Stroke (Hoboken, N.J.)最新文献

Background: Successive processing, a form of working memory function detected with the Das Naglieri Cognitive Assessment System, is selectively impaired in pediatric moyamoya disease. We aimed to test whether successive processing in children with moyamoya disease was improved after bypass surgery under the control of confounding.

Methods: The present retrospective cohort study included children with moyamoya disease who underwent direct or combined bypass surgery. Neuropsychological tests including the Das Naglieri Cognitive Assessment System were administered at 2 time points, before and after surgery, approximately 1 year apart. The least squares (LS) mean standard score and LS mean difference between time points were calculated using a mixed model for repeated measures, which included 5 clinical factors along with the time point. Models including an interaction term were also generated to assess the effect of each clinical factor. Cognitive intra-individual variability across 4 domains of the Das Naglieri Cognitive Assessment System was assessed with an analysis of variance at each time point.

Results: Of 60 patients who underwent surgery, 42 fulfilled the inclusion criteria. The median duration between assessments was 15 months. The LS mean standard scores of successive processing increased after surgery (LS mean, 95.8 versus 100.2; LS mean difference, 4.4 [95% CI, 1.5-7.3]; P = 0.004). The increase was more pronounced in those with a younger age at onset of neurological symptoms, shorter delay before surgery, preexisting infarct, posterior cerebral artery involvement, and more severe ischemic stage before surgery. Intraindividual variability, shown as the lowest score of successive processing at baseline, resolved after surgery (F = 3.56, P = 0.016 versus F = 1.21, P = 0.31). Successive processing was the domain most likely to be improved after surgery.

Conclusion: The present results suggest that successive processing is improved after bypass surgery. Larger and longer follow-up studies are required to confirm the influencing factors and long-term effects.

Background: The effect of different thresholds for packed red blood cell transfusion on neurologic outcomes in patients with subarachnoid hemorrhage and anemia is uncertain. This meta-analysis aimed to evaluate the effect of liberal versus restrictive transfusion strategies on functional outcomes in subarachnoid hemorrhage.

Methods: We systematically searched MEDLINE (inception-March 26, 2025) for randomized controlled trials comparing functional neurological outcomes in adults with aneurysmal subarachnoid hemorrhage assigned to receive packed red blood cell transfusion using high versus low hemoglobin thresholds. Risk of bias was assessed using Cochrane Risk of Bias tool 2.0. Unfavorable neurologic outcomes were defined based on trial-specific primary neurologic outcome definitions (Glasgow Outcome Scale Extended score ≤5 or modified Rankin Scale score ≥3 or modified Rankin Scale score ≥4). An exploratory analysis using Glasgow Outcome Scale Extended score ≤5 or modified Rankin Scale score ≥3 as unfavorable neurologic outcome was also performed. We calculated the pooled risk ratio (RR) with 95% CI for unfavorable neurologic outcome using random effect models and assessed heterogeneity using Cochran's Q test.

Results: Of 1628 studies, 3 trials (n = 953 patients) met the inclusion criteria. Over a follow-up of 3-12 months, 181/470 patients (38.5%) randomized to liberal transfusion strategies (hemoglobin<9-11.5g/dL) compared with 214/483 patients (44.3%) in the restrictive strategy group (hemoglobin<7-10g/dL) experienced unfavorable neurologic outcomes. Liberal (versus restrictive) packed red blood cell transfusion strategies resulted in a nonsignificant reduction (RR, 0.88; 95% CI, 0.77-1.01; P = 0.06; I² = 0%) in unfavorable neurologic outcomes per trial-specific definitions and RR = 0.89 (95% CI, 0.79-0.99; P = 0.04; I² = 0%) when unfavorable outcome was defined as Glasgow Outcome Scale Extended score ≤5 or modified Rankin Scale score ≥3. Sensitivity analysis, excluding the small pilot trial (n = 44) with a higher hemoglobin threshold, did not change the summary effect.

Conclusions: Our study demonstrated a trend toward better neurologic outcomes with liberal transfusion strategies in patients with subarachnoid hemorrhage. Further studies are required to determine the optimal transfusion strategy for this high-risk population and identify subgroups that are most likely to benefit from the liberal strategy.

Background: We aimed to determine the impact of body mass index (BMI) on outcomes in Japanese patients undergoing mechanical thrombectomy for acute ischemic stroke using a Japanese obesity cutoff.

Methods: The study sample consisted of consecutive patients undergoing thrombectomy for acute ischemic stroke at our institution from January 2020 to December 2023. Patients were divided into 3 groups by BMI: low (<18.5 kg/m²), normal (18.5-24.9 kg/m²), and high (≥25 kg/m²). Baseline patient characteristics and procedural, safety, and clinical outcomes were compared between the 3 groups.

Results: A total of 309 patients were analyzed, of whom 39 (12.6%) had a low BMI, 201 (65.0%) had a normal BMI, and 69 (22.3%) had a high BMI. There were significant differences in the nutritional status index scores between the 3 groups, namely the Geriatric Nutritional Risk Index, the Controlling Nutritional Status, and the Prognostic Nutritional Index. However, there were no significant differences in procedural and safety outcomes. There was no significant difference in the proportion of patients with a modified Rankin Scale score of 0-2 at 90 days between the 3 groups. However, there were significant differences in the proportion of patients with a modified Rankin Scale score of 0-3 (overall 51.8%; low 35.9%, normal 51.7%, high 60.9%; P = 0.045) and mortality (overall 14.6%; low 30.8%, normal 13.4%, high 8.7%; P = 0.006). A multivariate logistic regression analysis revealed that the odds of mortality at 90 days were significantly higher in the low BMI groups than in the normal BMI group (adjusted odds ratio, 2.69; 95% CI, 1.16-6.26; P = 0.02).

Conclusions: In a Japanese population, low BMI may be associated with poor clinical outcomes after thrombectomy for acute ischemic stroke, including increased mortality.

The global shortage of neurointerventionalists presents a challenge to timely stroke care, particularly in low- and middle-income countries. The Society of Vascular and Interventional Neurology Stroke Interventional Laboratory Consensus criteria aim to standardize training and certification in neurointervention to address these disparities. This white paper reviews existing training standards in various regions, identifies gaps, and proposes a structured framework encompassing entry requirements, program structure, and certification processes. The Stroke Interventional Laboratory Consensus criteria further outline requirements for training centers and program directors. By establishing global standards, the Stroke Interventional Laboratory Consensus criteria seek to improve patient outcomes and expand access to life-saving neurointerventional procedures.

Pediatric intracranial aneurysms are rare and challenging to manage due to the delicate nature of developing cerebrovasculature. Traditional neurosurgical approaches pose significant risks, particularly in infants. Reconstructive neuroendovascular techniques such as flow diversion have excellent outcomes in the adult population, although data in children are limited. This case report details use of a flow diverting stent in a 12-month-old male presenting with spontaneous subarachnoid hemorrhage due to a dissecting left M2 segment aneurysm. Initial management involved ventriculostomy and coil embolization, but persistent aneurysm filling necessitated additional treatment. Flow diversion was eventually successful. Postoperative management included antiplatelet therapy with aspirin and Plavix. Follow-up imaging at 9 months post procedure confirmed complete obliteration of the aneurysm with preserved vessel integrity. The patient remained neurologically intact without residual deficits. This case underscores the importance of individualized treatment in pediatric neurovascular pathology and highlights the evolving role of flow diversion. It also emphasizes the need for meticulous patient selection and precise endovascular technique. The report contributes valuable insights into the feasibility and safety of flow diversion for pediatric aneurysms, particularly in those as young as 12 months. Nevertheless, further research is needed to establish evidence-based guidelines for managing pediatric aneurysms.

Background: This study aims to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess the efficacy and safety of intra-arterial thrombolysis (IAT) following successful endovascular thrombectomy (EVT) in patients with stroke.

Methods: A systematic literature search was conducted to identify RCTs comparing IAT versus no IAT after successful EVT. The primary efficacy outcome was a modified Rankin Scale score of 0-1 at 90 days, and the primary safety outcomes included symptomatic intracranial hemorrhage and 90-day mortality. Subgroup meta-analyses were conducted based on expanded Thrombolysis in Cerebral Infarction (eTICI) and prior intravenous thrombolysis (IVT). Both random-effects and common-effect models were applied with model selection determined by the level of heterogeneity.

Results: Six RCTs were included, comprising 990 patients in the IAT group and 981 in the control group. Meta-analysis demonstrated that IAT following successful EVT improved the rate of disability-free survival at 90 days, with a pooled risk ratio (RR) of 1.24 (95% CI: 1.12-1.39) and no substantial heterogeneity (I² = 16.0%, P = 0.31). Additionally, IAT treatment did not increase the risk of symptomatic intracranial hemorrhage (RR: 1.14 [95% CI: 0.85-1.54]) or 90-day mortality (RR: 1.05 [95% CI: 0.87-1.26]). Subgroup meta-analysis suggested greater benefits from IAT in patients with eTICI 2b50/67 (RR: 1.51 [95% CI: 1.03-2.23]) than in those with eTICI 2c/3 (RR: 1.22, 95% CI: 0.99-1.50), and in patients without prior IVT (RR: 1.33 [95% CI: 1.08-1.65]) compared with those who received IVT (RR: 1.17 [95% CI: 0.85-1.62]).

Conclusion: IAT following successful EVT improved 90-day functional outcomes without increasing the risk of symptomatic intracranial hemorrhage or 90-day mortality. Patients in the eTICI 2b50/67 subgroup and those without prior IVT showed a trend toward greater benefit from IAT compared with the eTICI 2c/3 subgroup and those who received IVT prior to thrombectomy.

Background: To validate an artificial intelligence software (JLK CTL) for predicting anterior circulation large vessel occlusion (LVO) using noncontrast computed tomography (NCCT) and to investigate its clinical implications regarding both infarct volume and outcomes.

Methods: Between January 2021 and April 2023, we retrospectively included consecutive patients who concurrently underwent computed tomography angiography and NCCT within 24-hour of last known well from 6 stroke centers. Additionally, 274 subjects without stroke were included in this study to evaluate the specificity of the software. The performance to identify LVO was evaluated based on the area under the receiver operating characteristic curve, as well as its sensitivity and specificity. The association between predicted JLK CTL LVO scores and infarct volumes and functional outcomes was assessed using Pearson correlation and logistic regression analyses, respectively.

Results: Among 534 (mean age 69.9±13.2 years, 58.4% men) included patients, the median time from last known well to NCCT was 3.8 hours (interquartile range 1.7-9.5), with 30.7% (n = 164) presenting with LVO. The software demonstrated area under the receiver operating characteristic curve of 0.859 (95% CI, 0.827-0.887), with a sensitivity of 0.787 (95% CI, 0.716-0.847) and a specificity of 0.832 (95% CI, 0.790-0.869) at the predefined threshold. In subjects without ischemic stroke, the software achieved a specificity of 0.898 (95% CI, 0.887-0.922). The predicted JLK CTL LVO scores showed a correlation with infarct volumes on follow-up diffusion-weighted imaging (r = 0.54; P<0.001). After adjusting covariates, 1-point increment of JLK CTL LVO score was associated with 2% increase of unfavorable 3-month outcome (P = 0.011).

Conclusion: In this multicenter study, we validated the performance of artificial intelligence software in predicting LVO on NCCT. Furthermore, the associations between JLK CTL LVO score and follow-up infarct volume, as well as functional outcomes, support its clinical utility beyond merely screening patients who require rapid decision-making.

Background: Flow diverters (FDs) are the first line of treatment for specific intracranial aneurysms. However, aneurysm persistence at follow-up presents in up to 25%. Occlusion after flow diversion in older patients seems less effective due to clinical, anatomical, and physiological characteristics. We aimed to study the effect of age on aneurysm occlusion mediated by intraprocedural technical events.

Methods: We conducted a pooled analysis of 2 cohorts, including patients with unruptured saccular aneurysms in the internal carotid artery, treated with the Surpass Streamline FD. Multivariable logistic regression was used to identify predictors of complete occlusion at 12-month follow-up. A mediation analysis was performed to assess the role of intraprocedural technical events (eg, fish-mouthing of the distal end, poor device opening, FD twisting, foreshortening, excess friction of the FD and the delivery system during deployment, and delivery system kink) in the relationship between age and occlusion rates.

Results: A total of 316 patients (mean age 59.4 ± 11.2 years) were included. Complete aneurysm occlusion was achieved in 82% of cases at 12 months. Increasing age was associated with lower odds of occlusion (adjusted odds ratio = 0.962, P<0.001) and a higher incidence of intraprocedural technical events (adjusted odds ratio = 1.088, P<0.001). Intraprocedural technical events were inversely associated with occlusion (adjusted odds ratio = 0.265, P = 0.004), and mediation analysis revealed that 16.3% of the effect of age on aneurysm occlusion was mediated by these events.

Conclusion: Intraprocedural technical events partially mediate the effect of age on complete aneurysm occlusion after FD treatment. Identifying additional mechanisms that influence occlusion could improve procedural outcomes, particularly in older patients.

Background: Achieving excellent recanalization (Modified Thrombolysis in Cerebral Infarction 2c/3) in fewer attempts improves clinical outcomes. Previous studies suggest that switching techniques after a failed first pass may enhance reperfusion rates. This study evaluates whether technique switching improves subsequent reperfusion in a large multicenter registry.

Methods: We analyzed retrospective and prospective SVIN (Society of Vascular and Interventional Neurology) registry data from 12 US centers (October 2014-December 2021) involving endovascular therapy for M1 or internal carotid artery-terminus (ICA-T) occlusions. Patients with at least 2 recanalization attempts using stent retriever (SR), contact aspiration (CA), or combined technique (CT) were included. Primary outcome was the likelihood of achieving TICI 2c/3 reperfusion with or without technique switching on the second pass. Secondary outcomes included the likelihood of final TICI 2c/3 stratified by the technique and occlusion location.

Results: Among 2893 endovascular therapy treatments, 1089 patients (37.6%) had successful reperfusion after the first pass. First-pass TICI 2c/3 rates for ICA-T occlusions were 36.0% with SR, 23.6% with CA, and 35.8% with CT; for M1 occlusions, the rates were 38.8% with SR, 39.3% with CA, and 38.6% with CT. A total of 1420 treatments included at least 2 passes. ICA-T occlusions occurred in 20.4% and M1 occlusions in 79.6%. In multivariable analysis, in M1 occlusions, switching from CT to alternative technique after a failed first pass significantly increased the odds of achieving TICI 2c/3 after the second pass (adjusted odds ratio, 2.08 [95% CI, 1.18-3.67]). Patients who had 2 failed attempts using CA had significantly higher odds of achieving final TICI 2c/3 compared with those with 2 failed passes using the SR technique (adjusted odds ratio 1.65, [95% CI, 1.09-2.51]).

Conclusion: In M1-middle cerebral artery occlusion, switching from CT to SR or CA was associated with an improvement in TICI2c/3 rates on the second pass. In addition, after 2 failed passes with CA, additional passes increased the odds of achieving complete reperfusion compared with SR.