Stroke (Hoboken, N.J.)最新文献

Background: Stroke is often attributable to cardiothoracic factors, but the need for ECG gating and limited spatial resolution on conventional computed tomography often limits the detection of pathology relevant for secondary stroke prevention. The study objective was to evaluate the frequency of cardiothoracic pathology on non-ECG-gated photon-counting computed tomography angiography during initial stroke imaging.

Methods: Consecutive patients with a clinical suspicion of acute stroke, who were imaged using non-ECG-gated dual-source photon-counting computed tomography with diaphragm-to-vertex coverage at a comprehensive stroke center, were retrospectively included. Image quality was assessed using a 4-point Likert scale, and images were evaluated for cardiac stroke sources and thoracic pathology. Where available, results from echocardiography were collected.

Results: The study included 193 complete stroke investigations, 126 of which (65.3%; 95% CI: 58.3-71.6) had imaging-confirmed ischemic strokes. The image quality was generally high for cardiac imaging (excellent 9.8% [95% CI: 6.4-14.9], good 50.3% [95% CI: 43.3-57.2], moderate 37.3% (95% CI: [30.8-44.3]), poor 2.6% [95% CI: 1.1-5.9]) and thoracic imaging (excellent 7.8% [95% CI: 4.8-12.4]), good 59.6% [95% CI: 52.5-66.3]), moderate 32.6% [95% CI: 26.4-39.5]), poor 0% [95% CI: 0.0-2.0]). Clinically relevant cardioembolic findings were detected in 4.7% (95% CI: 2.5-8.6) of all patients: 6 cardiac thrombi (3.1%; 95% CI: 1.4-6.6), 3 aortic valve vegetations (1.6%; 95% CI: 0.5-4.5). Other findings that could affect patient management were detected in 31.6% (95% CI: 25.5-38.5) of scans, including 14 patent foramen ovale (7.3%; 95% CI: 4.4-11.8), 13 pulmonary embolisms (6.7%; 95% CI: 4.0-11.2), 29 pleural effusions (15.0%; 95% CI: 10.7-20.7), and 8 lung malignancies (4.1%; 95% CI: 2.1-8.0). Cardiac thrombi and vegetations were exclusively found in the ischemic stroke subgroup.

Conclusions: Cardiothoracic pathology relevant to patient management or secondary stroke prevention was commonly detected with good diagnostic image quality as part of the standard stroke imaging workup with non-ECG-gated high-pitch dual-source photon-counting computed tomography angiography.

Background: Approximately 20% of ischemic strokes in the United States result from carotid artery stenosis. Carotid artery stenting (CAS) can reduce stroke risk, but variability in poststenting health outcomes and their predictors is poorly understood. We examined the 30-day post-CAS health status and derived its most important predictors.

Methods: The Stenting and Angioplasty with Protection of Patients with High Risk for Endarterectomy (SAPPHIRE) Worldwide Registry measured preprocedural and 30-day health status for patients undergoing transfemoral CAS using the 36-item Short Form Survey Mental Component Summary and Physical Component Summary, EuroQoL 5-Dimension Index Value, and Visual Analogue Scale. Random Forest models ranked 66 preprocedural candidate variables by relative importance (RI) in predicting 30-day post-CAS health status, stratified by patient symptomatic status. Variables with the highest relative importance were identified and used to develop predictive multivariable linear regression models, which were evaluated using R-square (coefficient of determination) and root mean square error.

Results: Health status was assessed using the 36-item Short Form Survey in 3017 patients and EuroQoL 5-Dimension in 3930 patients. Random forest models identified 9 key predictors of post-CAS health status: preprocedural health status (RI 100%), Modified Rankin Scale score (RI 26.2%-76.5%), National Institutes of Health Stroke Scale score (RI 12.1%-28.0%), history of stroke (RI 9.2%-19.8%), congestive heart failure (RI 12.3%-19.7%), spinal immobility (RI 6.7%-31.0%), diabetes mellitus (RI 8.1%-32.9%), severe pulmonary disease/chronic obstructive pulmonary disease (RI 13.8%-45.6%), and non-Hispanic/Latino ethnicity (RI 8.4%-32.4%). Multivariable linear regression models explained ∼36%-61% of the health status variance, with 36-item Short Form Survey models (R-square = 36%-61%) outperforming EuroQoL 5-Dimension models (R-square 37%-44%) with regard to R-square and visual fit of observed versus predicted values.

Conclusions: We derived multivariable linear regression-based prediction models that partially explained 30-day post-CAS health status outcomes. Preprocedural health status scores, stroke scale scores, and medical comorbidities may have utility in appropriately risk-stratifying patients under consideration for CAS and should be considered when discussing health status benefits in pre-CAS treatment shared decision-making discussions.

Clinical trial registration information: This study analyzed data from the SAPPHIRE Worldwide: Stenting and Angioplasty with Protection of Patients with High Risk for Endarterectomy trial.

Clinicaltrialsgov id: NCT00403078.URL: https://clinicaltrials.gov/study/NCT00403078.

Background: Randomized-controlled trial evidence has demonstrated that minimally invasive intracerebral hemorrhage (ICH) evacuation can improve outcomes in properly selected patients. Yet, there remains a need to optimize patient selection, operative technique, and prognosis following ICH evacuation. Magnetic resonance diffusion tensor imaging (DTI) allows visualization and quantification of critical white matter tracts. Corticospinal tract DTI (CST-DTI) is associated with motor function, awareness of which may improve treatment and prognosis in patients undergoing ICH evacuation.

Methods: Patients who underwent ICH evacuation with perioperative DTI were retrospectively reviewed. CST metrics (fractional anisotropy, radial diffusivity, axial diffusivity, geodesic anisotropy, fiber count, and tract volume) were associated with contralateral motor function preoperatively and postoperatively via the Medical Research Council scale (hemibody maximum of 10). Pearson correlation was used to estimate relationships between exposures and clinical outcomes; changes in motor function over time were determined by Wilcox signed-rank testing.

Results: Seventeen patients were included, 12 each with preoperative and postoperative DTI, 7 with matched preoperative and postoperative DTI. Preoperative geodesic anisotropy was significantly associated with both preoperative motor function on the contralateral hemibody (R = 0.616, P = 0.032, Pearson correlation) and at postoperative day 1 (R = 0.606, P = 0.038). Restoration of a deformed CST could be seen in several patients from the preoperative to the immediate postoperative period. Postoperative axial diffusivity was associated with immediate postoperative motor function (R = 0.700, P = 0.011) and at median follow-up of 6.3 months post-ICH (R = 0.608, P = 0.036). There was a significant increase in motor scores on the affected hemibody from postoperative day 1 to last follow-up (median, 4.0 versus 6.0; P = 0.038, Wilcox signed-rank test).

Conclusions: Preoperative CST-DTI metrics are associated with both preoperative and immediate postoperative motor function after minimally invasive ICH evacuation. A restored CST after ICH evacuation could be seen in a subset of patients. Furthermore, postoperative axial diffusivity may be a marker of long-term motor function after ICH evacuation.

Background: A single dose of intravenous thrombolysis (IVT) is the only effective acute treatment for patients with ischemic stroke who do not qualify for endovascular thrombectomy. However, at least 50% of patients treated with only IVT remain disabled. Studies suggest that incomplete recanalization and reperfusion of the distal or microvasculature contribute to incomplete recovery after a single dose of IVT. Single IVT doses above the approved doses produce excessive bleeding. Another strategy might be to provide a more sustained lytic effect by administering a second dose of IVT. Tenecteplase (TNK) pharmacokinetics and preliminary data from clinical trials suggest a second full dose might be given safely 45 minutes after the first dose.

Methods: We propose a phase 2a preliminary safety study of a second dose of TNK given 45 to60 minutes after the first dose in 20 patients not responding to the first dose. Patients will be included if they qualify for and receive a first dose of TNK within 3 hours of symptom onset, do not qualify for thrombectomy, sign informed consent, have a National Institutes of Health Stroke Scale score ≥6 45 minutes later, no bleeding on a repeat computed tomography scan, and can receive the second TNK dose within 4.5 hours of onset.

Results: Primary outcome will be symptomatic intracerebral hemorrhage (type 2 parenchymal hemorrhage or parenchymal hemorrhage remote from the area of infarction with neurological deterioration) or major systemic bleeding; secondary outcomes will include other definitions of intracerebral hemorrhage and modified Rankin Scale score at hospital discharge and 90 days after stroke. The study will be stopped, and dual full-dose TNK therapy will be considered unsafe, if 4 symptomatic or major bleeding events occur.

Conclusion: We propose the first study of 2 sequential doses of TNK in patients with stroke. If successful, this study will be followed by a larger phase 2b controlled safety confirmation and pilot efficacy study.

Background: Recent trials of endovascular thrombectomy (EVT) for acute distal medium vessel occlusions (DMVOs) were negative but also used inconsistent imaging-based inclusion criteria, whereas many successful large vessel occlusion (LVO) EVT trials used empirically validated perfusion imaging-based target mismatch (TMM) criteria: an ischemic penumbra (time-to-maximum [Tmax] >6 s) to core (relative cerebral blood flow [rCBF] <30%) mismatch ratio ≥1.8 and mismatch volume ≥15 mL. We aimed to determine optimal corresponding definitions in DMVOs to improve patient selection for EVT.

Methods: We retrospectively analyzed patients with acute anterior DMVOs from prospectively collected databases at 4 comprehensive stroke centers. To assess core, we evaluated how well pretreatment rCBF <20%, <30%, <34%, and <38% volumes correlated with magnetic resonance imaging-based posttreatment follow-up infarct volumes in successfully recanalized patients. To evaluate penumbra, we assessed how well pretreatment Tmax >4 s, >6 s, >8 s, and >10 s volumes correlated with follow-up infarct volumes in unrecanalized patients. Then, we evaluated whether these improved parameters for core and penumbra better quantified LVO TMM and identified an optimal DMVO TMM definition.

Results: In 122 core (recanalized) patients, rCBF <38% most strongly correlated with follow-up infarct volumes (concordance correlation coefficient 0.30 [95% CI, 0.15-0.48]), outperforming rCBF <30% (concordance correlation coefficient 0.21 [0.10-0.35]) (P<0.001). In 70 penumbra (unrecanalized) patients, Tmax >8 s most strongly correlated with follow-up infarct volumes (concordance correlation coefficient 0.49 [0.25-0.77]), outperforming Tmax >6 s (concordance correlation coefficient 0.39 [0.17-0.68]) (P<0.001). In 180 patients undergoing EVT with Tmax >6 s to rCBF <30% mismatch ratio ≥1.8 and mismatch volume ≥15 mL, recomputing mismatch ratio and mismatch volume using Tmax >8 s and rCBF <38% separated those with favorable outcomes (P = 0.007), and Tmax >8 s to rCBF <38% mismatch ratio ≥2.2 and mismatch volume ≥10 mL maximally separated them (P<0.001, absolute risk reduction 26%).

Conclusion: In acute anterior DMVOs, rCBF <38% and Tmax >8 s best correspond to ischemic core and penumbra, respectively; more favorably quantify LVO TMM; and reveal optimal TMM criteria. These results should be prospectively investigated as inclusion criteria for EVT in this population and suggest recent negative DMVO EVT trials may have been confounded by suboptimal patient selection.

Background: The Alberta Stroke Program Early Computed Tomography Score and core volume on preoperative imaging are key predictors of clinical outcomes following endovascular therapy in patients with a large ischemic core. Although the corticospinal tract is essential for motor function, its prognostic impact in patients with a large ischemic core remains unclear.

Methods: This multicenter retrospective study analyzed preoperative imaging data from patients with Alberta Stroke Program Early Computed Tomography Score ≤5 who underwent endovascular therapy. The presence of lesions in the posterior corona radiata and lesions in the primary motor cortex was assessed. A good outcome was defined as a modified Rankin Scale score ≤3 at 90 days. The association between lesions in the posterior corona radiata, lesions in the primary motor cortex, and good outcome was analyzed using univariable and stepwise multivariable logistic regression, with variable selection based on Akaike information criterion corrected for small sample size.

Results: Among 107 patients, 37 (34.6%) achieved a good outcome. In univariable analysis, neither lesions in the posterior corona radiata nor core volume was significantly associated with a good outcome. In stepwise multivariable logistic regression, modified Rankin Scale score before onset (odds ratio, 0.30 [95% CI, 0.10-0.73]), cardioembolism (odds ratio, 0.25 [95% CI, 0.08-0.76]), absence of lesions in the primary motor cortex involvement (odds ratio, 13.49 [95% CI, 3.75-63.45]), and shorter onset-to-reperfusion time (odds ratio, 0.996 [95% CI, 0.992-0.998]) were independent predictors. Alberta Stroke Program Early Computed Tomography Score and the absence of multiple artery occlusion were retained in the final model but were not statistically significant.

Conclusion: Absence of lesions in the primary motor cortex involvement was independently associated with good outcome after endovascular therapy in patients with large ischemic core, suggesting its potential utility as a complementary imaging marker in this population.

Background: Effective collateral circulation significantly influences clinical outcomes in patients with acute ischemic stroke due to large vessel occlusion. We developed and evaluated a composite Perfusion Collateral Impairment Score (PCIS), combining the unfavorable dichotomizations of computed tomography perfusion-derived parameters (hypoperfusion intensity ratio, cerebral blood volume index, and prolonged venous transit), hypothesizing that higher scores, representing worse collateral status, are associated with poor functional outcomes at 90 days.

Methods: In this multicenter retrospective study, we analyzed 224 patients with acute ischemic stroke due to large vessel occlusion presenting within 24 hours of symptom onset who underwent diagnostic computed tomography perfusion imaging. PCIS was calculated (range 0-3) based on unfavorable values of hypoperfusion intensity ratio (≥0.4), cerebral blood volume index (<0.8), and presence of prolonged venous transit, where each unfavorable parameter is allotted 1 point when present. The primary outcome was 90-day modified Rankin Scale score, categorized as favorable (0-2) and unfavorable (3-6).

Results: Higher PCIS was associated with significantly worse outcomes. The proportion of patients with favorable 90-day outcomes (modified Rankin Scale 0-2) declined from 62% with PCIS 0 to 23% with PCIS 3 (P = 0.001). Multivariable analysis demonstrated that each 1-point increase in PCIS was independently associated with reduced odds of functional independence (adjusted odds ratio [OR], 0.60; 95% CI, 0.39-0.90; P = 0.015). Predicted probabilities of unfavorable outcome (modified Rankin Scale score 3-6) ranged from 38.2% (95% CI, 26.7-49.8) in PCIS 0 to 77.3% (95% CI, 59.8-94.8) in PCIS 3. The association between PCIS and outcomes persisted across treatment groups.

Conclusions: The PCIS, integrating 3 perfusion-based collateral parameters, is associated with 90-day functional outcomes in patients with acute ischemic stroke due to large vessel occlusion. This scoring system offers a prognostic tool to identify patients at higher risk for poor outcomes and may be useful for optimizing resource allocation. Prospective validation is warranted.

Background: The centroid radii model (CRM)-defined as the distance from aneurysm surface points to the centroid-has shown promise in distinguishing ruptured from unruptured intracranial aneurysms by capturing morphological characteristics. We propose a novel application of radiomics for analyzing CRM texture and patterns, extending radiomics beyond medical imaging-based analysis.

Methods: Three-dimensional rotational angiographic volumes from 187 aneurysms (49 ruptured) were analyzed. Aneurysm surfaces were segmented and converted to uniform triangular meshes. Established size and shape metrics (size, height, aspect ratio, height/width, size ratio, and nonsphericity) and CRM values were computed. CRM data were projected onto a unit sphere and mapped to grayscale images for radiomics analysis. Univariate and multivariate analyses were used to evaluate the established features and 93 radiomics features for the accuracy of rupture status discrimination.

Results: Ruptured aneurysms exhibited greater CRM texture complexity and heterogeneity, with higher entropy, variance, contrast, and gray-level nonuniformity. These aneurysms had localized high CRM intensities and widespread low CRM regions, as well as reduced pattern uniformity. All established morphological features were significantly elevated in ruptured aneurysms. Multivariate regression using radiomics features resulted in an area under the curve of 0.86 (specificity 0.81, sensitivity 0.78), compared with conventional features (area under the curve 0.82, specificity 0.75, sensitivity 0.81).

Conclusion: Radiomics-based histogram and texture analysis of surface CRM offers strong rupture status discrimination power, which compares favorably with established size and shape features. This novel use of radiomics on surface-based features provides additional insight into the characteristics of ruptured aneurysms and may have potential utility in risk stratification.

Intracranial perforator aneurysms are rare but potentially life-threatening vascular lesions that can lead to subarachnoid hemorrhage. Initial imaging is frequently negative, so a high level of suspicion is important for efficient detection of perforator aneurysms. The management of these lesions is challenging due to their location and delicate surrounding structures. Conservative management, endovascular treatment, and microsurgical clipping have been used to manage perforator aneurysms successfully. Because perforator aneurysms remain an underappreciated source of subarachnoid hemorrhage even when initial vascular imaging is negative, we aim to review this topic to raise awareness and the level of suspicion and provide an overview of treatment options for these challenging vascular lesions.