Journal of Investigative Medicine最新文献

Background and purpose: To date, no large cohort study has investigated the effects of intravenous thrombolysis (IVT) in Chinese patients aged over 80 years who had a stroke. This study aimed to assess the trends in the use of alteplase, the clinical characteristics and the outcomes of Chinese patients aged above 80 years who had an acute ischaemic stroke.

Methods: Data for this analysis were obtained from the China Stroke Center Alliance programme, a nationwide, multicentre, prospective registry encompassing 1751 hospitals across 31 provinces, covering the period from 1 January 2018 to 14 December 2022. The primary outcome was defined as a modified Rankin Scale (mRS) Score of 0-2 at discharge. Secondary outcomes included an mRS Score of 0-1 and independent ambulation on discharge. Safety outcomes assessed were in-hospital mortality and symptomatic intracranial haemorrhage (sICH).

Results: Out of 30 902 patients over 80 years old who qualified for thrombolysis, 8673 (median age (IQR), 84 (82-87) years) received alteplase treatment. Patients administered alteplase demonstrated improved short-term functional outcomes, such as an mRS Score of 0-2 (adjusted OR (aOR) 1.12, 95% CI, 1.06 to 1.18, p<0.001), an mRS Score of 0-1 (aOR 1.14, 95% CI, 1.08 to 1.19, p<0.001) and independent ambulation at discharge (aOR 1.14, 95% CI, 1.08 to 1.20, p<0.001). Moreover, no significant increase was observed in the risk of in-hospital mortality (aOR 1.12, 95% CI, 0.93 to 1.35; p=0.23). However, the risk of sICH was significantly higher among patients treated with alteplase (aOR 3.22, 95% CI, 2.77 to 3.75; p<0.001).

Conclusions: IVT with alteplase in elderly patients who had a stroke resulted in improved short-term functional outcomes without elevating the risk of in-hospital mortality. Nonetheless, this population remains at a higher risk of sICH.

Introduction: The incidence of cancer-associated ischaemic stroke (IS) is increasingly prevalent. This study aimed to assess the levels of enlarged perivascular spaces in basal ganglion (BG-EPVS) in cancer-associated patients who had a stroke compared with the control group, and to investigate the diagnostic utility of BG-EPVS in the context of cancer-associated stroke.

Method: A matched case-control study was conducted in Xiamen, China. A total of 184 IS patients (cancer vs control=1:1) were recruited. The severity of BG-EPVS was graded using high-resolution MRI. Patients' gender, age, clinical risk factors, other imaging changes and laboratory findings information at admission were collected. Logistic regression models were constructed and subgroup analysis by cancer treatment.

Result: Overall, 65.22% of the 184 subjects were male, with a mean (SD) age of 68.83±10.52 years. BG-EPVS had a significant influence on cancer-associated stroke (OR=1.85 (95% CI 1.29, 2.71), p=0.001) after adjusting for gender, age, clinical risk factors, other imaging changes and laboratory findings. The area under the curve of the diagnosis model that combined BG-EPVS and other factors was 0.848 (95% CI 0.787, 0.896), significantly higher than the other three models. Subgroup analysis suggested a heightened association between BG-EPVS and cancer-associated stroke within the cancer treatment group.

Conclusion: In conclusion, this is the first study to assess the diagnosis values of BG-EPVS on cancer-associated stroke and helps us understand the pathogenesis of cancer-associated stroke. Our findings demonstrate the effectiveness of BG-EPVS in diagnosing IS patients who may carry underlying cancer.

Background: The efficacy of percutaneous transluminal angioplasty and stenting (PTAS) relative to medical management in treating symptomatic intracranial arterial stenosis (ICAS) varies based on the qualifying artery. This study aims to evaluate PTAS compared with medical therapy alone in cases of ICAS involving the internal carotid artery (ICA), middle cerebral artery (MCA), vertebral artery (VA) and basilar artery (BA).

Methods: This study involves a thorough pooled analysis of individual patient data from two randomised controlled trials, evaluating the efficacy of PTAS in comparison to medical management for symptomatic ICAS with different qualifying arteries. The primary outcome was stroke or death within 30 days postenrolment, or stroke in the region of the qualifying artery beyond 30 days through 1 year. A methodology based on intention-to-treat was employed, and HR accompanied by 95% CIs were used to convey risk estimates.

Results: The data of 809 individuals were collected from Stenting vs Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis trial and China Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis trial. Four hundred were designated for PTAS, while 409 were assigned to medical therapy alone. For the primary outcome, patients with symptomatic BA stenosis had a significantly higher risk of receiving PTAS compared with medical therapy (17.17% vs 7.77%; 9.40; HR, 2.38 (1.03 to 5.52); p=0.04). However, PTAS had no significant difference in patients with symptomatic ICA (26.67% vs 16.67%; HR, 1.68 (0.78 to 3.62); p=0.19), MCA (8.28% vs 9.79%; HR, 0.85 (0.42 to 1.74); p=0.66) and VA stenosis (9.52% vs 10.71%; HR, 0.91 (0.32 to 2.62); p=0.86) compared with medical therapy.

Conclusions: PTAS significantly increases the risk of both short-term and long-term stroke in patients with symptomatic BA stenosis. Without significant technological advancements to mitigate these risks, PTAS offers limited benefits. For symptomatic ICA, MCA and VA stenosis, PTAS provided no significant advantage.

Background: CT is commonly used to image patients with ischaemic stroke but radiologist interpretation may be delayed. Machine learning techniques can provide rapid automated CT assessment but are usually developed from annotated images which necessarily limits the size and representation of development data sets. We aimed to develop a deep learning (DL) method using CT brain scans that were labelled but not annotated for the presence of ischaemic lesions.

Methods: We designed a convolutional neural network-based DL algorithm to detect ischaemic lesions on CT. Our algorithm was trained using routinely acquired CT brain scans collected for a large multicentre international trial. These scans had previously been labelled by experts for acute and chronic appearances. We explored the impact of ischaemic lesion features, background brain appearances and timing of CT (baseline or 24-48 hour follow-up) on DL performance.

Results: From 5772 CT scans of 2347 patients (median age 82), 54% had visible ischaemic lesions according to experts. Our DL method achieved 72% accuracy in detecting ischaemic lesions. Detection was better for larger (80% accuracy) or multiple (87% accuracy for two, 100% for three or more) lesions and with follow-up scans (76% accuracy vs 67% at baseline). Chronic brain conditions reduced accuracy, particularly non-stroke lesions and old stroke lesions (32% and 31% error rates, respectively).

Conclusion: DL methods can be designed for ischaemic lesion detection on CT using the vast quantities of routinely collected brain scans without the need for lesion annotation. Ultimately, this should lead to more robust and widely applicable methods.

Background and aims: Tenecteplase (TNK) offers logistical advantages in stroke thrombolytic therapy with its single bolus administration compared with alteplase. We aim to investigate the real-world evidence regarding its safety and effectiveness in China.

Methods: We conducted a retrospective study on patients receiving alteplase or TNK for acute ischaemic stroke (AIS) within 4.5 hours of onset between 1 March 2019 and 1 October 2023, from 18 stroke centres in China. Using propensity score matching (PSM), TNK-treated patients were matched 1:1 with alteplase-treated patients. The primary outcome was the rate of symptomatic intracranial haemorrhage (sICH) within 72 hours post-thrombolysis. Secondary outcomes comprised the rate of parenchymal haemorrhage type 2, any intracranial haemorrhage, any systematic bleeding and mortality at 90 days, as well as 24-hour National Institutes of Health Stroke Scale (NIHSS), early neurological improvement at 24 hours, modified Rankin Scale (mRS) shift, percentage of mRS 0-1 and mRS 0-2 at 90 days.

Results: We identified 1113 patients with AIS who received TNK and 2360 patients who received alteplase. Following PSM, 1113 TNK-treated patients with AIS were matched to 1113 patients treated with alteplase. No significant differences were observed in rates of sICH (1.8% vs 1.98%, p=0.864) or other safety outcomes. Moreover, TNK-treated patients demonstrated a lower rate of any intracranial haemorrhage (OR: 0.51, 95% CI: 0.31 to 0.86, p=0.012). A higher proportion of patients achieving early neurological improvement at 24 hours (OR: 1.76, 95% CI: 1.48 to 2.09, p=0.000), better 90-day mRS (OR: 0.67, 95% CI: 0.57 to 0.79, p=0.000) as well as higher percentages of 90-day mRS 0-1 (OR: 1.27, 95% CI: 1.05 to 1.54, p=0.012) and mRS 0-2 (OR: 1.41, 95% CI: 1.14 to 1.75, p=0.001) compared with alteplase.

Conclusions: Thrombolysis with TNK is not associated with an increased risk of sICH, and may result in better early neurological improvement and 90-day functional outcomes compared with alteplase in patients with AIS.

Objective: The Antiplatelet versus R-tPA for Acute Mild Ischaemic Stroke trial has demonstrated the non-inferiority of dual antiplatelet therapy (DAPT) to alteplase in minor non-disabling stroke. This prespecified secondary analysis aimed to investigate whether the treatment effects were similar across stroke territories.

Methods: Participants were divided according to stroke territory, which were subdivided into DAPT and alteplase. An excellent functional outcome at 90 days defined as modified Rankin Scale scoring 0-1 was primary outcome. National Institutes of Health Stroke Scale (NIHSS) score change and early neurological improvement measured by a 2-point decline in NIHSS score at 24 hours were secondary outcomes. Symptomatic intracerebral haemorrhage (sICH) and bleeding events were safety outcomes. Primary analyses adjusted unbalanced baseline characteristics between treatments by multivariate logistic regression.

Results: A total of 719 patients were included: 566 in anterior circulation stroke (ACS) and 153 in posterior circulation stroke (PCS). Primary outcome was 94.1% in DAPT and 91.7% in alteplase among ACS patients (adjusted risk difference (RD) and 95% CI, 1.5% (-1.5% to 4.6%), p=0.32), while 91.2% in DAPT and 91.8% in alteplase among PCS patients (adjusted RD and 95% CI, -2.1% (-8.5% to 4.4%), p=0.53). Compared with alteplase, DAPT was associated with lower risk of sICH (p=0.03) and bleeding events (p<0.001) in ACS, but only lower risk of bleeding events (p=0.007) in PCS. Additionally, among ACS patients, the alteplase was superior to DAPT in terms of decrease in NIHSS score at 24 hours compared with admission (adjusted geometric mean ratio and 95% CI, -0.09 (-0.16 to -0.03), p=0.005) and early neurological improvement (adjusted RD and 95% CI, -7.2% (-11.6% to -2.7%), p=0.001).

Conclusion: Among ischaemic stroke with minor non-disabling symptoms, DAPT was similar with intravenous alteplase regarding long-term functional outcome and better safety regardless of ACS or PCS. The potential benefit of intravenous alteplase regarding early neurological improvement in patients with ACS warrants further investigation.

Trial registration number: NCT03661411.

Background: Central retinal artery occlusion (CRAO) is an ophthalmic condition associated with cerebrovascular ischaemia. In patients with acute CRAO, the 2021 American Heart Association (AHA) scientific statement recommends a diagnostic evaluation for secondary stroke prevention, including cerebrovascular imaging, cardiac rhythm monitoring, echocardiogram and labs. This study aims to understand the national stroke evaluation rates for patients with CRAO before 2021.

Methods: Retrospective, cross-sectional analysis of inpatient admissions from the National Inpatient Sample between 2016 and 2021. Echocardiogram, head and neck vessel imaging and temporal artery biopsy completion during hospital admissions with a principal diagnosis of CRAO were measured. Clustering analysis was performed to characterise differences in stroke evaluations.

Results: 9615 inpatient stays for CRAO were identified. Only 0.3% underwent carotid ultrasounds, 10% underwent echocardiograms, and 8.5% underwent cerebrovascular imaging. Echocardiograms (10%) were most frequently performed, followed by temporal artery biopsy (6.4%). Clustering analysis reveals a cluster of older females on non-Health Maintenance Organisation Medicare receiving temporal artery biopsies. Other clusters consisted of younger males, who were more likely to receive an echocardiogram or cerebrovascular imaging and be discharged home. Independent predictors increasing the odds of undergoing stroke evaluations include female sex, transfer from another facility, residence in zip codes with a median household income of >$79 000, concurrent diagnosis of cerebral stroke, carotid atherosclerosis and nicotine dependence through cigarette use.

Conclusions: In this national cohort study, low percentages of patients with CRAO were evaluated for secondary stroke prevention before the 2021 AHA scientific statement on CRAO management. Notably, higher socioeconomic status patients underwent more comprehensive stroke evaluations.

Background: Remote ischaemic conditioning (RIC) is a potential non-invasive neuroprotective strategy, but it remains unclear whether its efficacy is influenced by smoking status. This study explored the impact of smoking status on the therapeutic effect of RIC in patients with acute moderate ischaemic stroke through a post hoc subgroup analysis.

Methods: Based on the data from the Remote Ischemic Conditioning for Acute Moderate Ischemic Stroke trial, 1717 patients with moderate stroke (National Institutes of Health Stroke Scale score 6-16) who did not undergo reperfusion therapy were included and categorised into current smokers (n=505) and non-smokers (n=1212) based on their smoking status. Patients were randomly assigned to receive either RIC (administered twice daily for 14 days) or standard treatment. The primary outcome was excellent functional prognosis at 90 days (modified Rankin Scale, mRS scores 0-1). Multivariable regression analysis was used to evaluate the interaction between smoking status and RIC.

Results: Among non-smokers, RIC significantly increased the proportion of patients achieving mRS 0-1 at 90 days (69.1% vs 62.8%; adjusted OR 1.487, 95% CI 1.143 to 1.936; p=0.003). Among current smokers, there was no significant difference in the proportion of mRS 0-1 at 90 days compared with the control group (64.1% vs 62.1%; adjusted OR 1.154, 95% CI 0.791 to 1.684; p=0.46). The interaction analysis revealed no significant association between smoking status and RIC efficacy (P for interaction=0.50).

Conclusions: In this analysis, RIC significantly improved the excellent functional prognosis of non-smoking stroke patients, but had no significant benefit for current smokers, suggesting that smoking may attenuate RIC efficacy.

Trial registeration number: NCT03740971.