Stroke (Hoboken, N.J.)最新文献

Background: Recent randomized trials showed no benefit of mechanical thrombectomy (MT) for ischemic stroke due to distal medium vessel occlusion (DMVO). We sought to understand the use of MT for DMVO stroke treatment before and after the publication of these trials.

Methods: We conducted an email survey of 47 comprehensive stroke centers across the United States, which are participating in a National Institutes of Health-funded randomized controlled trial (RCT; Unique identifier: NCT05948566). The questionnaire was developed and modified with expert feedback. Site principal investigators were asked to discuss the DMVO RCT results with their local clinical teams and to subsequently respond to survey questions in a manner that reflected team-based decision-making regarding MT for DMVO before and after the publication of the RCTs, considering the location of the vessel occlusion (nondominant M2 versus M3/M4/A1/A2). If the site principal investigator was responsible for >1 site with the same stroke team, only 1 survey response was tallied.

Results: Of the 43 site principal investigators surveyed representing 47 unique sites, 40 (93%) representing 44 unique sites completed the survey. Before the DMVO RCTs, 95% of respondents were treating nondominant M2 occlusions with MT. Only 15% will continue to be treated with MT, while 57.5% said that treatment was dependent on at least ≥1 variable following presentation of the DMVO RCTs. For all other anterior circulation DMVOs, 50% were treating DMVOs with MT before RCT results' presentation. Only 7.5% will continue to treat with MT, while 32.5% said that treatment was dependent on at least 1 other variable following presentation of the DMVO RCTs. The most common variable named by survey respondents as important to treatment decision was symptom severity.

Conclusions: In this survey of comprehensive stroke centers, the DMVO RCT results created a significant practice change in how stroke teams approach anterior circulation DMVO stroke with MT.

Background: To evaluate possible associations between anti-VEGF (vascular endothelial growth factor) therapy and cSDH (chronic subdural hematoma) outcomes.

Methods: We conducted a cohort study using the TriNetX Research Network, comparing patients with cSDH taking anti-VEGF agents to controls through propensity score matching. Outcomes measured were assessed at 6 months and 1 year follow-up and included cSDH rebleeding, endovascular or surgical cSDH treatment, mortality, headaches, stroke, arterial hypertension, proteinuria, and major bleeding (noncranial).

Results: After propensity matching, 737 patients were included in both anti-VEGF and control cohorts at 6 months, and 722 patients in each cohort at 1 year. Baseline characteristics were well balanced. At 6-months, the anti-VEGF group had significantly lower odds of rebleeding (odds ratio [OR], 0.204 [95% CI, 0.159-0.26]; P<0.001), craniotomy (OR, 0.340 [95% CI, 0.155-0.680]; P=0.002), and mortality (OR, 0.778 [95% CI, 0.615-0.990]; P=0.037). At 1-year, reduced odds persisted for rebleeding (OR, 0.158 [95% CI, 0.122-0.200]; P<0.001), craniotomy (OR, 0.250 [95% CI, 0.116-0.490]; P<0.001), embolization (OR, 0.380 [95% CI, 0.172-0.770]; P=0.007), and mortality (OR, 0.677 [95% CI, 0.520-0.880]; P=0.003). Arterial hypertension was higher in the anti-VEGF group at 6 months (OR, 1.240 [95% CI, 1.000-1.530]; P=0.048), but not 1 year (OR, 1.110 [95% CI, 0.904-1.350]; P=0.330). No significant differences were observed in headache, stroke, proteinuria, or major bleeding at either time point.

Conclusions: Anti-VEGF therapy is associated with significantly reduced rebleeding, reintervention rates, and mortality in patients with cSDH at both 6 months and 1 year. A transient increased incidence of arterial hypertension was noted at 6 months, but other major adverse events were not significantly different. Further randomized, prospective studies are warranted to confirm these results and optimize treatment strategies.

Background: Mechanical thrombectomy is a critical intervention for patients with acute ischemic stroke with large vessel occlusion. However, significant barriers remain in its widespread implementation, particularly in low- to middle-income countries, including a shortage of trained physicians and limited access to advanced medical technologies. This systematic review and meta-analysis aimed to comprehensively evaluate current mechanical thrombectomy training methodologies and assess their effectiveness in improving procedural skills among neurointerventional teams.

Methods: We conducted a systematic review following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, searching PubMed, Scopus, and Web of Science. Eight studies were included, with 3 studies eligible for meta-analysis. We assessed training approaches, participant demographics, and procedural outcomes using the Risk of Bias in Non-randomized Studies of Interventions tool and performed statistical analysis using OpenMetaAnalyst software.

Results: Various training modalities, including virtual reality simulations and hands-on workshops, consistently demonstrated positive effects on procedural skills and professional confidence, demonstrating significant improvements across multiple metrics. Our systematic review and meta-analysis revealed statistically significant reductions in total procedure time (average decrease of 17.84 minutes, 95% CI: [-22.19 to -13.48]), number of handling errors (decreased by 6.34 errors, 95% CI: [-13.16 to 0.48]), contrast volume (decreased by 27.35 mL, 95% CI: [-45.11 to -9.60]), and fluoroscopy time (reduced by 8.07 minutes, 95% CI: [-10.71 to -5.44]). Participants showed increased procedural steps completed, with an average increase of 6.52 steps (95% CI: [3.99-9.05]).

Conclusion: Structured, simulation-based mechanical thrombectomy training programs can significantly enhance procedural skills, clinical decision-making, and professional confidence among neurointerventional teams, potentially improving stroke care.

Background: Large vessel occlusions (LVOs), which account for approximately 25% of ischemic strokes, pose a significant challenge due to their severe impact and need for rapid diagnosis and treatment. Current diagnostic approaches-primarily based on clinical scales and imaging-often lack specificity or delay treatment, severely impacting patient outcomes. This review aims to evaluate the potential of blood biomarkers in improving the accuracy and efficiency of LVO diagnosis.

Methods: A systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were conducted with specific inclusion/exclusion criteria and multiperson screening. PubMed, Google Scholar, and Embase were searched using targeted queries related to LVO and biomarkers. Studies reporting the diagnostic accuracy, sensitivity, and specificity of blood biomarkers for LVO were included. Data were extracted and synthesized to categorize biomarkers and assess their diagnostic utility.

Results: Sixteen studies were included, categorizing biomarkers into 5 groups: coagulation and hemostasis, acute brain injury, inflammatory, angiogenic growth factors, and metabolic and structural markers.

Conclusions: The review highlights the critical role of biomarker blood testing to enhance LVO diagnosis, especially in acute clinical settings. Coagulation and hemostasis markers such as D-dimer offer rapid thrombus detection, and acute brain injury and angiogenic biomarkers provide insight into the extent of injury, localization, and vascular response. A combination of biomarkers from multiple categories is needed to provide an accurate clinical picture of LVO in patients. Excluding studies on embolic strokes, including cardioembolic subtypes, may also bias findings by neglecting their distinct biomarker profiles, warranting further investigation to fully assess biomarker utility across stroke etiologies. Despite promising results for multiple biomarkers, including glial fibrillary acidic protein, ubiquitin C-terminal hydrolase-L1, and D-dimer, further research is needed to validate these biomarkers in diverse populations and integrate them into clinical practice effectively.

Background: In acute ischemic stroke, the infarct core and hypoperfused regions are key indicators for assessing and prognosticating patients. They are typically estimated with computed tomography perfusion (CTP). However, because noncontrast CT and CT angiography are more widely available, we trained a neural network to estimate the ischemic lesion from noncontrast CT and CT angiography scans.

Methods: In this retrospective study, an nnU-Net model was trained to estimate infarcted and hypoperfused regions from noncontrast CT and CT angiography using reference standards from a commercial CTP software (StrokeViewer). We included data from 859 patients for training and 137 for testing. We used data from the Collaboration for New Treatments of Acute Stroke consortium, including MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands)-NO-IV, MR CLEAN-MED, MR CLEAN-LATE, and MR CLEAN-Registry, and a local cohort. In addition to testing our model against StrokeViewer, we also compared our results with 3 other commercial CTP software packages.

Results: Our model achieves a Dice of 0.45 (95% CI, 0.39-0.50) for core and 0.66 (95% CI, 0.62-0.69) for hypoperfused region, underestimating core volume by -9.3 mL (95% CI, -12.5 to -6.1) and hypoperfused region volume by -12.9 mL (95% CI, -21.1 to -4.7) compared with StrokeViewer. When comparing the 4 CTP software packages together, the average of their 2-by-2 agreement ranges from a Dice of 0.22 to 0.28 for core, and a Dice of 0.50 to 0.56 for hypoperfused region. This is similar to the average agreement of nnU-Net with these 4 software packages (average Dice 0.27 for core and 0.56 for hypoperfused). Furthermore, nnU-Net produces fewer connected components (1.3 for core, 1.6 for hypoperfused) than the average of the 4 CTP software packages (60.8 for core and 110.8 and hypoperfused), indicating more cohesive segmentations.

Conclusion: Our model's performance in segmenting infarct core and hypoperfused regions from noncontrast CT and CT angiography is comparable to commercial CTP software packages, with potentially fewer segmentation artifacts. It can therefore be used when CTP is not available.

Background: The purpose of this study is to assess the accuracy of automated artificial intelligence (AI) deep-learning-based modules in predicting suspected intracranial hemorrhage (ICH) or anterior circulation large vessel occlusion (LVO) on noncontrast computed tomography (NCCT) studies.

Methods: We conducted a multicenter international retrospective cohort study, involving 6 stroke centers from the United States and Europe. We included patients in whom an acute stroke was suspected on admission and who underwent an NCCT and a CT angiography when ICH was not observed. Two neuroradiologists and a third one in case of discrepancies retrospectively evaluated all images and established the presence of ICH on NCCT and LVO on computed tomography angiography (ground truth). All NCCT scans were analyzed using 2 automated AI deep-learning modules (Methinks, Barcelona, Spain) to assess the presence of ICH or LVO.

Results: To assess the performance of the NCCT-ICH module, a total of 200 patients were included in the study. The neuroradiologist's evaluation confirmed the presence of ICH in 97 cases (48.5%). To assess the performance of the NCCT-LVO module, 382 patients were analyzed, with the neuroradiologist identifying a LVO in 141 cases (36.9%). The AI module for NCCT-ICH detection demonstrated a sensitivity of 94.9% (95% CI]: 88.4%-98.3%) and specificity of 99.0% (95% CI: 94.7%-99.9%) with an area under the receiver operating characteristic curve of 0.974 (95% CI: 0.94-0.99). The LVO detection AI module on NCCT demonstrated a sensitivity of 81.6% (95% CI: 74.2-87.6), and specificity of 87.1% (95% CI: 82.2-91.1) with an area under the receiver operating characteristic of 0.915 (95% CI: 0.88-0.94).

Conclusions: The AI modules demonstrated high sensitivity and specificity in predicting ICH and LVO, suggesting their potential in offering support in clinical decisions in stroke networks immediately after NCCT is performed.

Background: Restrictive diffusion on magnetic resonance imaging is recognized as an early marker of ischemic brain damage, even though diffusion-weighted imaging lesion reversal (DWI-R) is well known. This study aimed to compare methodologies for detecting DWI-R, including voxel-based analysis, which captures subtle lesion dynamics, and to test their correlation with clinical outcomes.

Methods: We retrospectively analyzed magnetic resonance imaging data from 216 consecutive patients with acute ischemic stroke obtained before and after endovascular therapy. DWI-R was defined either as an increase in DWI-Alberta Stroke Program Early Computed Tomography Score, a decrease of total DWI signal volume or as partial reversal of the initial DWI lesion, irrespective of the final DWI load. Associations between 3-month poststroke modified Rankin scale score and DWI-R was assessed according to the different definitions of DWI-R using logistic binary regression.

Results: In patients undergoing endovascular therapy, 25% had increased DWI-Alberta Stroke Program Early Computed Tomography Score and 32% showed reduced DWI volume. Both measures were strongly associated with favorable outcomes (modified Rankin Scale score ≤2) with odds ratios of 4.90 and 5.60, respectively (95% CIs: 1.66-14.46 and 2.09-14.98). Voxel-based analysis revealed DWI-R of ≥20% of the initial lesion in 64.5% of cases. Even with an overall increase of lesion volume due to progression elsewhere, ≥20% reversal of initial lesion was associated with a significantly improved outcome compared with <20% reversal, odds ratio 2.22 (95% CIs: 1.05-4.70).

Conclusion: DWI-R was common in patients treated with endovascular therapy and linked to favorable outcomes. Subtle lesion dynamics detected only by the voxel-based analysis also conferred significant clinical benefits, supporting DWI-R as a continuum rather than a binary measure as "present" or "absent."

Background: Similar to many low- and middle-income countries, the barriers limiting wider mechanical thrombectomy (MT) access in Georgia are largely unknown. Recently, the MT access score (MTAS) was introduced as a new tool for identifying and characterizing barriers to MT access. This study aimed to implement the MTAS in Georgia, a middle-income country in Eastern Europe, to assess and characterize national barriers to MT.

Methods: We applied the MTAS, which comprises 12 weighted attributes, each scored on a 0-3 scale, resulting in a total score range of 0-36, 0 being the worst possible score. Eight members of the Mission Thrombectomy regional committee from different regions of Georgia were invited as panelists in this survey. The results of the survey are shown as a median with an interquartile range.

Results: The median MTAS for Georgia was 17. The lowest median scores were documented for 2 attributes: lack of prehospital large vessel occlusion-specific screening [0.0 (0.0-0.0)] and telestroke networks [0.0 (0.0-0.0)], with 87.5% of panelists assessing the score as 0 for both attributes. The highest scores were obtained for emergency medical services use [3.0 (2.0-3.0)], availability of MT operators [2.0 (2.0-2.5)] followed by MT device availability and government/insurance coverage [2.0 (2.0-2.0) for each].

Conclusion: MTAS is a valid tool for quantitatively assessing barriers to MT in Georgia. It identified a lack of information and the presence of physical barriers as major challenges. These findings underscore the need for targeted interventions through national stroke public health initiatives to improve access to MT.

Background: Current revascularization guidelines for symptomatic carotid artery stenosis were established based on randomized studies where stenosis was assessed with digital subtraction angiography. Pursuing revascularization in clinical practice is typically based on noninvasive imaging. We aimed to assess whether discrepancies exist between these 2 diagnostic methods when patients with recently symptomatic carotid stenosis referred for carotid revascularization based on noninvasive imaging, subsequently underwent DSA.

Methods: A retrospective study of patients presenting at 3 centers in the United States and Türkiye who routinely performed digitally subtracted angiography prior to revascularization between 2019 and 2024 was performed. Consecutive patients with acute ischemic events and concern for symptomatic ipsilateral carotid artery stenosis with moderate to severe stenosis on noninvasive imaging referred for digitally subtracted angiography were selected for inclusion. Digitally subtracted angiography was performed for intended carotid artery stenting in most cases as the first-line treatment method; patients referred for carotid endarterectomy who underwent preprocedure digitally subtracted angiography were also included. Exclusion criteria included prior carotid endarterectomy or carotid artery stenting or the presence of intraluminal thrombus precluding immediate revascularization. The primary outcome was the rate of disagreement between noninvasive imaging and digitally subtracted angiography.

Results: A total of 463 patients (65% males) were included, with a median age of 69 years. Disagreement regarding qualifying lesion severity for revascularization between noninvasive imaging and digitally subtracted angiography was found in 22.7% of patients. There was a significant difference in the proportion of immediate revascularization between the 2 cohorts (P<0.001). A total of 66/105 (63%) of those in the disagreement cohort were determined to have an etiology of stroke alternative to large artery atherosclerosis, requiring further diagnostic evaluation.

Conclusion: This study demonstrates that almost 1 in 4 patients referred for carotid revascularization based on noninvasive imaging are found to have insufficient stenosis on digitally subtracted angiography to support the decision to proceed with revascularization according to established stenosis severity thresholds.