Frontiers in stroke最新文献

Introduction: Carotid atherosclerotic disease (CAD) is a major cause of stroke, often requiring a combination of medical and surgical interventions. Current guidelines have established well the role of interventions such as carotid endarterectomy and carotid artery stenting (CAS) for unilateral carotid disease. However, there is still a paucity of evidence on the timing, procedural order, and complication rate of these procedures when there is bilateral carotid involvement. Hyperperfusion syndrome (HPS), with or without associated intracerebral hemorrhage, although rare, is a major source of morbidity and mortality after carotid interventions, especially in the setting of bilateral CAD. In select cases, staged bilateral CAS (BCAS) appears to attenuate periprocedural risks, including HPS.

Case report: A 62-year-old male presented with acute dysarthria and right-sided face and upper extremity weakness, amounting to an initial National Institutes of Health Stroke Scale (NIHSS) score of 6. Emergent neuroimaging revealed a dense left MCA sign, complete occlusion of the left proximal internal carotid artery (ICA), and severe stenosis of the contralateral ICA. The patient received intravenous thrombolysis and underwent perfusion imaging for possible mechanical thrombectomy. Although the imaging was favorable for endovascular recanalization, the patient continued to clinically improve to an NIHSS score of 3 during angiography, which showed interval recanalization of left proximal ICA, so the procedure was aborted in favor of a delayed staged BCAS. On the day of the first procedure, angiography revealed interval recanalization of the distal ICA and collateral flow to the middle cerebral artery territory associated with early hyperemia. The risks of symptomatic CAS in light of these findings were discussed with the patient, and a shared decision was made to first pursue endovascular treatment of the asymptomatic severe right CAD, followed by treatment of the symptomatic left CAD, to avoid periprocedural complications such as HPS. The patient continued to improve clinically after both procedures and was able to attain functional independence and resume all previous activities following interventions.

Conclusion: This case and literature review suggest that, although both simultaneous and staged BCAS may be feasible treatment options for bilateral CAD, staged BCAS appears to have fewer periprocedural complications such as HPS.

Background: Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke that is more common in young, especially female, adults and can be challenging to diagnose due to its frequently non-specific presentation and diverse risk factors. Most cases are idiopathic, and international guidelines do not recommend routine investigations for underlying thrombophilia. Timely diagnosis, with prompt neuroimaging and guideline-based treatment, leads to good outcomes. However, in the literature on CVST from sub-Saharan Africa, the gap is substantial, with the few cases described as being related to systemic and/or brain infections. We describe here the largest cohort of CVST from the region with novel findings that may be relevant to everyday clinical practice.

Methods: We conducted a retrospective cross-sectional study of patients diagnosed with CVST from 2010 to 2022 at our tertiary regional neurology referral center in Nairobi, Kenya.

Results: We identified 122 cases: 67.2% (82/122) were female, 80.3% (98/122) were Black African, and the median (interquartile range) age was 36.8 (31.5-45.7) years. Apart from headaches (86.9%, 106/122), the most common presenting symptoms were visual disturbance (26.2%, 32/122) and seizures (23.8%, 29/122); 11 patients developed seizures later. Intracranial hemorrhage with and without venous infarction occurred in 27.9% (34/122) of patients. New diagnoses of thrombophilia were made in 30.3% (37/122). Other causes were HIV, hepatitis B/C, or other brain infections (18.0%, 22/118); pregnancy, including postpartum (14.6%, 12/82); contraceptive use (8.5%, 7/82); and malignancy (8.1%, 10/122). The most common treatment was with warfarin in 50% (61/122), followed by rivaroxaban (29.5%, 36/122) and dabigatran [14.8% (18/122)]. Complete thrombus resolution occurred in only 53.9% (55/102) at follow-up scanning (at a median of 178 days). In terms of outcomes (modified Rankin Score [mRS]), 32.8% (40/122) had an mRS score = 0, 59.9% (73/122) had an mRS score = 1-2, and there was one fatality who also had concurrent systemic malignancy.

Conclusion: Thrombophilia was more prevalent in our cohort of CVST than infections, which is a novel finding compared to what has been published about CVST from sub-Saharan Africa. Most patients were managed with appropriate anticoagulants, but only about half the patients had complete resolution of the CVST at last follow-up. We therefore recommend that thrombophilia should be routinely investigated in all patients with CVST in our setting.

Background and aims: Cognitive impairment (CI) after stroke is still a neglected consequence compared to other neurological deficits for which rehabilitation pathways are routinely available. Cognitive teleRehabilitation (CTR) represents an emerging approach that has the potential to reduce healthcare costs and potentially reaching many patients. By means of a randomized controlled trial, the aims are to investigate the prevalence of cognitive impairment after stroke and the efficacy of a CTR program in: (a) reducing the risk of CI 6 months after stroke; (b) generalizability of the cognitive training to real life; (c) impact on cognitive performances. In the treated group, feasibility, adherence and appreciation of the CTR will also be evaluated.

Methods and outcomes: The CIPS-TER study is a 2-year prospective, single-blind, randomized clinical trial. One hundred patients with ischemic or hemorrhagic stroke will be enrolled in the study, within 5-21 days after onset, and randomized to treatment or standard care. The CTR program will consist of up to 40 h (8 weeks) of individual treatment based on memory, attention, executive functions, and visuospatial tasks to be autonomously performed with a tablet. The study outcomes will be evaluated at 6-month follow-up visit and will include the diagnosis of cognitive impairment, activities of daily living, quality of life, changes in frailty status and cognitive efficiency.

Conclusions: CIPS-TER study will expand our knowledge on the potential effect of cognitive rehabilitation on future cognitive and functional decline after stroke.

Background: Ischemic stroke (IS) causes significant death and disability. Stroke-Heart Syndrome (SHS) involves cardiovascular complications, worsening outcomes. Diabetes mellitus (DM) increases the risk of myocardial injury following IS. This study explores risk factors for myocardial injury in acute ischemic stroke (AIS) with DM patients to improve early identification and prevention.

Methods: This is a retrospective cohort study. Inclusion criteria: neuroimaging-confirmed AIS, admission within 72 h, and measured cardiac troponinT (cTnT) levels. Exclusion criteria included acute hemorrhagic stroke, other cTnT elevation causes, severe organ failure, infections, malignancies, and missing data. Logistic and LASSO regression analyses identified independent risk factors for myocardial injury.

Results: Myocardial injury occurred in 194 patients. Independent risk factors identified were coronary heart disease (CHD), insular cortex lesions, peak brain natriuretic peptide precursor (peak NT-proBNP), C-reactive protein (CRP), and higher National Institutes of Health Stroke Scale (NIHSS) scores. These factors were significantly associated with myocardial injury and ROC analysis showed that the AUC for CHD was 0.621, the AUC for insular cortex lesions was 0.648, the AUC for NIHSS score was 0.726, the AUC for peak NT-proBNP was 0.816 and the AUC for CRP was 0.764. Subgroup analysis suggested that reperfusion therapy was associated with increased myocardial injury risk in various patient subgroups.

Conclusion: CHD, insular cortex lesions, peak NT-proBNP and CRP levels, and higher stroke severity (NIHSS score) are significant risk factors for myocardial injury in AIS patients with DM.

Background: Conventional MRI sequences are insufficient for the detailed depiction of intracranial atherosclerotic disease (ICAD) plaques. The aim of this study was to investigate the association between ischemic events and intracranial atherosclerotic plaque characteristics using a high-resolution T1-weighted black-blood MRI technique (DANTE T1-SPACE) in the anterior circulation in the Japanese population.

Methods: Patients with a total of 108 lesions causing ≥40% stenosis on the C1-5 segments of the intracranial internal carotid artery (ICA) or M1 segment of the middle cerebral artery (MCA) were included. Hyperintense plaques (HIPs) were defined as plaques with a spot of signal intensity (SI) higher than 1.5-fold SI of the ipsilateral temporal muscle on DANTE T1-SPACE. The vessel wall lesions were divided into symptomatic and asymptomatic groups. The lesions in the symptomatic group were classified as artery-to-artery embolism, hemodynamic infarction, cardiac embolism, undetermined and transient ischemic attack (TIA).

Results: Among the 108 plaques, 19 were symptomatic and 89 were asymptomatic. The percentage of HIPs in the symptomatic group was significantly higher than in the asymptomatic group (57.9% vs. 24.7%, p = 0.01). In the symptomatic group, the proportion of HIPs in the A-to-A embolism subgroup was higher than in the other subgroups.

Conclusions: DANTE T1-SPACE may aid in the identification of intracranial plaques with imaging characteristics suggestive of increased stroke risk, particularly hyperintensity potentially reflecting intraplaque hemorrhage.

The Heads Up test, initially described in 2017, offers a potential tool for assessing likelihood of collateral failure in patients with acute large vessel occlusion (LVO) but low or resolving NIH who may become candidates for mechanical thrombectomy (MT). By raising the head of bed and performing serial exams (Heads Up test), detection of early symptomatic worsening may indicate vulnerability of collateral blood supply. The present study aims to examine the practical applications and outcomes of the Heads Up test in one institution over 9 years by analyzing 15 consecutive cases of documented Heads Up testing. Our findings suggest that the Heads Up test can provide valuable guidance in treatment decisions, but further data is needed to refine its criteria and applicability in the evolving neurointerventional practice.

Stroke affects hundreds of thousands of people each year and leads to neuronal damage and often long term disabilities. This study served as an exploratory study investigating astrocyte to neuron reprogramming as a potential treatment for ischemic stroke using a canine model to assess anatomical and functional recovery. The study's exploratory nature involved a small sample size, precluding statistically significant conclusions. For treatment, an adeno associated viral (AAV) vector was constructed such that it would target astrocytes and allow expression of NeuroD1 for the intent of reprogramming them into neurons. Animals were analyzed anatomically using MRI scanning, behaviorally with neurological severity score testing, and cellularly with immunohistochemistry staining. Behaviorally, treated animals recovered more rapidly and to a greater extent than controls; anatomically, treated animals also showed much less ventricle enlargement post stroke; and on the cellular level, treated animals showed a decreased level of astrocyte and microglial activation. These findings suggest that NeuroD1-mediated astrocyte reprogramming may reduce neuroinflammation and enhance functional recovery in ischemic stroke, warranting further exploration of this therapeutic approach.

Delirium after stroke is a serious condition associated with worse long-term cognition. However, the mechanism of delirium is not well understood. The aberrant stress response has been postulated as a mechanism for delirium.

Aim: to explore the relationship between cortisol dysregulation and delirium over the first year after stroke in a prospective cohort study of patients admitted to an acute stroke unit.

Methods: consecutive patients admitted to an acute stroke unit over a 1 year period were identified and recruited if they were aged age ≥ 60 years and not taking steroids. Patients with incapacity were included if proxy consent could be obtained. Baseline data included stroke severity, cognition, illness severity, and pre-stroke cognition. Patients were assessed at 1, 3, 5, 7, 14, 21, 28 days, 4 months and 12 months for delirium. Salivary samples were taken morning and evening for cortisol analysis.

Results: of the 831 patients screened, 304 met inclusion criteria and of these 95 agreed to participant. Twenty-six (27%) had delirium at some point during the 12 months follow-up. Delirium was associated with increasing age (mean age 83.5 years vs. 74 years, p < 0.001), being female (62% vs. 23%, p = 0.013), not independent in pre-stroke activities of daily living (35% vs. 33%), higher IQCODE score median 3.56 vs. 3.19), worse stroke severity (median National Institute of Stroke Scale 5 vs. 8.5) p = 0.009) and having had a total anterior circulation stroke (p < 0.001). Univariable analyses identified several associations between delirium and cortisol in the first 28 days but not at 4 or 12 months. However, on multivariable analyses there were no significant associations between delirium and cortisol at any time point, e.g., odds ratio for median 9 am cortisol 0.95 (95% CI 0.89 to 1.01, p = 0.08).

Conclusion: there was no independent association between delirium and cortisol dysregulation after stroke. If an association does exist, it is likely to be small.

Stroke is the second leading cause of death and disability in Africa, disproportionately affecting individuals in their most productive years and placing an immense socio-economic burden on families and healthcare systems. Despite the growing stroke burden, Africa faces a severe shortage of trained stroke specialists, with only three neurologists per 10 million people compared to up to 900 per 10 million in high-income countries. This gap has led to inadequate acute management, limited rehabilitation services, and poor long-term outcomes. To address this crisis, the African Stroke Organization (ASO) established an Education and Training Committee focused on developing a structured stroke education framework. This proposal outlines ASO's strategic initiatives to build stroke care capacity through research, professional training, service development, and advocacy. By implementing a comprehensive stroke education program-including online courses, hands-on workshops, conference-based training, and a future summer school, ASO aims to train 5,000 by 2030. Through this initiative, ASO seeks to empower African healthcare professionals, reduce disparities in stroke care, and ultimately improve stroke outcomes across the continent. This proposal presents the rationale, objectives, and implementation strategies for the ASO Stroke Education Program and calls for international collaboration to support this critical effort.

Background: stroke is one of the leading causes of death and disability globally. Despite advancements in acute stroke care, long-term outcomes have not been extensively studied in Tanzania. This study aimed to investigate the long-term post-stroke outcomes among adults admitted with stroke to a large tertiary hospital in northwestern Tanzania.

Methods: adults (≥18 years) with stroke who were enrolled in the Lake Zone Stroke Registry Study (LZSS) at Bugando Medical Center between March 2020 and October 2021 were prospectively followed up until October 2024. Stroke diagnosis and classification were confirmed using brain imaging, and baseline stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS). Data on case fatality were collected using the modified Rankin Scale along with information on secondary stroke prevention. The Kaplan-Meier analysis was used to describe survival, and the Cox regression model was used to examine independent factors associated with fatality.

Results: the study included 301 adults, with a mean age of 65.5 ± 14 years, of whom 51% (153/301) were female and 68% (205/301) had ischemic strokes. Case fatality rates were 42.9% (98/228) at 1 year, 75.9% (173/228) at 2 years, and 96.5% (220/228) at 3 years. Independent factors associated with fatality were severe stroke (adjusted hazard ratio (aHR) 7.9, 95% CI [2.3, 27.4], p = 0.001), moderate to severe stroke (aHR 4.6, 95% CI [1.3, 16.1], p = 0.017), a lack of health insurance coverage (aHR 3.7, 95% CI [1.9, 6.8], p < 0.001), and previous stroke (aHR 3.3, 95% CI [1.3, 8.3], p = 0.01). Attendance rates of follow-up clinics and physiotherapy among survivors were 28.6% (86/301) and 8.6% (26/301), respectively. Among stroke survivors with hypertension and diabetes, 32% (83/257) and 41% (20/49) were adherent to antihypertensive and diabetic medications, respectively.

Conclusion: this study highlights the high long-term case fatality rates among adults with stroke in northwestern Tanzania, with stroke severity, a lack of health insurance, and previous strokes being key factors associated with fatality. Low attendance rates at follow-up clinics and poor adherence to medications among survivors of stroke with hypertension and diabetes underline the importance of strengthening post-stroke care systems, including health insurance coverage, to improve survival and quality of life.