Stroke (Hoboken, N.J.)最新文献

Background: Venous sinus stenting (VSS) is increasingly performed for managing venous sinus stenosis associated with refractory idiopathic intracranial hypertension and/or pulsatile tinnitus. The Monopoint System (MS; Route 92 Medical, San Mateo, CA) is a telescoping catheter system with a single point of control outside the body, consisting of an 8F Guide Catheter (Base Camp), a 0.088-in. inner diameter catheter-extender (HiPoint 88), and a ledge-reducing delivery catheter (Tenzing 8). In this study, we describe the MS technique for VSS and our multicenter clinical experience.

Methods: We retrospectively reviewed consecutive patients who underwent VSS with the MS from 2022 to 2023 for intracranial hypertension and/or pulsatile tinnitus at 13 sites. Base Camp is placed in the internal jugular bulb. HiPoint 88 is advanced over the Tenzing 8 through the stenosis. The stent-delivery system is placed across the stenosis (inside the HiPoint 88), then unsheathed by HiPoint pull-back, followed by successful stent deployment. Operators were also surveyed on MS performance.

Results: Seventy-one patients were included, 97% female, mean age 40 ± 11 years, body mass index 35 ± 11. The primary indication for venous stenting was intracranial hypertension (79%, 56/71) and/or debilitating pulsatile tinnitus (87%, 62/71). Visual changes were present in 74%, with papilledema in 63%. Hipoint 88 advanced beyond the stenosis over Tenzing 8 in all cases, and all stents (diameters 6-10 mm and lengths 30-80 mm) successfully deployed. Median stenosis decreased from 80% (interquartile range 75-87) to 0% (interquartile range 0-0) post stenting (P<0.001). There were no Monopoint-related complications. compared with the operators' typical VSS catheter setup/technique, MS was rated "better" in 93% and "slightly better" in 6%; operators cited ease of crossing the stenosis, improved trackability and support, as well as lack of stent-catheter length incompatibilities. Headache, pulsatile tinnitus, and papilledema improved in 81%, 95%, and 91%, respectively.

Conclusion: The MS is a safe and effective catheter platform for VSS.

Background: In patients with acute cerebral ischemia (ACI) and mild deficit, acute infarction on magnetic resonance imaging (diffusion-weighted imaging [DWI]-positivity) is inconsistently detected. Our objective was to characterize the rate of detection in the first dedicated trial of a population with mild, nondisabling stroke and assess the detection and its association with baseline clinical and imaging characteristics. We hypothesized that white matter hyperintensity (WMH) would independently predispose patients to DWI-positivity.

Methods: The phase 3b, randomized, double-blinded PRISMS (Potential of Alteplase for Ischemic Strokes with Mild Symptoms) trial compared administration of intravenous alteplase to aspirin for mild (National Institutes of Health Stroke Scale score 0-5), nondisabling stroke at ≤3 hours from onset. For the current, prespecified study, patients with a final diagnosis of neurovascular mimic were excluded. Central readers, blinded to the treatment arm, assessed day 2 magnetic resonance imaging for prior infarct, WMH burden (graded quantitatively [volume] and qualitatively [(Fazekas]), and presence of DWI-positivity (primary outcome). Alteplase treatment, demographics, and clinical covariates were prespecified for adjustment in regression modeling.

Results: Of 313 patients enrolled, 273 (87%) had a final diagnosis of ACI. Of 212 (77%) cases of ACI with magnetic resonance imaging, 109 (51%) had DWI positivity (median lesion volume 1.20 cc, interquartile range 0.57-2.50 cc). Univariately, the proportion with higher Fazekas grade (grade 2-3: 27% vs 41%; P = 0.02) and prior infarct (45% vs 27%, P<0.01) were associated with DWI positivity. WMH was not associated with DWI positivity in adjusted analysis (adjusted odds ratio [aOR]: 1.01, 95% CI: 0.99-1.03). The multivariable model also showed alteplase treatment inversely associated with DWI-positivity (aOR: 0.48, 95% CI: 0.25-0.93).

Conclusions: Among patients presenting with mild, nondisabling ACI, WMH is not associated with DWI-positivity. A hypothesis emerges that alteplase treatment may reduce DWI positivity in mild, nondisabling ACI.

Background: Although bypass surgery can reduce rebleeding risk in hemorrhagic moyamoya disease, the risk remaining after surgery is not negligible. We hypothesized that the postoperative persistence of periventricular anastomosis (PA), a fragile periventricular collateral manifestation, is associated with rebleeding.

Methods: This retrospective cohort study included patients with moyamoya disease who underwent direct bypass at 2 institutions after hemorrhagic presentation. Either presence or absence of PA after surgery was radiologically determined by grading of each subtype, lenticulostriate, thalamic, or choroidal anastomosis, 3-6 months after surgery. The time interval between the surgery and the rebleeding event or last visit was calculated.

Results: Of 116 eligible patients comprising 232 hemispheres, 172 hemispheres underwent surgery. Rebleeding occurred in 16 hemispheres of 15 patients (2.0% per person-year) during the median follow-up period of 6.3 years. The hemisphere-based annual rebleeding rate was 2.0% in the PA-positive hemispheres as compared with 0.46% in the PA-negative hemispheres. The adjusted hazard ratio of rebleeding for positive PA relative to negative PA was 4.11 (95% CI, 1.07-15.82). Among subtypes of PA, lenticulostriate anastomosis was the most likely to persist after surgery (34 of 62 anastomoses) and to cause rebleeding (8 of 16 hemispheres).

Conclusion: The persistence of PA, especially that of lenticulostriate anastomosis, might be associated with rebleeding after surgery. This suggests the importance of assessing and optimally managing PA for improving long-term outcomes.

Background: The blood biomarkers GFAP (glial fibrillary acidic protein)  and D-dimer have been shown to accurately diagnose large vessel occlusion ischemic stroke. The Upfront DX LVOne is a novel lateral flow-based point-of-care test used for the detection of GFAP and D-dimer. This study sought to (1) assess the performance of LVOne against commercially available point-of-care test platforms, which independently detect GFAP and D-dimer (Abbott iSTAT TBI Plasma and LumiraDx D-dimer), and to (2) assess the diagnostic performance of LVOne in large vessel occlusion detection.

Methods: Manufacturer-reported detection thresholds of the LVOne test for GFAP and D-dimer (213 pg/mL and 600 ng/mL, respectively) were compared against commercial hospital-based point-of-care test platforms using 20 randomly selected plasma samples for each biomarker. D-dimer correlation between LVOne and LumiraDx was assessed using Spearman's Rank correlation coefficient; GFAP correlation between LVOne and the Abbott iSTAT TBI results were assessed using point biserial correlation. Diagnostic performance of the LVOne point-of-care test in conjunction with clinical assessment for detection of large vessel occlusion in plasma samples from 210 patients with suspected stroke was validated.

Results: There was a strong positive correlation (Rho = 0.86, P<0.001) between the qualitative scoring of the lateral flow test and serum GFAP concentrations. Similarly, there was a significant positive correlation between the D-dimer quantification and LVOne semiquantitative measurements (Rho = 0.90; P<0.0001). In our cohort of 210 patients with suspected stroke, the LVOne test in conjunction with clinical assessment had a sensitivity of 75% (95% CI, 51%-91%), a specificity of 92% (95% CI, 87%-95%), a positive predictive value of 48% (95% CI, 30%-67%), and a negative predictive value of 97% (95% CI, 94%-99%) for detection of large vessel occlusion.

Conclusion: Our results validate detection thresholds for the LVOne test in a representative cohort of plasma samples of patients with suspected stroke. Further studies are required to demonstrate the efficacy, safety, and diagnostic performance of LVOne in capillary blood during emergency care/clinical triage.

Background: Endovascular thrombectomy allows for detailed study of thrombus composition in acute ischemic stroke. Differences in thrombus composition can affect outcomes, and the impact of sex on coagulation physiology is recognized. This study investigates whether thrombus composition in acute ischemic stroke varies between sexes.

Methods: Retrospective study on consecutive endovascular thrombectomy-treated patients with acute ischemic stroke at Niguarda Hospital in 2023. Thrombi were stained with hematoxylin and eosin, and the percentages of fibrin, red blood cells (RBCs), and white blood cells (WBCs) were quantified as proportions of the total thrombus area. Univariate and multivariate analyses were performed to identify histological differences between sexes-multivariate analysis adjusted for variables associated with each thrombus component with a P value <0.1.

Results: Seventy-three cases (50.7% female) were included in the study. Male patients exhibited a higher percentage of RBCs within the thrombus (median 51.5% versus 33.8%, P = 0.004), whereas female patients had a higher percentage of fibrin (median 58.3% versus 45.1%, P = 0.020) and WBCs (median 6.5% versus 4.4%, P = 0.045). Univariate analysis indicated that sex was associated with all 3 thrombus components: fibrin (β = 10.08 [95% CI, 1.29-18.87], P = 0.025), RBCs (β = -12.12 [95% CI, l-21.04 to -3.21], P = 0.008), and WBCs (β = 2.05 [95% CI, 0.23-3.86], P = 0.028). In the multivariate analysis, sex lost its association with both fibrin and RBC percentages, and only baseline RBC count maintained its independent association with these 2 components. For the percentage of WBCs in the thrombus, both sex (β = 2.13 [95% CI, 0.25-4.01], P = 0.027) and stroke etiology (β = 0.81 [95% CI, 0.03-1.58], P = 0.041) showed significant and independent associations.

Conclusion: Our exploratory study shows that sex independently affects the percentage of WBCs in thrombi. The percentage of fibrin and RBC does not have an independent association with sex and may be mediated by different RBC count. Future research in this field should consider sex and baseline laboratory values.

Background: Comorbidity burden may affect the outcome following endovascular thrombectomy (EVT) for medium-vessel occlusions. Since patients with high comorbidity burden are likely to be underrepresented in trials on EVT for medium-vessel occlusions, observational data are needed to assess the benefit of EVT for these patients.

Methods: We conducted an observational study on all prestroke independent patients treated with EVT for medium-vessel occlusions in the MCA territory in Sweden from 2015 to 2021. Comorbidity burden was weighted according to the Charlson Comorbidity Index (CCI) and categorized into no comorbidity (CCI 0); moderate to severe comorbidity (CCI 1-2); and very severe comorbidity (CCI ≥3). The primary outcome was a favorable outcome (modified Rankin Scale 0-2) at 90 days after EVT in relation to comorbidity burden. Excellent outcome (modified Rankin Scale 0-1) and symptomatic intracranial hemorrhage were secondary outcomes. In an exploratory analysis, we compared outcomes on the basis of successful recanalization (modified Thrombolysis in Cerebral Infarction 2b-3).

Results: Among 983 patients, 37% had no comorbidity (CCI 0), 35% had moderate to severe comorbidity burden (CCI 1-2), and 27% had a very severe comorbidity burden (CCI ≥3). Favorable and excellent outcomes were most frequent in the CCI 0 group (61% and 25%) and least frequent in the CCI ≥3 group (29% and 13%) (P < 0.001), but there was no significant difference in symptomatic intracranial hemorrhage rates. Successful recanalization reduced the severity of stroke symptoms (National Institutes of Health Stroke Scale) and was associated with increased rates of favorable outcomes for all CCI groups: CCI 0: odds ratio, 4.25 (95% CI, 2.18-8.25); CCI 1 to 2: odds ratio, 3.39 (95% CI, 1.71-6.72); and CCI ≥3: odds ratio, 2.57 (95% CI, 1.14-6.00).

Conclusion: Moderate to very severe comorbidity burden is common among EVT-treated patients with medium-vessel occlusions in routine clinical practice and is associated with worse prognosis compared with patients with no comorbidity. Our results highlight the importance of achieving successful recanalization, which appears highly beneficial across all comorbidity levels.

Background: The use of the Surpass Evolve flow diverter for intracranial aneurysms (IAs) has shown promising results, but there are no studies that evaluated its effectiveness for remnant previously treated IAs. This study aimed to evaluate the safety and effectiveness of Surpass Evolve for previously treated IAs.

Methods: This subanalysis is derived from the SEASE (Safety and Effectiveness Assessment of Surpass Evolve) registry, a retrospective, multicentric, international cohort conducted across 15 academic institutions in North America and Europe between July 2020 and October 2022. Adult patients undergoing Surpass Evolve implantation for single saccular IAs were grouped into those with previously treated IAs by coiling or intrasaccular-devices and those with untreated IAs. Baseline characteristics and outcomes were compared.

Results: This study included 257 patients with IAs. Of those, 66 patients had previously treated IAs (median time between diagnosis and initial treatment and retreatment: 6.28 months), and 191 patients had untreated IAs. Of the 246 patients with 10.5 months of imaging follow-up, the core lab adjudicated complete occlusion was less in previously treated IAs compared with untreated IAs (59.7% versus 72.3%; adjusted odds ratio, 0.43 [95% CI, 0.21-0.88]; P = 0.022). Furthermore, we found similar rates of adequate occlusion between previously treated IAs (83.9%) and untreated IAs (82.1%, P = 0.746). There was no difference in rates of major stroke (1.5% versus 2.6%, P>0.999), mortality (1.5% versus 1.0%, P>0.999), modified Rankin Scale score 0-2 (93.7% versus 95.7%, P = 0.504), and retreatment (1.6% versus 3.3%, P = 0.684) between the 2 groups.

Conclusion: Our results revealed reasonable rates of occlusion and an acceptable safety profile for the use of Surpass Evolve to treat previously treated IAs. Future prospective studies with longer follow-ups are warranted to explore the findings further.

Cerebral proliferative angiopathy (CPA) is a rare vascular disorder that affects normal blood circulation in the brain. Although the structural changes in CPA can be characterized using standard radiologic modalities, assessing the vascular hemodynamics in patients with CPA remains challenging due to inadequate imaging technologies. Arterial spin labeling (ASL) is a noninvasive magnetic resonance technique that allows quantitative assessments of cerebral blood flow. ASL with multiple labeling delays (multidelay ASL) also enables the quantification of arterial transit time. Here, we report the first application of multidelay ASL in a patient with CPA before and after bypass surgery. Our study demonstrated that ASL can be effectively applied to evaluating hemodynamic changes in patients with CPA. Our quantitative results indicated that, in regions affected by CPA, cerebral blood flow increased by at least 14% and arterial transit time decreased by 9.4% after bypass surgery.

Background: Adequate venous drainage of brain parenchyma is essential to maintain cerebral perfusion and clearance of cerebrospinal fluid. The cortical vein opacification score (COVES) is a radiographic metric calculated from a computed tomography angiogram that provides a measure of venous drainage using 3 cortical veins in each hemisphere. Emerging evidence indicates that longitudinal declines in COVES correlates with poor outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH), but the clinical factors associated with a low COVES, and the relationship between COVES and other outcomes remains poorly understood.

Methods: We performed a single-center retrospective analysis of 54 patients with aSAH to characterize the relationship between the COVES score and radiographic vasospasm.

Results: We found that patients with high-grade aSAH (Hunt and Hess 4-5) had worse cortical venous drainage (mean total COVES±SEM, 10.2±0.2, n = 21) compared with patients with lower grade aSAH (Hunt and Hess 2-3, n = 33, 9.5±0.3, P<0.05, 2-tailed t-test) and that venous drainage improves at longitudinal follow-up after discharge (mean increase in total COVES: 1.3±0.3, P<0.01). Logistic regression revealed that patients whose admission computed tomography angiogram showed impairment in sphenoparietal drainage were at the highest risk for radiographic vasospasm (odds ratio, 0.34 [95% CI, 0.13-0.84]).

Conclusion: These results suggest a potential mechanistic link between impaired venous drainage and radiographic vasospasm and provide the basis for further study of COVES as a prognostic tool in patients with aSAH. We found that patients with more severe presentations of aneurysmal subarachnoid hemorrhage had impairment in cortical venous drainage. Impairments in venous drainage were associated with a higher likelihood of radiographic vasospasm.