Stroke (Hoboken, N.J.)最新文献

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.

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.