Stroke (Hoboken, N.J.)最新文献

Background: Endovascular thrombectomy is an effective treatment for acute ischemic stroke, and accurate determination of thrombus length (TL) remains pivotal to successful endovascular thrombectomy. However, to date, no modality could estimate the TL with sufficient efficiency, especially in the emergent setting. In the current study, we presented a novel microcatheter design known as the Tip-End Multi-Side Orifices (TIMSO) microcatheter, which could provide real-time TL assessment.

Methods: The efficacy of the TIMSO was initially validated in an endovascular simulator with continuous saline circulation. After the TIMSO passed the sham thrombus, colored saline was injected through the TIMSO. The length of the ink defect region was integrated with the sham TL. Subsequently, in the live swine acute ischemic stroke model, the efficacy of TIMSO was further evaluated under digital subtraction angiography.

Results: In the simulation, a strong positive correlation was observed between the actual TL and the length indicated by the TIMSO (n=20, R²=0.95, P<0.01). In the in vivo test, the TIMSO could also demonstrate TL (n=10). Interestingly, the TIMSO also detected tandem thrombi, newly formed emboli associated with thrombus fragmentation, and the precise arterial branches towards which the thrombi tend to migrate at arterial bifurcations.

Conclusions: Conclusively, the TIMSO microcatheter could facilitate real-time assessment of TL during endovascular thrombectomy. Furthermore, TISMO has the capacity to discern special embolization scenarios. These characteristics of TIMSO have the potential to contribute to the facilitation of endovascular thrombectomy in future clinical practice.

Background: Large vessel occlusion accounts for 28% to 46% of acute ischemic strokes, with mechanical thrombectomy (MT) demonstrating established efficacy. However, functional independence rates remain suboptimal, necessitating adjuvant neuroprotective strategies. Therapeutic hypothermia represents the most promising intervention among evaluated neuroprotective approaches. Our previous multicenter pilot trial indicated that catheter-based focal intracranial hypothermia exhibits a favorable safety profile and may confer prognostic benefits. However, this preliminary finding mandates rigorous validation. This trial aims to evaluate the efficacy and safety of catheter-based focal intracranial hypothermia combined with MT in patients with acute anterior circulation large artery occlusion.

Methods: The CHILL-ART (Catheter-Based Focal Intracranial Hypothermia Combined With Endovascular Reperfusion Therapy for Patients With Acute Anterior Circulation Large Artery Occlusion) is an investigator-initiated, multicenter, PROBE (Prospective Randomized Open-label Blinded End Point) trial. Twenty-six comprehensive stroke centers across China will enroll 262 eligible patients with occlusion of the internal carotid artery and the M1 segment of the middle cerebral artery within 24 hours of onset. Participants will be randomized 1:1 to receive either MT plus 350 mL of 4 °C saline (hypothermia group) or MT plus 350 mL of room-temperature (22-25 °C) saline (control group).

Results: The primary outcome is the proportion of patients achieving a modified Rankin Scale score of 0 to 2 at 90 days. Secondary outcomes include excellent outcome (modified Rankin Scale score, 0-1), ordinal modified Rankin Scale shift analysis, reperfusion success rate (modified Thrombolysis in Cerebral Infarction [mTICI] score, 2b-3), infarct volume at 72 hours to 7 days, recurrent occlusion rate, rectal temperature, and early neurological deterioration. Safety end points comprise symptomatic intracranial hemorrhage within 72 hours, any intracranial hemorrhage, pneumonia, and urinary tract infections, cerebral herniation, coagulation disorders, bradycardia, electrolyte disturbances, vasospasm, deep vein thrombosis, and 90-day mortality.

Conclusions: The CHILL-ART trial will provide evidence of the efficacy and safety of catheter-based focal intracranial hypothermia as adjuvant therapy combined with MT for patients with acute anterior circulation large artery occlusion.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT06758609.

Background: Hyperintense vessel signs in the cerebral sulci have recently been identified on vessel wall magnetic resonance imaging in moyamoya disease, referred to as the vessel wall magnetic resonance ivy sign (VIS). This study aimed to establish a novel scoring system for the VIS score and elucidate its clinical implications.

Methods: This retrospective analysis included 125 patients with moyamoya disease (nonstroke group, n=27; ischemic group, n=61; and hemorrhagic group, n=37), and VIS was examined in the superior frontal sulcus, inferior frontal sulcus, precentral sulcus, central sulcus, postcentral sulcus, and intraparietal sulcus. The total VIS score (TVIS) ranged from 0 to 6. A multinomial logistic regression analysis was performed to explore the association of TVIS with hemorrhagic and ischemic stroke. A receiver operating characteristic curve analysis was used to assess the ability of TVIS in discriminating between hemorrhagic and ischemic strokes. TVIS also correlated with the hemodynamic stage on single-photon emission computed tomography.

Results: Among the 125 patients, VIS score was present in 43.2%, 66.4%, 67.2%, 75.2%, 70.4%, and 48.8% in the superior frontal, inferior frontal, precentral sulcus, central sulcus, postcentral sulcus, and intraparietal sulcus, respectively. Multinomial logistic regression model indicated that choroidal anastomosis (odds ratio, 3.60 [95% CI, 1.06-12.17]; P=0.039) and TVIS (per 1-score increase: odds ratio, 1.51 [95% CI, 1.10-2.05]; P=0.009) were independently associated with the hemorrhagic group. Furthermore, TVIS (per 1-score increase: odds ratio, 1.78 [95% CI, 1.33-2.36]; P<0.001) was identified as an independent factor for the ischemic group. The area under the curve for TVIS in distinguishing between hemorrhagic and ischemic strokes were 0.776 and 0.812, respectively. TVIS demonstrated a strong correlation with single-photon emission computed tomography-identified hemodynamic stages (Spearman ρ=0.646, P<0.001).

Conclusions: We developed a TVIS system that demonstrates strong correlations with stroke subtypes and hemodynamic status in moyamoya disease. A higher TVIS was independently and commonly associated with higher risks of hemorrhagic and ischemic strokes, highlighting its potential as a predictive imaging biomarker. Asymptomatic patients with a higher TVIS may represent a subgroup at particularly high risk for subsequent stroke.

Emerging evidence suggests that disturbances in cerebral venous outflow may play a meaningful role in the development and progression of cognitive impairment. The brain's glymphatic system, which facilitates the clearance of metabolic waste, including β-amyloid and tau, relies on stable venous pressure gradients to drive perivascular and interstitial fluid movement. Venous insufficiency, whether from structural narrowing or functional outflow obstruction, can disrupt these gradients, reducing clearance efficiency and promoting protein accumulation, neuroinflammation, and white matter injury. Age-related changes in venous compliance, increased pulsatility, and stenosis of the dural venous sinuses have been observed in patients with mild cognitive impairment and dementia, raising the possibility that such hemodynamic alterations may be a significant part of neurodegenerative pathology. As venous sinus stenosis is a potentially treatable condition, it may represent a future therapeutic target. This review synthesizes current knowledge on the interplay between venous circulation and glymphatic function in brain health, outlines the mechanistic basis for venous contributions to cognitive decline, and highlights the need for systematic investigation of further therapeutic treatments in the context of age-related cognitive impairment.

Background: The Society of Vascular and Interventional Neurology (SVIN) Guidelines and Practice Standards Committee issues Brief Practice Updates to provide concise, evidence-based recommendations and suggestions on focused topics relevant to vascular and interventional neurology. Currently, there is limited published guidance on the technical performance and interpretative parameters of cerebral digital subtraction angiography for the determination of cerebral circulatory arrest in patients being evaluated for brain death/death by neurological criteria. In this Brief Practice Update, we present consensus-based suggestions for standardizing the performance, interpretation, and application of digital subtraction angiography in this context.

Methods: This Brief Practice Update was developed using the SVIN Standards and Parameters for Guideline Development in the classification of evidence and Class of Recommendation when evidence is available and Expert Opinion recommendation when evidence is lacking. The Guidelines and Practice Standards committee convened a multidisciplinary writing group to establish key clinical questions and develop a survey assessing Expert Opinion on the role of digital subtraction angiography in cerebral circulatory arrest determination. Survey items addressed technical considerations, interpretation criteria, and clinical integration. Iterative refinement was achieved through group consensus, and the final survey was distributed to a panel of experts in neurointervention and neurocritical care. The SVIN Guidelines and Practice Standards Quality Committee reviewed the findings for adherence to SVIN's internal evidence evaluation guidelines before submission to the SVIN board for societal endorsement.

Results: Evidence was evaluated by the writing group when available, and Expert Opinion was assessed using survey results. Suggested recommendations follow the established SVIN guideline framework for Class of Recommendation and Level of Evidence, with an Expert Opinion endorsement category for areas lacking high-quality evidence at the time of publication.

Conclusions: This update standardizes how to perform, interpret, and report digital subtraction angiography when used to assess cerebral circulatory arrest in brain death/death by neurological criteria evaluations, aiming to improve reproducibility across centers. It provides a structured framework to improve consistency and reliability among practitioners performing and interpreting cerebral angiography in this setting.

Background: Mechanical thrombectomy is a critical intervention for patients with acute ischemic stroke with large vessel occlusion. However, significant barriers remain in its widespread implementation, particularly in low- to middle-income countries, including a shortage of trained physicians and limited access to advanced medical technologies. This systematic review and meta-analysis aimed to comprehensively evaluate current mechanical thrombectomy training methodologies and assess their effectiveness in improving procedural skills among neurointerventional teams.

Methods: We conducted a systematic review following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, searching PubMed, Scopus, and Web of Science. Eight studies were included, with 3 studies eligible for meta-analysis. We assessed training approaches, participant demographics, and procedural outcomes using the Risk of Bias in Non-randomized Studies of Interventions tool and performed statistical analysis using OpenMetaAnalyst software.

Results: Various training modalities, including virtual reality simulations and hands-on workshops, consistently demonstrated positive effects on procedural skills and professional confidence, demonstrating significant improvements across multiple metrics. Our systematic review and meta-analysis revealed statistically significant reductions in total procedure time (average decrease of 17.84 minutes, 95% CI: [-22.19 to -13.48]), number of handling errors (decreased by 6.34 errors, 95% CI: [-13.16 to 0.48]), contrast volume (decreased by 27.35 mL, 95% CI: [-45.11 to -9.60]), and fluoroscopy time (reduced by 8.07 minutes, 95% CI: [-10.71 to -5.44]). Participants showed increased procedural steps completed, with an average increase of 6.52 steps (95% CI: [3.99-9.05]).

Conclusion: Structured, simulation-based mechanical thrombectomy training programs can significantly enhance procedural skills, clinical decision-making, and professional confidence among neurointerventional teams, potentially improving stroke care.

Background: Large vessel occlusions (LVOs), which account for approximately 25% of ischemic strokes, pose a significant challenge due to their severe impact and need for rapid diagnosis and treatment. Current diagnostic approaches-primarily based on clinical scales and imaging-often lack specificity or delay treatment, severely impacting patient outcomes. This review aims to evaluate the potential of blood biomarkers in improving the accuracy and efficiency of LVO diagnosis.

Methods: A systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were conducted with specific inclusion/exclusion criteria and multiperson screening. PubMed, Google Scholar, and Embase were searched using targeted queries related to LVO and biomarkers. Studies reporting the diagnostic accuracy, sensitivity, and specificity of blood biomarkers for LVO were included. Data were extracted and synthesized to categorize biomarkers and assess their diagnostic utility.

Results: Sixteen studies were included, categorizing biomarkers into 5 groups: coagulation and hemostasis, acute brain injury, inflammatory, angiogenic growth factors, and metabolic and structural markers.

Conclusions: The review highlights the critical role of biomarker blood testing to enhance LVO diagnosis, especially in acute clinical settings. Coagulation and hemostasis markers such as D-dimer offer rapid thrombus detection, and acute brain injury and angiogenic biomarkers provide insight into the extent of injury, localization, and vascular response. A combination of biomarkers from multiple categories is needed to provide an accurate clinical picture of LVO in patients. Excluding studies on embolic strokes, including cardioembolic subtypes, may also bias findings by neglecting their distinct biomarker profiles, warranting further investigation to fully assess biomarker utility across stroke etiologies. Despite promising results for multiple biomarkers, including glial fibrillary acidic protein, ubiquitin C-terminal hydrolase-L1, and D-dimer, further research is needed to validate these biomarkers in diverse populations and integrate them into clinical practice effectively.

Background: In acute ischemic stroke, the infarct core and hypoperfused regions are key indicators for assessing and prognosticating patients. They are typically estimated with computed tomography perfusion (CTP). However, because noncontrast CT and CT angiography are more widely available, we trained a neural network to estimate the ischemic lesion from noncontrast CT and CT angiography scans.

Methods: In this retrospective study, an nnU-Net model was trained to estimate infarcted and hypoperfused regions from noncontrast CT and CT angiography using reference standards from a commercial CTP software (StrokeViewer). We included data from 859 patients for training and 137 for testing. We used data from the Collaboration for New Treatments of Acute Stroke consortium, including MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands)-NO-IV, MR CLEAN-MED, MR CLEAN-LATE, and MR CLEAN-Registry, and a local cohort. In addition to testing our model against StrokeViewer, we also compared our results with 3 other commercial CTP software packages.

Results: Our model achieves a Dice of 0.45 (95% CI, 0.39-0.50) for core and 0.66 (95% CI, 0.62-0.69) for hypoperfused region, underestimating core volume by -9.3 mL (95% CI, -12.5 to -6.1) and hypoperfused region volume by -12.9 mL (95% CI, -21.1 to -4.7) compared with StrokeViewer. When comparing the 4 CTP software packages together, the average of their 2-by-2 agreement ranges from a Dice of 0.22 to 0.28 for core, and a Dice of 0.50 to 0.56 for hypoperfused region. This is similar to the average agreement of nnU-Net with these 4 software packages (average Dice 0.27 for core and 0.56 for hypoperfused). Furthermore, nnU-Net produces fewer connected components (1.3 for core, 1.6 for hypoperfused) than the average of the 4 CTP software packages (60.8 for core and 110.8 and hypoperfused), indicating more cohesive segmentations.

Conclusion: Our model's performance in segmenting infarct core and hypoperfused regions from noncontrast CT and CT angiography is comparable to commercial CTP software packages, with potentially fewer segmentation artifacts. It can therefore be used when CTP is not available.

Background: The purpose of this study is to assess the accuracy of automated artificial intelligence (AI) deep-learning-based modules in predicting suspected intracranial hemorrhage (ICH) or anterior circulation large vessel occlusion (LVO) on noncontrast computed tomography (NCCT) studies.

Methods: We conducted a multicenter international retrospective cohort study, involving 6 stroke centers from the United States and Europe. We included patients in whom an acute stroke was suspected on admission and who underwent an NCCT and a CT angiography when ICH was not observed. Two neuroradiologists and a third one in case of discrepancies retrospectively evaluated all images and established the presence of ICH on NCCT and LVO on computed tomography angiography (ground truth). All NCCT scans were analyzed using 2 automated AI deep-learning modules (Methinks, Barcelona, Spain) to assess the presence of ICH or LVO.

Results: To assess the performance of the NCCT-ICH module, a total of 200 patients were included in the study. The neuroradiologist's evaluation confirmed the presence of ICH in 97 cases (48.5%). To assess the performance of the NCCT-LVO module, 382 patients were analyzed, with the neuroradiologist identifying a LVO in 141 cases (36.9%). The AI module for NCCT-ICH detection demonstrated a sensitivity of 94.9% (95% CI]: 88.4%-98.3%) and specificity of 99.0% (95% CI: 94.7%-99.9%) with an area under the receiver operating characteristic curve of 0.974 (95% CI: 0.94-0.99). The LVO detection AI module on NCCT demonstrated a sensitivity of 81.6% (95% CI: 74.2-87.6), and specificity of 87.1% (95% CI: 82.2-91.1) with an area under the receiver operating characteristic of 0.915 (95% CI: 0.88-0.94).

Conclusions: The AI modules demonstrated high sensitivity and specificity in predicting ICH and LVO, suggesting their potential in offering support in clinical decisions in stroke networks immediately after NCCT is performed.