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: Cerebral white matter disease (WMD) may result from the accumulation of silent embolic brain infarcts in the setting of subclinical, nonstenotic cervical carotid atherosclerosis. The contribution of cervical plaque to the burden of WMD is not well established.

Methods: A multicenter, retrospective cohort of consecutive adult patients with stroke due to cervical carotid atherostenosis (>50% luminal stenosis), small vessel disease, or cryptogenic mechanism with unilateral hemispheric stroke was queried. Maximum cervical carotid plaque thickness was used to predict higher grade WMD (Fazekas grade 2-3 versus 0-1) in unadjusted logistic regression, stratified by quartile of interside plaque (mean total plaque in axial dimension of the left and right cervical carotid arteries), and adjusted for age, stroke mechanism, atherosclerotic risk factors, and clustering by site.

Results: Of the 375 included patients, the median age was 66 years (interquartile range 58-74), 170 (45.3%) were female, and the median interside cervical internal carotid artery plaque thickness was 1.8 mm (interquartile range 0.2-3.2). Compared with patients in the lowest quartile of interside plaque (<0.2 mm), those in higher quartiles had higher grade WMD (Q3 adjusted odds ratio [aOR] 1.44, 95% CI, 1.09-1.89; Q4 aOR 1.85, 95% CI, 1.37-2.50). The association with higher grade WMD persisted in a sensitivity analysis considering interside plaque thickness as a continuous variable (adjusted incidence rate ratio/1 mm plaque 1.09, 95% CI, 1.02-1.17). The effect was preserved across stroke mechanisms, sex, and infarct pattern (cortical versus subcortical); however, younger patients had a stronger association between plaque thickness and WMD, whereas the eldest patients had no association (P _interaction <0.01).

Conclusions: In this cohort of patients with noncardioembolic stroke, greater interside cervical carotid plaque thickness was strongly associated with greater WMD. This association supports a potential role of subclinical cervical carotid artery atherosclerosis as a contributor to WMD, which may represent the accumulation of silent brain infarcts.

Background: This study investigates the relationship between procedure time during stroke thrombectomy and acute posthospital disposition, as well as the associated costs. Despite extensive literature focusing on long-term outcomes, immediate posthospital patient disposition and its economic impact remain underexplored.

Methods: This retrospective study analyzed 721 patients undergoing thrombectomy at a single neuroendovascular practice from 2011 to 2020. Key metrics included disposition and time from groin puncture to recanalization (PTR). Patient dispositions were categorized into 4 groups: acute/subacute rehabilitation, home/home with physical therapy (PT), death/hospice, and long-term care. Multinomial logistic regression, adjusted for age, National Institutes of Health Stroke Scale score, and comorbidities, was used to model predicted disposition probabilities over a range of PTR times. Disposition-based direct acute care costs were applied to estimate the cost impact of PTR delays.

Results: PTR was significantly associated with disposition (P = 0.003). In adjusted multinomial regression, each 15-minute PTR increase was associated with higher odds of death/hospice (odds ratio [OR]: 1.020, 95% CI: [1.008-1.032], P =  0.001) and no significant change in acute/subacute rehab (OR: 1.007, 95% CI: [0.997-1.017], P = 0.152) and long-term care (OR: 1.007, 95% CI: [0.990-1.025], P = 0.432) relative to home/home with PT. Additionally, every 15-minute delay was associated with a 2-4.6 percentage point increase in the likelihood of death/hospice, and a 1.5-2.5 percentage point decrease in the likelihood of home/home with PT. A cost analysis suggested that each 15-minute delay in PTR resulted in an approximate $190 (95% CI: [$184-$196], P<0.001) increase in direct acute care costs per stroke episode.

Conclusion: Longer PTR is associated with increased death/hospice dispositions and measurable cost increases. Extrapolating nationally, every 15-minute PTR delay results in a $7.2-$7.7 million annual increase in stroke-related health care costs.

Background: Frequent false-positive stroke alerts can strain health resources. Machine learning models can predict stroke alert accuracy and potentially reduce this strain, but these models require time-consuming labeling of large data sets. Weak labeling can accelerate machine learning model development by assigning annotations based on expert-defined heuristic rules rather than manual review. We sought to label a large, unlabeled sample of stroke alerts according to a binary outcome (presence/absence of acute cerebrovascular disease) using weak labeling.

Methods: We developed a weak labeling heuristic ensemble consisting of 4 hierarchical tiers, each of which generated a binary label using custom labeling algorithms. Tier 1 used rule-based named-entity recognition to generate binary labels from brain radiology reports. Tier 2 aggregated Tier 1 outputs over a 48-hour window. Tier 3 determined labels using diagnosis codes from stroke alert hospital encounters. Tier 4 generated a "final" encounter-level label based on label output combinations of Tiers 2 and 3. In 3 separate samples of stroke alerts, we determined sensitivity, specificity, and F1 scores of Tiers 1, 2, 3, and 4 by comparing Tier outputs to manual chart review.

Results: We identified 16 512 stroke alert activations between 2011 and 2021. For Tier 1, performance metrics were based on an initial manual review of 300 neuroimaging reports, achieving a sensitivity of 0.84, specificity of 0.96, and an F1 of 0.87. Tier 2 incorporated 716 neuroimaging reports with a sensitivity of 0.93, specificity of 0.90, and an F1 of 0.91. Tiers 3 and 4 were validated against 250 encounters. Tier 3 achieved a sensitivity of 0.77, specificity of 0.89, and an F1 of 0.80. Tier 4 achieved a sensitivity of 0.92, specificity of 0.86, and an F1 of 0.87.

Conclusions: We successfully labeled a large registry of stroke alerts using weak labeling. This framework can potentially be extended to other clinical data sets.

Background: The benefit of endovascular thrombectomy (EVT) in patients with basilar artery occlusion and severe neurological deficits is well established. However, its effectiveness in those with mild-to-moderate deficits remains uncertain. This study compared outcomes of EVT(±intravenous thrombolysis [IVT]) versus IVT alone in patients with basilar artery occlusion and mild-to-moderate stroke severity.

Methods: We used data from the international multicenter EVA-TRISP (Endovascular Treatment and Thrombolysis for Ischemic Stroke Patients) and TRISP (Thrombolysis for Ischemic Stroke Patients) collaboration. All patients with radiologically confirmed basilar artery occlusion, National Institutes of Health Stroke Scale score <10, and a time to first treatment within 6 hours were included. Main outcomes of interest were favorable (functional) outcome (modified Rankin Scale [mRS] score 0-2), overall distribution of mRS, mortality at 3 months, and symptomatic intracranial hemorrhage. We applied binary logistic and ordinal regression using covariate adjustment and inverse probability of treatment weighting.

Results: Among 274 patients from 18 centers, 176 (64.3%) received EVT (mean age 68±15 years, 38% female, median [interquartile range] National Institutes of Health Stroke Scale score 5 [3-8], 34% with bridging IVT) and 98 (35.8%) received IVT alone (mean age 70±13 years, 43% female, median National Institutes of Health Stroke Scale score 5 [4-8]). Favorable outcome occurred in 63.6% of patients with EVT(±IVT) and in 64.3% of patients with IVT alone (adjusted odds ratio [OR] 0.89, 95% CI 0.46-1.72). There was an association of EVT(±IVT) with unfavorable distribution of the mRS (adjusted OR 1.83, 95% CI 1.10-3.06), and mortality was higher in the EVT(±IVT) group (15.9% versus 6.1%, adjusted OR 3.38, 95% confidence interval 1.30-8.75). Rates of symptomatic intracranial hemorrhage did not differ between groups (2.0% versus 0%). The results remained unchanged after additional inverse probability of treatment weighting analyses.

Conclusions: In this multicenter observational cohort study, EVT(±IVT) in patients with basilar artery occlusion with mild-to-moderate stroke, was not associated with improved clinical outcome but higher mortality compared with IVT-treatment. Our findings underscore equipoise and the need for prospective trials in this population.

Background: There is limited information on systemic blood pressure goals and variability before and during mechanical thrombectomy and how it affects outcomes in large vessel ischemic stroke.

Methods: A longitudinal cohort study of patients with acute ischemic stroke and large vessel occlusion who underwent thrombectomy at a comprehensive stroke center in southwestern Colombia (January 2017-January 2023). Two groups were defined: group H (hypotension before thrombectomy, defined as >30 mmHg systolic blood pressure drop between arrival and anesthesia induction) and no hypotension (NH) group. Primary outcomes included functional status (modified Rankin Scale score, 0-2 favorable; 3-6 unfavorable) and mortality (modified Rankin scale score = 6) at discharge and 90-day follow-up. Inverse probability weighting was used to reduce confounding.

Results: A total of 167 patients (44.3% female), median age 66 (interquartile range, 53-76), underwent thrombectomy. Admission National Institutes of Health Stroke Scale score and Alberta Stroke Program Early Computed Tomography Score were similar (16.5 versus 16; Alberta Stroke Program Early Computed Tomography Score 9 in both). Thrombolysis was used in 45.4% (H: 23.3% versus NH: 22.1%). Door-to-needle time: 56 minutes versus 47 minutes; door-to-groin: 138 minutes versus 129.5 minutes. Procedure duration was longer in H (100 minutes versus 85 minutes). Successful reperfusion was not significantly different (modified Thrombolysis in Cerebral Infarction≥2b) 73.05% (H: 76.6%, NH: 70%, P = 0.29). Unfavorable modified Rankin scale score at discharge: H: 70.1%, NH: 68.9% (P = 0.86). Mortality at discharge: H: 32.5%, NH: 16.7% (P = 0.2); at 90 days: H: 37.7%, NH: 18.9% (P = 0.02) with inverse probability weighting analysis showing higher mortality in H both at discharge (odds ratio [OR] = 2.16, 95% CI: 0.93-5.04, P = 0.07) and 90 days (OR = 2.93, 95% CI: 1.25-6.86, P = 0.01) only the latter with statistical significance.

Conclusion: Hypotension before thrombectomy in large vessel occlusion stroke was associated with increased 90-day mortality. Worse functional outcomes were also observed, though not statistically significant. Early blood pressure control during anesthetic induction may improve prognosis.

Stroke-associated hyperkinetic movements are most often linked to basal ganglia lesions, while cortical or insular involvement is rarely reported. Hemichorea is an uncommon manifestation of acute ischemic stroke and may pose diagnostic and therapeutic challenges. We report the case of an 81-year-old woman presenting with acute Broca-type aphasia and left hemibody choreic movements. Initial computed tomography (CT)/computed tomography angiography revealed an occlusion of the right M2 segment of the middle cerebral artery. Perfusion imaging showed a significant ischemic penumbra without established infarction. Mechanical thrombectomy, performed eight hours after symptom onset, achieved complete reperfusion (Thrombolysis in Cerebral Infarction grade 3). Within 24 hours, aphasia resolved, and hemichorea markedly improved, persisting only as mild distal movements at discharge and completely disappearing within weeks. Magnetic resonance imaging demonstrated a small acute ischemic lesion confined to the right insular region. This case highlights the role of corticalsubcortical motor networks beyond the basal ganglia in the pathogenesis of post-stroke hyperkinetic movements. The insula, through its influence on temporalbasal ganglia pathways, may contribute to chorea generation. To our knowledge, this is the first reported case of hemichorea due to insular infarction successfully treated with thrombectomy, with complete clinical recovery.

Background: Unexpected occlusive events, such as thrombosis, can cause serious complications during neuroendovascular treatment. Angiography provides only intermittent assessments, potentially missing rapidly developing occlusions, highlighting the need for continuous monitoring. This retrospective study assessed how accurately continuous monitoring of intracranial arterial pressure waveforms can detect occlusive events.

Methods: We computed wavelet-based time-frequency amplitude of intracranial arterial pressure waveforms at frequencies ranging from 6 to 18 Hz in each of the 6444 trials obtained from 43 arteries in 37 patients. We determined whether modulation of this amplitude correctly classified the patent or occluded states defined by angiography.

Results: Mixed-model analysis revealed a significant increase in time-frequency amplitude during occlusive events (P < 0.001). Receiver operating characteristic analysis indicated that an increase of ≥13.9% from baseline in the 6-18 Hz time-frequency amplitude could detect occlusive events with a sensitivity of 88.5%, specificity of 87.5%, positive predictive value of 36.1%, and negative predictive value of 96.4%. A sustained increase of ≥14.3% for 5 or more consecutive trials could detect occlusive events with a sensitivity of 82.3%, specificity of 96.8%, positive predictive value of 75.5%, and negative predictive value of 94.8%.

Conclusions: Our preliminary study suggests that continuous intracranial arterial pressure monitoring holds promise as an adjunctive tool to accurately detect occlusive events. A prospective study is warranted to definitively establish its diagnostic value during neuroendovascular treatment.

Background: The optimal first-line device choice for endovascular treatment (EVT) of cancer-related stroke remains largely unknown. In this study, we evaluated the efficacy and safety of the EVT methods for treating cancer-related stroke thrombi.

Methods: We retrospectively analyzed 78 patients with cancer-related stroke who underwent EVT between February 2011 and July 2024. Patients were compared based on the first-line EVT technique (combined [n = 29] versus stent retriever [SR] only [n = 35] versus contact aspiration [CA, n = 14]) and the type of the SR (the dual-layered stent retriever [Embotrap] [n = 13], the single-layered stent retriever (Trevo [n = 16], and the Solitaire [n = 35]) group. The primary efficacy end point was the first-pass effect (achieving a modified Thrombolysis in Cerebral Infarction score of 2c or 3 after the first pass). The primary safety end point was the symptomatic intracranial hemorrhage rate.

Results: The primary efficacy did not differ between the first-line EVT techniques (first-pass effect: combined 34.5% versus SR only 17.1% versus CA 35.7%; P = 0.2). Among the SR groups, the dual-layered stent retriever group showed a higher rate of first-pass effect compared with the single-layered stent retriever (Trevo) and the single-layered stent retriever (Solitaire) groups (53.8% versus 25.0% versus 14.3%, P = 0.023). The dual-layered stent retriever group was independently associated with a higher rate of first pass effect (adjusted odds ratio, 11.0 [95% CI 1.4-126.0]; P = 0.031). The incidence of symptomatic intracranial hemorrhage after the procedure did not significantly differ between the groups.

Conclusions: In EVT for cancer-related stroke, the dual-layered stent retriever device demonstrated superior efficacy in higher rates of first-pass effect without increasing the risk of symptomatic intracranial hemorrhage. These findings suggest that the dual-layered SR may be preferred as the first-line treatment option for EVT in cancer-related stroke.