Stroke (Hoboken, N.J.)最新文献

Background: Intracranial aneurysm (IA) wall remodeling remains a critical yet poorly understood process despite extensive research into clinical, morphological, and hemodynamic determinants of IA formation, growth, and rupture. This study aimed to systematically characterize IA wall phenotypes-thin walled, thick walled, and heterogeneous-and to identify clinical, morphological, and hemodynamic determinants associated with these categories using intraoperative imaging and advanced computational analyses.

Methods: Intraoperative video recordings allowed for detailed annotation of wall regions, classifying distinct areas as red-translucent-acellular (thin) or white-hyperplastic/fibrotic and yellow-atherosclerotic (thick), along with associated blebs. Based on these observations, 12 subcategories were initially defined and then consolidated into 3 groups: Group A (thin-walled), Group B (thick-walled), and Group C (heterogeneous-walled). Statistical analyses, including chi-square tests, Mann-Whitney U tests, and univariate logistic regression, were employed to evaluate clinical variables (age, smoking, hypertension), morphological features (size, shape, curvature), and hemodynamic factors (flow rate, wall shear stress metrics, flow complexity).

Results: Analysis of 135 IAs from 122 patients revealed that older age and smoking were strongly associated with thick-walled (Group B) and heterogeneous (Group C) aneurysms, whereas younger patients predominantly exhibited thin-walled aneurysms (Group A). Group A aneurysms were generally smaller, more elongated, and subjected to higher wall shear stress (WSS) and greater local curvature, suggesting shear-induced thinning. In contrast, Group B aneurysms were larger, with wider necks, exhibited lower WSS and higher relative residence time, and were likely influenced by chronic inflammatory processes, leading to a more fibrotic or atherosclerotic remodeling. Group C aneurysms demonstrated the most complex remodeling patterns; they displayed both thin and thick regions, irregular shapes, and strong intra-aneurysmal flow characterized by high inflow rates and turbulent flow complexity, which may contribute to simultaneous thinning and thickening within the same lesion.

Conclusion: These results suggest that IA wall remodeling follows a continuum influenced by an interplay of clinical, morphological, and hemodynamic factors. Recognizing these distinct phenotypes may improve risk stratification and inform personalized treatment strategies. Although the direct prediction of rupture risk remains to be established, this multidimensional approach provides novel insights into the pathophysiological evolution of IA wall characteristics and highlights potential avenues for further investigation.

Background: Augmented Reality (AR) enables visualization of and interaction with both physical and virtual environments. Holograms can allow 3D image transmission to distant sites, allowing patients to interact with providers as if in the same space. Our prior publication resulted in high satisfaction/immersion for patients interacting with Holo-Stroke providers. Our aim here was to determine if providers assessing CTAs for large vessel occlusion (LVO) would result in reliability and satisfaction.

Methods: Thirty-six head CTAs were de-identified and scored by Stroke Faculty, Fellows, and Nurse Practitioners for LVO using DICOM viewer. CTAs were presented 2 months later via Holo-Stroke. Holograms were positioned in 3D-space, viewable through the Hololens-2, and scored by the same providers. Kappa Reliability was assessed comparing scores to gold-standard (radiology report). Satisfaction was assessed via Likert scale.

Results: Thirteen providers scored the CTAs. Overall Kappa reliability, compared to gold standard, was 0.78(81%)DICOMvs.0.94(94%)Holo-Stroke-CTA(p<0.0001). Overall %correct was 81%vs.94%(p<0.001). Holo-Stroke-CTA's reliability improved for most examiners: Overall (κ=0.78(81%)vs.0.94(94%)), Faculty (κ=0.85(87%)vs.0.92(93%)), NPs (κ=0.81(83%)vs.0.90(92%)), and Fellows (κ=0.68(72%)vs.0.97(97%)). Overall MCA (κ=0.76(86%)vs.0.93(96%)), ICA (κ=0.8(88%)vs.0.9(94%)), and Basilar (κ=0.73(95%)vs. 0.82(96%)) scored high, with marked improvement for ACA (κ=0.3(39%)vs. 0.91(94%)), and PCA (κ=0.55(70%)vs.0.95(98%)). Likert satisfaction "Overall" was (18DICOM,48Holo-Stroke-CTA;p=0.002) with %increasing from 39% to 96%. "Immersion" scores were (0,10;p=0.001), "Ease of Use" (5,9;p=0.002), "Accuracy" (7,9;p=0.002), "Technology Advancement" (4,10;p=0.001), and "Interest" (3,10;p=0.002).

Conclusions: Holo-Stroke-CTA resulted in higher reliability and satisfaction vs. standard DICOM tele-stroke tele-radiology. Providers noted the ability to see 3D vessels in virtual space, vs. scrolling through axial/sagittal/coronal images, resulted in higher accuracy. Even for trainees and difficult to assess vessels, providers were more able to identify LVOs using Holo-Stroke-CTA. Providers were enthusiastic for the immersive radiology assessment, with the ability to immersively resize, rotate, and investigate hologram in 3D virtual space. Though further assessments are needed, Holo-Stroke-CTA can help providers more easily, and at-a-glance, evaluate CTA for LVO.

Background: Predicting and managing spontaneous Cervical Artery Dissections (CeAD) is challenging due to the absence of tools for early identification of high-risk individuals. This study seeks to gather evidence on the predictive value of high-intensity transient signals (HITS) detected by Transcranial Doppler for recurrent ischemic events (IEs) following CeAD.

Methods: We performed a systematic review and meta-analysis of published studies along with the data from our cohort. Following PRISMA guidelines, we searched Pubmed, Embase and Scopus to identify studies that evaluated HITS in patients with CeAD with the aim of predicting IEs. Data were pooled using a random effects model, with odds ratio (OR) and its 95% confidence interval (CI) as the effect size. Heterogeneity was assessed with the Q statistic and I² test, while subgroup analysis evaluated the impact of dissected artery (carotid vs vertebral) on the relationship between HITS and ischemic events. Our retrospective study included consecutive patients diagnosed with CeAD, followed for 90 days to record IEs. Univariable and multivariable analyses were performed to identify factors associated with recurrent TIAs or strokes within 90 days post-CeAD.

Results: Our systematic review included five prior studies, which, combined with our center's sample size, provided data for a total of 306 patients. The meta-analysis indicated that HITS is a significant predictor of IEs (OR: 13.25, 95% CI [2.97-59.13], p<0.01) with low heterogeneity (I2 = 42%, p = 0.13). However, subgroup analysis indicated that HITS are a significant predictor only for carotid artery dissections (p<0.01), and not for vertebral artery dissections (p=0.11). The cohort consisted of 34 patients (mean age: 46.8 years, 55.9% male). The incidence of IEs was 20% in our cohort and all of them (100%) had HITSs in TCD. In multivariable analysis, the presence of HITS (p=0.006) and intra-luminal thrombosis (p=0.02) were significant predictors of IEs.

Conclusions: The presence of HITS detected by TCD is a strong predictor of IEs in patients with Carotid artery dissections. This highlights the clinical value of TCD in identifying high-risk patients and emphasizes the need for proactive management strategies to reduce the risk of future IEs in this subgroup.

Background: The characterization of hemorrhage following acute stroke intervention has largely been CT-based. We sought to compare MRI- and CT-based scoring of hemorrhage after acute endovascular therapy (EVT) applying the Heidelberg Bleeding Classification (HBC) to assess inter-modal agreement and quantify inter-rater agreement.

Methods: Consecutive acute stroke patients were included in this retrospective study if they: i) had MRI and CT ≤12 hours of each other OR ii) had CT bracketed by MRI pre- and post-CT [i.e. MRI-CT-MRI] ≤7 days post-EVT. The concordance of the HBC ratings by consensus panel were compared between CT and T2*GRE MRI.

Results: For the 87 EVT-treated patients included, median age was 68 years [60-74], admit NIHSS 18 [13-23], 47% were treated with IV/IA thrombolytics, and 93% were successfully recanalized (mTICI 2b/3). Hemorrhage was detected on at least one modality in 60% (52/87) of patients. We found a 68% (59/87, 95% CI [57-77%]) agreement overall between CT and MRI for hemorrhage classification post-EVT. MRI had the best inter-rater agreement for HBC 0 (no hemorrhage) with excellent concordance (κ=0.882), compared to CT (κ=0.683). T2*GRE MRI tended to have increased sensitivity to scattered petechial hemorrhage (HBC 1a) as compared to CT with 17% (2/12) inter-modal agreement. The inter-rater agreement of HBC class 2 (i.e. PH-2) was substantial for MRI (κ=0.781) and excellent in CT (κ=0.951), with 67% (8 /12) inter-modal agreement. SAH was detected in 24% (21/87) of patients on CT and/or MRI with 29% (6/21) inter-modal agreement.

Conclusions: With the exception of SAH and minor petechial hemorrhagic transformation, we found that MRI and CT are overall interchangeable for detecting and classifying hemorrhage after endovascular therapy, reassuring findings for both clinical-decision making and research application. Given the complexity of hemorrhage subtypes post-EVT, work to further refine a post-EVT hemorrhage classification scale with clinical correlation would be beneficial.

Background: Currently, endovascular treatment of intracranial aneurysms (ICAs) is limited by low complete occlusion rates. The advent of novel endovascular technology has expanded the applicability of endovascular therapy; however, the superiority of novel embolic devices over the traditional Guglielmi detachable coils (GDCs) is still debated. We performed a systematic review of literature that reported Raymond-Roy occlusion classification (RROC) rates of modern endovascular devices to determine their immediate and follow-up occlusion effectiveness for the treatment of unruptured saccular ICAs.

Methods: A search was conducted using electronic databases (PUBMED, Cochrane, ClinicalTrials.gov, Web of Science). We retrieved studies published between 2000-2022 reporting immediate and follow-up RROC rates of subjects treated with different endovascular ICA therapies. We extracted demographic information of the treated patients and their reported angiographic RROC rates.

Results: A total of 80 studies from 15 countries were included for data extraction. RROC rates determined from angiogram were obtained for 21,331 patients (72.5% females, pooled mean age: 58.2 (95% CI: 56.8-59.6), harboring 22,791 aneurysms. The most frequent aneurysm locations were the internal carotid artery (46.4%, 95% CI: 41.9%-50.9%), the anterior communicating artery (26.4%, 95% CI: 22.5%-30.8%), the middle cerebral artery (24.5%, 95% CI:19.2%-30.8%) and the basilar tip (14.4%, 95% CI:11.3%-18.3%). The complete occlusion probability (RROC-I) was analyzed for GDCs, the Woven EndoBridge (WEB), and flow diverters. The RROC-I rate was the highest in balloon-assisted coiling (73.9%, 95% CI: 65.0%-81.2%) and the lowest in the WEB (27.8%, 95% CI:13.2%-49.2%). The follow-up RROC-I probability was homogenous in all analyzed devices.

Conclusions: We observed that the coil-based endovascular therapy provides acceptable rates of complete occlusion, and these rates are improved in balloon-assisted coils. Out of the analyzed devices, the WEB exhibited the shortest time to achieve >90% probability of follow-up complete occlusion (~18 months). Overall, the GDCs remain the gold standard for endovascular treatment of unruptured saccular aneurysms.

Background: Untreated intracranial aneurysms can rupture and result in high rates of morbidity and mortality. Although there are numerous approved endovascular aneurysm treatment devices, most require dual anti-platelet therapy, are minimally biocompatible, or are prone to recanalization. Neurovascular Controlled Uniform Rapid Embolic (NeuroCURE) is an innovative polymer gel material with long-term stability, biocompatibility, and hemocompatibility developed for the treatment of large, wide-neck aneurysms.

Methods: Sidewall aneurysms were surgically created in 10 canines and NeuroCURE was injected through a 0.025 microcatheter under a single balloon inflation period. Aneurysm treatment was angiographically assessed post-embolization and pre-term with Raymond-Roy occlusion classification and a qualitative flow grade scale. Aneurysm neck stability and biocompatibility was histologically assessed to grade platelet/fibrin thrombus, percent endothelialization, and neointimal formation. Aneurysm sac stability was assessed by NeuroCURE sac content, inflammation, and neo-angiogenesis scales.

Results: Explanted aneurysms exhibited a smooth surface at the aneurysm neck with nearly complete neointimal coverage at 3-months. By 6-months, neck endothelialization was 100% in all animals (average Raymond-Roy occlusion classification of 1.2), with no instances of aneurysm recanalization or parent vessel flow compromise. Biocompatibility assessments verified a lack of inflammatory response, neo-angiogenesis, and platelet/fibrin thrombus formation.

Conclusion: The NeuroCURE material promotes progressive occlusion of wide-necked side wall aneurysms over time without the need for dual antiplatelet agents. NeuroCURE also promotes neointimal tissue infill without dependence on thrombus formation and thus resists aneurysm recanalization. NeuroCURE remains a compelling investigational device for the treatment of intracranial aneurysms.