the derivation cohort were computed. Validation was performed using baseline MRIs of the validation cohort.

Results: The derivation cohort included 3605 MRIs in 2922 patients and the validation cohort 844 MRIs in 844 patients. FVA-index demonstrated strong predictive value for DWI-FLAIR mismatch in baseline MRIs from the derivation (n = 2453, AUC = 0.85, 95%CI: 0.84-0.87) and validation cohort (n = 844, AUC = 0.86, 95%CI: 0.84-0.89). With an optimal FVA-index cutoff at 0.5, we obtained a kappa of 0.54 (95%CI: 0.48-0.59), 70% sensitivity (378/537, 95%CI: 66-74%) and 88% specificity (269/307, 95%CI: 83-91%) in the validation cohort.

Discussion and conclusion: The model accurately predicts DWI-FLAIR mismatch in AIS patients with unknown stroke onset. It could aid readers when visual rating is challenging, or FLAIR unavailable.

Introduction: In patients with spontaneous Intracerebral haemorrhage (ICH), ICH volume is associated with neurological and functional outcome and it is an important factor in neurosurgical decision-making. This study aims to assess the agreement between automated ICH volume measurement, the ABC/2 method and semi-automatic segmentation.

Patients and methods: We retrospectively collected data from 300 consecutive adult patients (November 2018-June 2023) with spontaneous, supratentorial ICH, with a symptom onset-to-CT time ≤ 24 hours. We measured ICH volumes with automated StrokeViewer software, the manual ABC/2 method and semi-automated Brainlab software (reference standard). We performed a Bland-Altman analysis to compare measurements, considering a deviation of 10% or less from the reference standard as clinically acceptable.

Results: The median age was 69 years (IQR, 57-76), 124 (41.3%) were women and the median NIHSS was 18 (IQR, 11-23). Median ICH volume was 26.0 mL (IQR, 9.3-59.2) (Brainlab). StrokeViewer also segmented hyperdense structures other than ICH, but occasionally, it only segmented part of the ICH accurately. The mean absolute differences were 11.2 mL (limits of agreement [LoA] -34.3 to 56.7) between StrokeViewer and Brainlab, -0.42 mL (LoA -65.0 to 64.9) between StrokeViewer and ABC/2 and 10.1 mL (LoA -36.2 to 56.4) between ABC/2 and Brainlab.

Conclusion: There is substantial disagreement between the 3 methods for the measurement of ICH volume. Considering a clinical limit of acceptance of 10% or less, neither StrokeViewer nor ABC/2 agreed with our reference standard. Therefore, StrokeViewer results should not be used for volume-based clinical decisions without visual confirmation of adequate segmentation.

Background: Chronic kidney disease (CKD) is a frequent comorbidity of patients with intracerebral haemorrhage (ICH) and is associated with more severe cerebral small vessel disease. Whether CKD is associated with recurrent stroke after ICH is unknown.

Patients and methods: We conducted a retrospective cohort study of 2 comprehensive stroke centres, collecting data from consecutive patients with ICH. Patients with secondary causes of ICH were excluded. We defined CKD according to Kidney Disease: Improving Global Outcomes definitions, namely 2 measurements of estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 ≥ 3 months apart. The primary outcome was time to any stroke (recurrent ICH or ischaemic stroke), investigated using Cox regression adjusted for age, sex and comorbidities. Outcomes were confirmed by neuroimaging review.

Results: A total of 1062 patients (mean age 68 ± 14 years, 45% female) with ICH were included, 239 with CKD. Over a median (IQR) follow-up of 2.3 (0.7-5.0) years, there was a higher rate of any stroke in the CKD group, 8.4 (95% CI, 6.2-11.1) events per 100 person-years vs 4.4 (3.6-5.3) events in the group with normal eGFR (adjusted hazard ratio [aHR] 1.75: 95% CI, 1.23-2.50, P = .002). CKD was also independently associated with both recurrent ICH (aHR 1.81: 95% CI, 1.15-2.85) and ischaemic stroke (aHR 1.78: 95% CI, 1.06-3.01).

Conclusion: Patients with ICH and CKD are at increased risk of recurrent ICH and ischaemic stroke compared to those with normal eGFR. Further research is needed into this high-risk patient group to identify new prevention treatments.

Introduction: Acute myocardial injury occurs in about every fourth patient in the early phase after ischemic stroke. It may be caused by an imbalance between myocardial oxygen supply and demand, potentially leading to type 2 myocardial infarction (MI). However, little is known about the prevalence of potential triggers of such demand ischemia in acute stroke.

Patients and methods: Consecutive patients with and without post-stroke acute myocardial injury (elevated high-sensitivity cardiac troponin T [hs-cTnT] levels with a rise/fall >20%) were matched for age and sex and retrospectively screened for presence of predefined triggering conditions of myocardial demand ischemia and fulfillment of diagnostic criteria for acute MI.

Results: Among 508 stroke patients analyzed (median age 81 [73-86] years, 52% female), predefined potential triggers of demand ischemia were present in 107/254 (42%) patients with acute myocardial injury and in 61/254 (24%) matched controls (adjusted OR 2.30, 95%CI 1.51-3.52, p < 0.001). Patients with a trigger were older, more often female, had more severe strokes, and more often insular cortex involvement. The most prevalent triggers were respiratory failure, sustained hypertension, supraventricular tachyarrhythmia, and hemodynamic shock. MI criteria were fulfilled in 44/254 (17%) patients with acute myocardial injury including 27/44 (61.4%) with a trigger of demand ischemia (i.e. suspected type 2 MI).

Conclusions: Conditions triggering a myocardial oxygen demand/supply mismatch are highly prevalent in patients with acute myocardial injury detected after stroke, notably in those fulfilling the criteria of acute MI. Stroke-specific aspects such as stroke severity or lesion location may play a role in the development of such triggers.

Introduction: The role of CT angiography (CTA) and CT perfusion (CTP) in patient selection for thrombolysis <4.5 h after onset is unclear. Additional imaging may improve specificity of diagnosis by excluding stroke mimics or those without salvageable tissue, but may delay treatment.

Patients and methods: In a multicentre prospective randomised trial, thrombolysis-eligible patients <4.5 h from symptom onset were randomised 1:1 to non-contrast CT (NCCT) or multimodal CT (NCCT + CTA + CTP). The primary endpoint was the proportion receiving thrombolysis. Secondary end-points were times to decision-making and treatment delivery, early neurological recovery, functional recovery at 3 months and incidence of symptomatic intracerebral haemorrhage (SICH).

Results: Between March 2015 and May 2018, 271 patients were randomised, 134 to multimodal CT and 137 to NCCT. After initial NCCT, 114 had no contraindication to thrombolysis in the multimodal CT group and 108 in the NCCT group. Mean age was 67.5 years and median NIHSS score was 6 (interquartile range 3-12). Fewer patients assigned multimodal CT received thrombolysis (56/114, 49.1%) compared to NCCT (73/108, 67.6%, adjusted odds ratio (aOR) 0.46 (95% CI: 0.25-0.83), p = 0.0102). Times to treatment decision or thrombolytic administration, early neurological recovery and day 90 functional outcome did not differ significantly. SICH occurred in two patients, both assigned NCCT. Mortality was 6/114 (5.3%) in the multimodal CT group compared to 11/108 (10.2%; aOR 0.46 (95% CI: 0.16, 1.31), p = 0.147) in the NCCT group.

Discussion: Despite fewer patients receiving thrombolysis after multimodal imaging, treatment decision times and clinical outcomes did not differ significantly. Multimodal CT may identify patients who do not require thrombolysis such as stroke mimics and non-disabling strokes.

Conclusion: Among acute stroke patients imaged <4.5 h from symptom onset, multimodal CT reduced use of thrombolysis. Treatment decision times and clinical outcomes did not differ between groups.

Introduction: Emergent intracranial stenting (EIS) is increasingly employed in the context of the acute ischaemic stroke treatment, but requires intraprocedural antiplatelet therapy (APT), which may raise haemorrhagic risk. This study aimed to evaluate the safety and effectiveness of different APT regimens during EIS.

Patients and methods: This is a subanalysis of the RESISTANT registry, which is a multicenter retrospective registry of patients with acute ischaemic stroke treated with intracranial EIS between 2016 and 2023. Patients receiving intraprocedural antithrombotics were included. Primary efficacy outcomes were stent patency (intraprocedural and within 24 hours) and 3-month mRS. Secondary outcome was successful reperfusion (modified thrombolysis in cerebral infarction ≥ 2b), and the safety outcome was sICH. Multivariable and propensity score-matched analyses were performed.

Results: Among 827 patients, 4 APT strategies were identified: single APT (n = 102), oral dual antiplatelet therapy (dAPT) (Aspirin + Clopidogrel or Ticagrelor; n = 83), Cangrelor (n = 92) and GP IIb/IIIa inhibitors (GPi) (n = 550). Intravenous agents (Cangrelor/GPi) showed a trend towards lower risk of intraprocedural stent occlusion compared to oral dAPT (adjusted odds ratio [aOR] 0.30, [95% CI, 0.09-1.01], P = .053), though this did not reach statistical significance. GP IIb/IIIa inhibitors continued to demonstrate a protective trend at 24 hours (aOR 0.25, [95% CI, 0.06-0.99], P = .047), without a significant increase in sICH. Both intravenous agents were independently associated with higher odds of successful final reperfusion (odds ratio [OR] 4.35, [95% CI, 1.57-12.09], P = .001). No significant differences emerged between GPi and Cangrelor in matched analysis. No significant difference was observed on good functional outcome between APT strategies.

Conclusion: In the setting of EIS, intravenous APT agents (Cangrelor or GPi) were associated with improved stent patency and higher rates of successful reperfusion, without a significant increase in symptomatic haemorrhage.

Introduction: Inflammation is important in the pathogenesis of acute ischemic stroke (AIS). The association between CRP and outcomes in patients with large vessel occlusion (LVO) stroke receiving endovascular therapy (EVT) has not been fully elucidated.

Patients and methods: We used data from the MR CLEAN Registry (2014-2017), including LVO-AIS patients with intracranial carotid atherosclerotic disease (ICAD), extracranial carotid atherosclerotic disease (ECAD) or atrial fibrillation (AF). The primary outcome was modified Rankin Scale (mRS) score at 90 days. Secondary outcomes included mRS ⩾3 at 90 days, all-cause mortality, successful recanalization, and symptomatic intracranial hemorrhages. CRP was analyzed both dichotomously (>3.0 vs ⩽3.0 mg/L) and continuously, using multivariable regression adjusted for potential confounders.

Results: Among 865 included patients (ICAD: 286; ECAD: 154; AF: 425), median CRP level was 3.4 mg/L (IQR: 2.0-6.1) and 446 patients had elevated CRP (>3.0 mg/L). AF patients had higher CRP than ICAD and ECAD patients (4.0-3.0-3.2 mg/L, p = 0.002). CRP >3.0 mg/L was not associated with mRS in the full cohort (acOR 0.983, 95% CI (0.767, 1.260)) or in any etiological subgroups (ICAD: acOR = 0.968, 95% CI (0.626, 1.496), ECAD: acOR = 1.114, 95% CI (0.617, 2.012), AF: acOR = 0.937, 95% CI (0.653, 1.344)). There was also no association between CRP and any of the other outcomes. When analyzed as a continuous variable, CRP was also not associated with any other outcomes.

Conclusions: We did not observe an association between CRP levels and clinical and radiological outcomes after LVO stroke.