Stroke (Hoboken, N.J.)最新文献

Background: Restrictive diffusion on magnetic resonance imaging is recognized as an early marker of ischemic brain damage, even though diffusion-weighted imaging lesion reversal (DWI-R) is well known. This study aimed to compare methodologies for detecting DWI-R, including voxel-based analysis, which captures subtle lesion dynamics, and to test their correlation with clinical outcomes.

Methods: We retrospectively analyzed magnetic resonance imaging data from 216 consecutive patients with acute ischemic stroke obtained before and after endovascular therapy. DWI-R was defined either as an increase in DWI-Alberta Stroke Program Early Computed Tomography Score, a decrease of total DWI signal volume or as partial reversal of the initial DWI lesion, irrespective of the final DWI load. Associations between 3-month poststroke modified Rankin scale score and DWI-R was assessed according to the different definitions of DWI-R using logistic binary regression.

Results: In patients undergoing endovascular therapy, 25% had increased DWI-Alberta Stroke Program Early Computed Tomography Score and 32% showed reduced DWI volume. Both measures were strongly associated with favorable outcomes (modified Rankin Scale score ≤2) with odds ratios of 4.90 and 5.60, respectively (95% CIs: 1.66-14.46 and 2.09-14.98). Voxel-based analysis revealed DWI-R of ≥20% of the initial lesion in 64.5% of cases. Even with an overall increase of lesion volume due to progression elsewhere, ≥20% reversal of initial lesion was associated with a significantly improved outcome compared with <20% reversal, odds ratio 2.22 (95% CIs: 1.05-4.70).

Conclusion: DWI-R was common in patients treated with endovascular therapy and linked to favorable outcomes. Subtle lesion dynamics detected only by the voxel-based analysis also conferred significant clinical benefits, supporting DWI-R as a continuum rather than a binary measure as "present" or "absent."

Background: Similar to many low- and middle-income countries, the barriers limiting wider mechanical thrombectomy (MT) access in Georgia are largely unknown. Recently, the MT access score (MTAS) was introduced as a new tool for identifying and characterizing barriers to MT access. This study aimed to implement the MTAS in Georgia, a middle-income country in Eastern Europe, to assess and characterize national barriers to MT.

Methods: We applied the MTAS, which comprises 12 weighted attributes, each scored on a 0-3 scale, resulting in a total score range of 0-36, 0 being the worst possible score. Eight members of the Mission Thrombectomy regional committee from different regions of Georgia were invited as panelists in this survey. The results of the survey are shown as a median with an interquartile range.

Results: The median MTAS for Georgia was 17. The lowest median scores were documented for 2 attributes: lack of prehospital large vessel occlusion-specific screening [0.0 (0.0-0.0)] and telestroke networks [0.0 (0.0-0.0)], with 87.5% of panelists assessing the score as 0 for both attributes. The highest scores were obtained for emergency medical services use [3.0 (2.0-3.0)], availability of MT operators [2.0 (2.0-2.5)] followed by MT device availability and government/insurance coverage [2.0 (2.0-2.0) for each].

Conclusion: MTAS is a valid tool for quantitatively assessing barriers to MT in Georgia. It identified a lack of information and the presence of physical barriers as major challenges. These findings underscore the need for targeted interventions through national stroke public health initiatives to improve access to MT.

Background: Current revascularization guidelines for symptomatic carotid artery stenosis were established based on randomized studies where stenosis was assessed with digital subtraction angiography. Pursuing revascularization in clinical practice is typically based on noninvasive imaging. We aimed to assess whether discrepancies exist between these 2 diagnostic methods when patients with recently symptomatic carotid stenosis referred for carotid revascularization based on noninvasive imaging, subsequently underwent DSA.

Methods: A retrospective study of patients presenting at 3 centers in the United States and Türkiye who routinely performed digitally subtracted angiography prior to revascularization between 2019 and 2024 was performed. Consecutive patients with acute ischemic events and concern for symptomatic ipsilateral carotid artery stenosis with moderate to severe stenosis on noninvasive imaging referred for digitally subtracted angiography were selected for inclusion. Digitally subtracted angiography was performed for intended carotid artery stenting in most cases as the first-line treatment method; patients referred for carotid endarterectomy who underwent preprocedure digitally subtracted angiography were also included. Exclusion criteria included prior carotid endarterectomy or carotid artery stenting or the presence of intraluminal thrombus precluding immediate revascularization. The primary outcome was the rate of disagreement between noninvasive imaging and digitally subtracted angiography.

Results: A total of 463 patients (65% males) were included, with a median age of 69 years. Disagreement regarding qualifying lesion severity for revascularization between noninvasive imaging and digitally subtracted angiography was found in 22.7% of patients. There was a significant difference in the proportion of immediate revascularization between the 2 cohorts (P<0.001). A total of 66/105 (63%) of those in the disagreement cohort were determined to have an etiology of stroke alternative to large artery atherosclerosis, requiring further diagnostic evaluation.

Conclusion: This study demonstrates that almost 1 in 4 patients referred for carotid revascularization based on noninvasive imaging are found to have insufficient stenosis on digitally subtracted angiography to support the decision to proceed with revascularization according to established stenosis severity thresholds.

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.