Stroke (Hoboken, N.J.)最新文献

Background: Recent trials demonstrate mechanical thrombectomy (MT) benefits patients with large core infarcts. This study assesses the cost-effectiveness of MT in this population across a range of international health care systems.

Methods: A decision tree model coupled with a Markov model compared MT with medical management. Clinical outcomes, quality-adjusted life years, and costs were projected over a lifetime horizon. Data from recent randomized controlled trials and country-specific cost inputs informed the model. Univariate, bivariate deterministic, and probabilistic sensitivity analyses assessed parameter uncertainty.

Results: MT was consistently cost effective across all 11 health care systems, even though the magnitude of cost savings or added costs varied. Although MT resulted in net cost savings in Belgium, it was associated with increased costs in Australia and China; however, even in these systems, the added cost per quality-adjusted life year gained remained within acceptable thresholds. Incremental quality-adjusted life years gains were consistent across systems (1.16-1.98). Incremental cost-effectiveness ratios were below $20 000/quality-adjusted life years in all countries. Sensitivity analyses confirmed the robustness of these findings. Acute care costs for severely disabled patients (modified Rankin Scale score 4-6) most influenced cost-effectiveness.

Conclusion: Our study demonstrates the consistent value of mechanical thrombectomy for large core stroke patients across various health care settings, even with differences in costs between countries. This supports expanding mechanical thrombectomy access, which, although requiring investment, offers the potential for long-term cost-effectiveness through reduced disability and improved quality of life. It is important to note that this analysis adopts a health care system perspective, excluding indirect costs, and that assumptions regarding long-term outcomes may even potentially lead to an underestimation of the comprehensive cost-effectiveness of MT.

Background: Middle meningeal artery embolization with a liquid embolic is a minimally invasive adjunctive endovascular treatment for chronic subdural hematoma (cSDH). TRUFILL n-butyl cyanoacrylate Liquid Embolic System provides a possible option for middle meningeal artery embolization. The aim of this study is to evaluate safety/effectiveness of TRUFILL n-butyl cyanoacrylate versus standard-of-care alone for middle meningeal artery embolization in patients with cSDH.

Methods: MEMBRANE (Middle Meningeal Artery Embolization for the Treatment of Subdural Hematomas With TRUFILL n-BCA) is a prospective, multicenter, open-label, randomized-controlled trial enrolling ∼376 adults at ∼35 sites in the United States and China. Site physicians will determine whether participants will undergo surgery or nonsurgical management. After demonstrating cSDH stability, participants will be randomized within the surgical or nonsurgical cohort to receive standard-of-care with/without TRUFILL n-butyl cyanoacrylate middle meningeal artery embolization, with follow-ups at 1, 3, 6, and 12 months post procedure.

Results: Primary effectiveness end point is the occurrence of residual or re-accumulation of hematoma (>10 mm) at 6 months (assessed by independent imaging core laboratory) or reoperation/surgical procedure on the hematoma within 6 months. The primary safety end point is the occurrence of all adverse events through 6 months. Other end points include good functional outcome at 3 months (modified Rankin scale score: 0-2 or no worsening from baseline if baseline modified Rankin scale score ≥3); change in hematoma volume; complete cSDH resolution; development of acute component or new cSDH; requirement for cSDH surgery; death, stroke, myocardial infarction, or thromboembolic complications; new-onset seizures; change in modified Rankin Scale/Markwalder Grading Scale scores; quality of life; and healthcare resource use.

Conclusion: Results will provide valuable information on the safety/effectiveness of TRUFILL n-butyl cyanoacrylate as a minimally invasive standalone or adjunct treatment for cSDH.

Clinical trial registration information: http://clinicatrials.gov; Identifier: NCT04816591.

Background: The optimal treatment of carotid artery disease in patients who have suffered a recent stroke or transient ischemic attack has potentially changed since best medical therapy has improved, and the perioperative risk of carotid revascularization has decreased. The objective is to highlight consensus and discrepancies between guidelines on carotid revascularization in patients with symptomatic carotid artery disease.

Methods: We systematically searched PubMed for international guidelines from around the world published after January 1, 2015 on carotid revascularization in patients with symptomatic carotid artery disease. All recommendations and strengths of recommendations on carotid endarterectomy and carotid artery stenting for patients with mild (<50%), moderate (50%-69%), and severe (>70%) stenosis were collected and analyzed.

Results: Sixteen guidelines on carotid revascularization from 14 different regions were identified. Two guidelines suggested carotid revascularization for patients with mild stenosis, when refractory to optimal medical therapy. All guidelines recommended carotid revascularization, with varying certainty, for at least a subgroup of patients with moderate carotid stenosis. All guidelines strongly recommend carotid revascularization for patients with severe stenosis. Plaque vulnerability was suggested to be an indication for carotid revascularization by 2 guidelines (13%).

Conclusion: There are important discrepancies between current guidelines for patients with mild and moderate stenosis. Contemporary clinical trials are essential to evaluate the comparative effectiveness of current optimal medical therapy and revascularization and assess the influence of plaque vulnerability on the effectiveness of treatments. The development, validation, and impact evaluation of a novel risk score could enhance the integration of plaque vulnerability assessments into clinical decision-making.

Background: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are commonly prescribed for the management of type 2 diabetes, and recent studies have highlighted their neuroprotective and anti-inflammatory properties. However, their influence on clinical outcomes in patients undergoing endovascular treatment for unruptured intracranial aneurysms remains largely unexplored.

Methods: This retrospective cohort study utilized the TriNetX database to identify patients with type 2 diabetes (International Classification of Diseases, Tenth Revision [ICD-10]: E11) and unruptured intracranial aneurysms (ICD-10: I67.1). Patients were categorized based on the use of GLP-1RAs. The outcomes included overall survival, poor functional outcome, new subarachnoid hemorrhage, and hydrocephalus. The propensity score matching method was applied.

Results: A total of 6824 patients met the inclusion criteria, with 447 patients in each group following propensity score matching. No statistically significant differences were observed in short- and mid-term mortality between GLP-1RAs users and non-users. However, long-term mortality was significantly lower in the GLP-1 group (odds ratio 0.58, 95% CI 0.36-0.94). Furthermore, GLP-1RAs users demonstrated significantly reduced risks of poor functional outcomes (odds ratio 0.37, 95% CI 0.21-0.66), new subarachnoid hemorrhage (odds ratio 0.39, 95% CI 0.27-0.56), and hydrocephalus (odds ratio 0.57, 95% CI 0.33-0.97) at 3 months, with similar trends persisting in mid- and long-term follow-up.

Conclusion: Use of GLP-1RAs in patients with unruptured intracranial aneurysms treated via endovascular intervention is associated with improved long-term survival and reduced risks of subarachnoid hemorrhage, hydrocephalus, and poor functional outcomes. These findings suggest a potential therapeutic benefit beyond glycemic control. Prospective studies are needed to validate these results and explore their implications for clinical decision-making in aneurysm treatment.

Ischemic stroke, a leading cause of global mortality, is often linked to large-artery atherosclerosis, including carotid artery atherosclerotic disease and intracranial atherosclerotic disease. Endothelial cells, which are central to vascular homeostasis, are pivotal in the pathophysiology of these conditions. This systematic review explores the genetic and molecular characteristics of endothelial cells in carotid artery atherosclerotic disease and intracranial atherosclerotic disease, emphasizing their roles in disease progression and potential therapeutic applications. The findings reveal significant differences in the underlying mechanisms of carotid artery atherosclerotic disease and intracranial atherosclerotic disease, reflecting the unique genetic, inflammatory, and vascular remodeling processes associated with each condition. Endovascular biopsy is examined as a minimally invasive method for isolating endothelial cells, providing a valuable tool for studying disease-specific pathways and advancing precision medicine, although improvements in technique and consistency are still required. This review underscores the importance of integrating advanced genetic and transcriptomic analyses with refined biopsy methods to better understand the molecular drivers of cerebrovascular atherosclerosis. These advancements are critical for identifying novel therapeutic targets, improving diagnostic accuracy, and ultimately enhancing patient outcomes.

Arteriovenous malformations (AVM) of the brainstem are a rare subgroup of vascular malformation that present a unique clinical and surgical challenge due to the anatomic location and life-threatening complications. Ruptured brainstem AVMs carry a higher risk of rebleeding and mortality. Various treatments including microsurgical resection, radiosurgery, and endovascular embolization have been used to treat brainstem AVMs with varying degree of success. Transvenous embolization of the AVM with flow arrest is an approach of growing interest that may offer curative elimination of AVMs. We present a technical report describing a case of a male in his 50s who presented with a ruptured AVM in the brainstem supplied by right superior cerebellar artery and basilar artery perforators. Venous outflow was via right sigmoid and straight sinuses. Young age with highly eloquent brainstem location and a prenidal aneurysm warranted a transvenous endovascular approach for obliteration of the AVM. The patient underwent transvenous liquid embolization of the brainstem AVM with selective simultaneous arterial and venous flow arrest in order to decrease intranidal flow and achieve higher nidal occlusion rates. A HyperGlide compliant balloon was employed in the basilar artery and a Scepter C balloon was employed in the internal cerebral vein to perform liquid embolization with Onyx. We describe a unique technique to treat brainstem AVMs using transvenous embolization, exemplifying the novel tactic of using arterial and venous flow arrest with balloons to achieve local limitation of flow in AVMs.

Background: Computed tomography angiography (CTA) tends to overestimate restenosis after cervical carotid stenting because of the substantial blooming artifacts from metallic stent materials. Hence, we propose a new measurement method to address this issue and assess the accuracy and reliability of evaluating the degree of in-stent stenosis (ISS) compared with digital subtraction angiography (DSA) as a post-hoc analysis of the CAS-CARE (Carotid Artery Stenting with the Cilostazol Addition for Restenosis) trial.

Methods: Among the image data registered for the trial, 197 paired data sets of poststenting images obtained using both CTA and DSA were used. We measured the ISS degree according to the NASCET (North American Symptomatic Carotid Endarterectomy Trial) criteria with the conventional and new methods using the inner edge and midportion of the stent materials as a boundary to the lumen and compared the stenotic severities with those obtained from DSA.

Results: The ISS degrees measured using CTA with the conventional method were remarkably higher than those measured using CTA with the new method and DSA (median, 49.5% versus 11.3% and 9.8%; P<0.001). The agreements of the ISS degree between CTA and DSA were significantly improved when using the new measurement method (intraclass correlation coefficient = 0.67 [95% CI, 0.59-0.74]) when compared with the conventional method (0.24 [95% CI, -0.08 to 0.57]). In addition, there were no significant systemic biases against DSA in the new method, whereas there were significant biases (mean difference, 39.3%; P<0.001; slope, 0.14; P = 0.034) in the conventional method, although correlations with DSA were comparable between the 2 methods (r = 0.68 [95% CI, 0.59-0.75] and 0.65 [95% CI, 0.56-0.72], respectively).

Conclusion: Measurement using CTA with the midportion of the stent materials significantly improved the accuracy of the ISS degree, which was comparable to that using DSA.