Stroke (Hoboken, N.J.)最新文献

Background: For acute ischemic stroke due to intracranial large-vessel occlusion in the anterior circulation, guidelines recommend treatment with intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator and endovascular thrombectomy (EVT). We investigated whether plasma fibrinolysis biomarkers were associated with the treatment effect of EVT, with or without IVT with recombinant tissue plasminogen activator, and their potential implications for clinical and radiological outcomes.

Methods: In this post hoc analysis of MR CLEAN-NO IV, we measured fibrinolytic biomarkers (tissue plasminogen activator, global clot lysis time, and D-dimer) before and 24 hours post reperfusion and assessed their associations with patients' clinical and radiological outcomes based on National Institutes of Health Stroke Scale score, modified Rankin Scale (mRS) score, post-EVT extended thrombolysis in cerebral infarction score, and final infarct size. To quantify these associations, we used linear and logistic regression.

Results: Blood was collected from 214 of 536 included patients, who received IVT+EVT (N = 108) or EVT alone (N = 106). In the IVT+EVT group, D-dimer levels 24 hours after treatment were higher and clot lysis time lower than in the EVT group, indicating more fibrinolysis. Pearson correlation showed that high D-dimer levels before and 24 hours after EVT were correlated with unfavorable long-term functional outcomes (mRS at 90 days), and D-dimer levels 24 hours after EVT linked to large infarct size. High tissue plasminogen activator levels after IVT+EVT were correlated with successful reperfusion. However, regression analysis adjusted for confounders showed no associations between fibrinolytic biomarkers and clinical or radiological outcomes.

Conclusion: None of the fibrinolysis biomarkers were independently associated with outcomes in adjusted regression analysis, failing to support their use as predictors for treatment decisions or therapeutic effectiveness. However, exploratory analyses suggested that higher tissue plasminogen activator levels after IVT+EVT correlated with successful reperfusion, whereas elevated D-dimer levels were linked to unfavorable outcomes and larger infarct size post-EVT. Larger studies are needed to clarify their role in stroke treatment with IVT and/or EVT.

Clinical trial registration: This study is a substudy of the MR CLEAN-NO IV trial, which is registered at the ISRCTN registry (ISRCTN80619088, https://www.isrctn.com/ISRCTN80619088).

Background: The optimal therapeutic approach for acute ischaemic stroke due to distal medium vessel occlusion remains uncertain. The use of endovascular therapy in this context is restricted by challenges in navigating distal vessels with available devices. This study aimed to assess the safety and effectiveness of the Red43 aspiration catheter (Penumbra, Alameda, CA) in patients experiencing stroke due to distal medium vessel occlusion.

Methods: A retrospective analysis was conducted on consecutive patients who underwent mechanical thrombectomy for acute ischemic stroke at a single high-volume comprehensive stroke center from April 2023 to March 2024. Patients were included if they had an acute ischemic stroke with distal medium vessel occlusion and were treated using the Red43 aspiration catheter.

Results: The Red43 aspiration catheter successfully reached the occlusion site in 94% of cases. modified treatment in cerebral ischemia 2b-3 reperfusion was achieved in 77% of patients following initial use of the Red43 catheter, whereas modified treatment in cerebral ischemia 2c-3 reperfusion was observed in 66%. No cases of symptomatic intracranial hemorrhage, vessel perforation, or dissection occurred during the procedure.

Conclusion: The Red43 aspiration catheter demonstrated a high rate of successful reperfusion with a favorable safety profile in the treatment of distal medium vessel occlusion stroke.

Background: Recanalization sometimes fails during endovascular thrombectomy due to target vessel access failure. Two-dimensional/3-dimensional fusion imaging in the Siemens ARTIS Icono biplane platform may facilitate access by fusing the preoperative computed tomography angiography with procedural imaging. This observational study aimed to evaluate vascular access, success rates, and procedure times in endovascular thrombectomies with fusion imaging compared to standard treatment.

Methods: Patients treated with endovascular thrombectomy for ischemic stroke at Skåne University Hospital in Lund, Sweden, were consecutively included. Baseline and procedural characteristics were gathered from radiological patient records. Procedural success rate and lead times such as groin-to-recanalization times were evaluated. Associations between fusion imaging and first-pass recanalization and groin to first pass <30 minutes were also assessed.

Results: Of 347 patients, fusion imaging was used in 68 cases. Failure to reach the occlusion occurred in 6 (2%) of the nonfusion cases compared with none in the fusion group. Successful recanalization (modified Treatment in Cerebral Infarction score ≥2b) was obtained in all fusion cases, compared with 86% in the nonfusion group (P = 0.001). First-pass recanalization occurred in 72% and 49% of the fusion and nonfusion groups respectively (P<0.001). The groin-to-recanalization time was significantly shorter in fusion cases compared with nonfusion (33 versus 43 min, P = 0.04). When adjusting for age and sex, fusion was significantly associated with first-pass recanalization (odds ratio, 2.70; [95% CI, 1.51-4.86]; P<0.001).

Conclusion: Fusion imaging use in the Siemens ARTIS Icono biplane platform in endovascular thrombectomy is not associated with worsened procedural results and appears to decrease failed target artery access risk and increase procedural success rate as well as first-pass success rate, without procedure prolongation. These initial observational findings need to be further evaluated in prospective randomized studies.

Background: Augmented Reality (AR) enables visualization of and interaction with both physical and virtual environments. Holograms can allow 3D image transmission to distant sites, allowing patients to interact with providers as if in the same space. Our prior publication resulted in high satisfaction/immersion for patients interacting with Holo-Stroke providers. Our aim here was to determine if providers assessing CTAs for large vessel occlusion (LVO) would result in reliability and satisfaction.

Methods: Thirty-six head CTAs were de-identified and scored by Stroke Faculty, Fellows, and Nurse Practitioners for LVO using DICOM viewer. CTAs were presented 2 months later via Holo-Stroke. Holograms were positioned in 3D-space, viewable through the Hololens-2, and scored by the same providers. Kappa Reliability was assessed comparing scores to gold-standard (radiology report). Satisfaction was assessed via Likert scale.

Results: Thirteen providers scored the CTAs. Overall Kappa reliability, compared to gold standard, was 0.78(81%)DICOMvs.0.94(94%)Holo-Stroke-CTA(p<0.0001). Overall %correct was 81%vs.94%(p<0.001). Holo-Stroke-CTA's reliability improved for most examiners: Overall (κ=0.78(81%)vs.0.94(94%)), Faculty (κ=0.85(87%)vs.0.92(93%)), NPs (κ=0.81(83%)vs.0.90(92%)), and Fellows (κ=0.68(72%)vs.0.97(97%)). Overall MCA (κ=0.76(86%)vs.0.93(96%)), ICA (κ=0.8(88%)vs.0.9(94%)), and Basilar (κ=0.73(95%)vs. 0.82(96%)) scored high, with marked improvement for ACA (κ=0.3(39%)vs. 0.91(94%)), and PCA (κ=0.55(70%)vs.0.95(98%)). Likert satisfaction "Overall" was (18DICOM,48Holo-Stroke-CTA;p=0.002) with %increasing from 39% to 96%. "Immersion" scores were (0,10;p=0.001), "Ease of Use" (5,9;p=0.002), "Accuracy" (7,9;p=0.002), "Technology Advancement" (4,10;p=0.001), and "Interest" (3,10;p=0.002).

Conclusions: Holo-Stroke-CTA resulted in higher reliability and satisfaction vs. standard DICOM tele-stroke tele-radiology. Providers noted the ability to see 3D vessels in virtual space, vs. scrolling through axial/sagittal/coronal images, resulted in higher accuracy. Even for trainees and difficult to assess vessels, providers were more able to identify LVOs using Holo-Stroke-CTA. Providers were enthusiastic for the immersive radiology assessment, with the ability to immersively resize, rotate, and investigate hologram in 3D virtual space. Though further assessments are needed, Holo-Stroke-CTA can help providers more easily, and at-a-glance, evaluate CTA for LVO.

Background: Predicting and managing spontaneous Cervical Artery Dissections (CeAD) is challenging due to the absence of tools for early identification of high-risk individuals. This study seeks to gather evidence on the predictive value of high-intensity transient signals (HITS) detected by Transcranial Doppler for recurrent ischemic events (IEs) following CeAD.

Methods: We performed a systematic review and meta-analysis of published studies along with the data from our cohort. Following PRISMA guidelines, we searched Pubmed, Embase and Scopus to identify studies that evaluated HITS in patients with CeAD with the aim of predicting IEs. Data were pooled using a random effects model, with odds ratio (OR) and its 95% confidence interval (CI) as the effect size. Heterogeneity was assessed with the Q statistic and I² test, while subgroup analysis evaluated the impact of dissected artery (carotid vs vertebral) on the relationship between HITS and ischemic events. Our retrospective study included consecutive patients diagnosed with CeAD, followed for 90 days to record IEs. Univariable and multivariable analyses were performed to identify factors associated with recurrent TIAs or strokes within 90 days post-CeAD.

Results: Our systematic review included five prior studies, which, combined with our center's sample size, provided data for a total of 306 patients. The meta-analysis indicated that HITS is a significant predictor of IEs (OR: 13.25, 95% CI [2.97-59.13], p<0.01) with low heterogeneity (I2 = 42%, p = 0.13). However, subgroup analysis indicated that HITS are a significant predictor only for carotid artery dissections (p<0.01), and not for vertebral artery dissections (p=0.11). The cohort consisted of 34 patients (mean age: 46.8 years, 55.9% male). The incidence of IEs was 20% in our cohort and all of them (100%) had HITSs in TCD. In multivariable analysis, the presence of HITS (p=0.006) and intra-luminal thrombosis (p=0.02) were significant predictors of IEs.

Conclusions: The presence of HITS detected by TCD is a strong predictor of IEs in patients with Carotid artery dissections. This highlights the clinical value of TCD in identifying high-risk patients and emphasizes the need for proactive management strategies to reduce the risk of future IEs in this subgroup.

Background: Two randomized clinical trials have failed to demonstrate the superiority of anticoagulation over antiplatelet therapy in acute cervical artery dissection, with many patients still receiving anticoagulation despite bleeding risks. In this analysis, we assessed temporal changes in antithrombotic strategies of cervical artery dissection following publication of these 2 trials.

Methods: This is a secondary analysis of a retrospective multinational observational cohort study evaluating outcomes related to antithrombotic treatment for acute cervical artery dissection (January 2015-December 2022). The odds of oral anticoagulant use (over single or combination antiplatelet) therapy across each year were estimated using multivariable logistic regression and joinpoint regression. Least absolute shrinkage and selection operator-adjusted regression was used to assess the odds of anticoagulation each year following 2016.

Results: Among 3345 included patients, 862 (25.8%) were treated with anticoagulation (n = 436 treated with anticoagulation and antiplatelet therapy). Nearly half (45.1%) were female with a median age of 46 years (interquartile range, 37-56). Compared with patients treated in 2015, those treated in subsequent years showed a stepwise decrease in treatment with any oral anticoagulation (odds ratio [OR] 0.91, 95% CI: 0.87-0.94). Independent predictors of increased anticoagulant use included female sex (adjusted OR [aOR] 1.22, 95% CI: 1.03-1.46), presence of infarct on imaging (aOR 1.45, 95% CI: 1.19-1.77), and partially occlusive thrombus (aOR 3.09, 95% CI: 2.38-4.01). Meanwhile, independent predictors of decreased anticoagulant use included lower baseline National Institutes of Health Stroke Scale score (aOR 0.95, 95% CI 0.93-0.97) and single vertebral artery involvement (aOR 0.63, 95% CI: 0.52-0.76). Meanwhile, independent predictors of decreased anticoagulant use included lower baseline National Institutes of Health Stroke Scale score (aOR 0.95, 95% CI: 0.93-0.97) and single vertebral artery involvement (aOR 0.63, 95% CI: 0.52-0.76). Each year following 2016 was associated with a lower rate of anticoagulation (average annualized percent change -13.91%, 95% CI: -18.73% to -9.10%). In 2021, there was a significant difference in the monthly rate of decline of anticoagulation use when compared with preceding years (P<0.001).

Conclusion: These real-world clinical practice data indicate a decline in the use and duration of oral anticoagulation for acute cervical artery dissection.

Background: Repeat imaging when regional and remote patients with stroke arrive at a comprehensive stroke center can delay endovascular thrombectomy. We examined outcomes amongs patients transferred for endovascular therapy from nonmetropolitan primary stroke centers.

Methods: In this prospective observational study patients who were transferred from remote nonmetropolitan hospitals with large vessel occlusion were recruited between 2020-2023. The control group was defined as patients with repeat neuroimaging at the comprehensive stroke center in the radiology/emergency department. Direct-to-angio (direct to angiography) included patients who proceeded directly to the angiography suite without any repeat neuroimaging or routine flat panel computed tomography. Logistic regression with propensity matching was performed to assess factors associated with 3-month independent outcome (modified Rankin scale score 0-2). A secondary analysis was performed to assess factors associated with recanalization.

Results: Between June 2020 and February 2023, 227 patients with large vessel occlusion were transferred for endovascular clot retrieval. A total of 47 (26%) patients recanalized by time of arrival and 180 had persistent large vessel occlusion. Primary stroke centers were a median distance of 185 km from the comprehensive stroke center (interquartile range 130-256). After propensity matching 138 patients remained. Characteristics between direct-to-angio and control groups were similar with regard to age (68 versus 66), primary stroke centers National Institutes of Health Stroke Scale score (15 versus 13), and onset to referral (200 versus 246 min). Direct-to-angio increased independent functional outcome at 3 months (adjusted odds ratio, 2.2 [95% CI, 1.0-4.9]; P = 0.05). Direct-to-angio resulted in shorter door-to arterial puncture time (43 versus 77 min, P<0.001) and a higher likelihood of receiving endovascular therapy (100% versus 65%, P<0.001).

Conclusion: In patients who have already received telestroke review at the primary stroke centers, our results suggest a direct-to-angio approach is likely to result in better outcomes.

Background: Cerebral venous sinus thrombosis (CVST) is a rare condition, accounting for 0.5% to 3% of all strokes. The standard treatment is anticoagulation, whereas thrombectomy is reserved for severe or refractory cases. Although guidelines recommend thrombectomy for refractory CVST, large, randomized trials are still needed. This study aims to compare the outcomes of CVST hospitalizations with and without thrombectomy.

Methods: We abstracted data from the Nationwide Readmissions Database from 2016 to 2021 to identify CVST hospitalizations. The primary objective was to compare 30- and 90-day all-cause readmissions between patients who underwent thrombectomy and those who did not. Secondary objectives included inpatient mortality, routine discharge, length of stay, and hospital costs. To assess whether all-cause readmissions, inpatient mortality, and routine discharge differed by the receipt of a thrombectomy, logistic regression models were estimated. To assess whether length of stay and hospital cost differed by the receipt of a thrombectomy, log-normal models were estimated. Multivariable models were estimated to adjust for age and comorbidity burden.

Results: Hospitalizations carrying a CVST diagnosis and receiving a thrombectomy had a 30-day all-cause readmission rate of 8.78% compared with 14.21% for hospitalizations without a thrombectomy (P = 0.018; Table 1). Similarly, hospitalizations with thrombectomy had a 90-day all-cause readmission rate of 13.06% compared with 22.97% for hospitalizations without a thrombectomy (P = 0.003; Table 1). However, hospitalizations with thrombectomy were associated with 2.92 times greater inpatient mortality, 2.02 times longer stays, 3.22 times greater costs, and 62% lower odds of routine discharge compared with hospitalizations without thrombectomy.

Conclusion: Our findings showed lower 30- and 90-day all-cause readmissions in hospitalizations with CVST who underwent thrombectomy, pointing to an association between thrombectomy and long-term benefit. The higher inpatient mortality, costs, and length of stay associated with thrombectomy indicate the need to be highly selective in offering this intervention for patients with CVST.