Stroke (Hoboken, N.J.)最新文献

Background: Patients with severe prestroke disability (PSD) remain underrepresented in mechanical thrombectomy studies, despite their growing relevance in aging populations. This study used data from the German Stroke Registry-Endovascular Treatment to evaluate functional recovery, mortality, and poststroke care outcomes in this high-risk population.

Methods: We analyzed 9456 mechanical thrombectomy-treated patients with stroke from the German Stroke Registry-Endovascular Treatment (2015-2021), categorized by premorbid modified Rankin Scale (mRS): no PSD (mRS score, 0-1), moderate PSD (mPSD; mRS score, 2-3), and severe PSD (sPSD; mRS score, 4-5). Favorable outcomes were defined as an mRS score of 0 to 2 or return to baseline. Logistic regression adjusted for age, National Institutes of Health Stroke Scale, intravenous thrombolysis, reperfusion success, and sex was used to predict outcomes. A neural network subsequently explored feature importance.

Results: Among 9456 patients, 7387 had no PSD, 1648 mPSD, and 421 sPSD. Unadjusted 90-day outcomes showed increasing mortality with PSD severity and fewer favorable outcomes in both PSD groups. At 90 days, favorable outcomes occurred in 3020 patients without PSD (40.9%), 232 with mPSD (14.1%), and 85 with sPSD (20.2%). After adjustment, only mPSD was associated with lower odds of favorable outcomes, while both mPSD and sPSD remained independent predictors of higher mortality. Complication rates were similar across groups, except for higher vasospasm in patients without PSD. Including rebalanced sPSD samples in predictive models resulted in minor performance improvements but notable shifts in feature importance, with age and Alberta Stroke Program Early Computed Tomography Score emerging as key predictors, National Institutes of Health Stroke Scale decreasing in relevance, and factors such as local anesthesia and occlusion location becoming more prominent.

Conclusions: Despite higher mortality, approximately a fifth of patients with PSD achieved favorable outcomes, suggesting that this group should not be routinely excluded from mechanical thrombectomy. Further studies should refine patient selection criteria and outcome definitions for this vulnerable population.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03356392.

Background: Endovascular therapy (EVT), including mechanical thrombectomy and intraarterial thrombolysis, is increasingly applied in patients with acute ischemic stroke caused by distal medium vessel occlusions. However, its efficacy and safety in this specific population remain inconclusive.

Methods: We conducted a systematic review and meta-analysis of studies comparing EVT and non-EVT for distal medium vessel occlusion patients, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). Data were extracted from PubMed, Embase, and Cochrane Library up to February 16, 2025. The primary efficacy outcomes were excellent (90-day modified Rankin Scale score, 0-1) and functional independence (90-day modified Rankin Scale score, 0-2), while safety outcomes included symptomatic intracranial hemorrhage and 90-day mortality.

Results: A total of 30 studies (4 randomized controlled trials, 23 cohort studies, 3 case-control studies) involving 9210 patients were included in the meta-analysis, with 48.2% patients receiving EVT. No significant improvement was observed in excellent outcome (odds ratio, 0.98 [95% CI, 0.89-1.07]) or functional independence (odds ratio, 0.99 [95% CI, 0.90-1.08]) in patients receiving EVT compared with non-EVT. However, EVT was associated with higher risks of symptomatic intracranial hemorrhage (odds ratio, 1.79 [95% CI, 1.45-2.20]) and mortality (odds ratio, 1.40 [95% CI, 1.21-1.63]). Subgroup analysis revealed that patients with medium anterior circulation occlusions achieved higher odds of efficacy outcomes, while those with posterior circulation occlusions experienced higher risks of symptomatic intracranial hemorrhage and mortality and lower odds of efficacy outcomes.

Conclusions: EVT demonstrates significant efficacy in patients with medium anterior circulation occlusions (M2, A1) without additional safety risks. However, its benefit in distal anterior circulation occlusions remains uncertain, and EVT in posterior circulation occlusions (P1, P2, P3) is associated with higher risks and lower efficacy assessed by the modified Rankin Scale. Further randomized controlled trials focusing on distal and anterior cerebral artery occlusions are warranted to clarify these findings. The conclusions were mainly based on observational studies.

Registration: URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42025643022.

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: In the case of failed reperfusion or severe stenosis during endovascular treatment of acute stroke, intracranial stenting is a growing practice. We aimed to study clinical and radiological outcomes in a large multicenter cohort.

Methods: The RESISTANT registry (Registry of Endovascular Salvage for Intracranial Stenting in Thrombectomy-Refractory Stroke; 2016-2023) is a multicenter single-arm retrospective registry of patients with acute stroke who underwent intracranial stenting during endovascular treatment across 36 international centers. The primary end point was functional outcome at 90 days. Secondary end points were final successful reperfusion (modified Thrombolysis in Cerebral Infarction, 2b-3) and stent patency at 24 hours. Safety outcomes included procedural complications, symptomatic intracranial hemorrhage, and in-hospital mortality. Logistic regression models including those variables that achieved statistical significance, along with age, baseline National Institutes of Health Stroke Scale, and baseline modified Rankin Scale, were used to define independent predictors.

Results: Among 904 patients enrolled, 876 fulfilled inclusion criteria. Median age was 67.0 (interquartile range, 59.0-77.0) years, 567 (64.8%) were men, and the median National Institutes of Health Stroke Scale score was 12.0 (interquartile range, 7.0-19.0). Anterior circulation was involved in 624 (71.6%), and the rate of tandem extracranial/intracranial occlusion was 4.9%. Stenting was performed in 469 patients (53.5%), owing to failed reperfusion (expanded Thrombolysis in Cerebral Infarction, 0-2a), and in 320 patients (36.5%) because of residual severe stenosis. After stenting, immediate successful recanalization was achieved in 777 (89.5%). At 90 days, the rate of modified Rankin Scale score of 0 to 2 was 41.2%. The number of thrombectomy attempts (adjusted odds ratio, 0.810 [95% CI, 0.707-0.929]; P=0.003) and the final successful recanalization (adjusted odds ratio, 19.394 [95% CI, 5.486-68.560]; P<0.001) were associated with good functional outcome. During admission, the reocclusion rate was 12.2%, most of them within 48 hours. Symptomatic intracranial hemorrhage was diagnosed in 8.4% of patients; no variables were independently associated with a higher probability.

Conclusions: Acute intracranial stenting was a feasible therapy for patients with failed reperfusion or severe stenosis. Successful reperfusion and a lower number of thrombectomy attempts predicted functional outcome. Prospective studies are warranted to confirm efficacy and safety.

Background: Time to mechanical thrombectomy (MT) is a critical predictor of functional outcomes in large vessel occlusion stroke. This study compares 2 large vessel occlusion stroke treatment approaches: the one-stop management approach (OSM), in which patients are directly transferred to the angiosuite for flat detector computed tomography and MT, versus the conventional approach, which includes multidetector CT before MT.

Methods: Between March 2014 and December 2019, 205 patients with acute ischemic stroke with a National Institutes of Health Stroke Scale (NIHSS) score of ≥7 and symptom onset ≤4.5 hours underwent large vessel occlusion stroke-treatment using the OSM approach at the University Medical Center Göttingen, Germany. After confirmation of LVO, eligible patients received intravenous thrombolysis followed by MT. Ordinal regression corrected for all confounders. Primary end points included door-to-groin and door-to-reperfusion times, NIHSS at discharge, NIHSS improvement, and modified Rankin Scale at 90 days. Propensity score matching accounted for age, sex, NIHSS, thrombolysis, Thrombolysis in Cerebral Ischemia score, and post-MT intracranial hemorrhage. Treatment times were noncensored.

Results: Compared with 2470 patients from the German Stroke Registry treated conventionally (non-OSM group), OSM patients had significantly shorter door-to-groin (33.33±±17.91 versus 95.73±±158.33 minutes; P<0.001) and door-to-reperfusion (78.06±±30.33 versus 147.47±±165.32 minutes; P<0.001) times. While baseline NIHSS was similar, OSM patients showed greater NIHSS improvement and better modified Rankin Scale at 90 days (OR, 2.26 [95% CI, 1.16-4.42]; P<0.05).

Conclusions: In this observational trial, direct angiosuite transfer for large vessel occlusion stroke treatment reduces periprocedural times and is associated with improved functional outcomes compared with a conventional approach using multidetector CT before MT.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03356392.

The burgeoning field of brain health innovation demands a convergence of clinical insight and entrepreneurial strategy. Despite the immense global burden of neurological disorders and associated economic costs, there are precious few examples of evidence-based and scalable innovations addressing these challenges. To bridge this gap, the multidisciplinary forum Brainstorme! Entrepreneurship in Brain Health convened on October 5, 2024, in Los Angeles, bringing together physicians, scientists, investors, and industry leaders to share actionable insights on advancing diagnostics, digital health solutions, drug development, and devices in neurology. This article encapsulates the event's key themes, emphasizing unique stakeholder strategies to accelerate innovation while aligning with the health care value chain and the triple aim of improved patient experience, population outcomes, and cost efficiency. We highlight a case study of Brainstorme, a cloud-based brain imaging platform, to illustrate how entrepreneurial initiatives can address unmet needs, leveraging new federal interoperability rules and novel business models, to empower patients and reduce system inefficiencies. Finally, we integrate perspectives from recent literature on early-career physician entrepreneurship, digital health, and health economics to underscore how innovation can be cultivated within an ecosystem that values collaboration, evidence generation, and sustainable value creation.