Cerebrovascular Diseases最新文献

Introduction: The aim of this study was to establish the score for predicting the 5-year risk of hemorrhagic stroke in patients with asymptomatic moyamoya disease (MMD) using the Asymptomatic Moyamoya Registry (AMORE) data and to evaluate its reproducibility.

Methods: The AMORE study was a prospective cohort study that recruited participants from 18 centers in Japan. A total of 103 patients completed the 5-year follow-up and of these, 6 patients experienced hemorrhagic stroke. According to the results of multivariate analysis, we selected age ≥46 years, Grade -2 choroidal anastomosis, and microbleeds as variables in the prediction model. The cumulative rates of hemorrhagic stroke were estimated per hemisphere using the Kaplan-Meier method. Nonparametric bias-corrected confidence intervals based on the Bootstrap sample were calculated to assess the reproducibility of the 5-year risk of hemorrhagic stroke.

Results: We created the AMORE score (0-3 points) to estimate the 5-year risk of hemorrhage with 1 point for each of age ≥46 years, Grade -2 choroidal anastomosis, and microbleeds. The AMORE score was applied to a total of 135 MMD hemispheres. The 5-year risk of hemorrhagic stroke per hemisphere was 1.8%, 1.6%, 15.4%, and 50.0% for AMORE scores of 0, 1, 2, and 3, respectively. The cumulative rate of hemorrhagic stroke for AMORE score 3 was significantly higher than for AMORE score 0 (Hazard ratio (HR), 38.7; 95% confidence interval (CI), 3.45-433; p = 0.003) and score 1 (HR, 41.8; 95% CI, 3.74-468; p = 0.002). The corresponding 90% CIs were 0% to 5.6%, 0% to 5.2%, 0% to 38.5%, and 0% to 100%, and the corresponding 80% CIs were 0% to 4.7%, 0% to 4.5%, 5.9% to 33.3%, and 23% to 100% for AMORE scores 0, 1, 2, and 3, respectively.

Conclusion: The 5-year risk of hemorrhagic stroke in patients with asymptomatic MMD can be adequately estimated using the AMORE score.

Introduction: Existing guidelines lack comprehensive recommendations for stroke prevention. This network meta-analysis aimed to evaluate the comparative efficacy of non-pharmacological interventions in preventing total stroke and fatal stroke in high-risk adults.

Methods: We pooled only randomized controlled trials (RCTs). Relative risks (RRs), 95% confidence intervals (CIs), and P-scores were computed to compare and rank the efficacy of interventions in preventing stroke.

Results: 50 RCTs with 673624 participants were pooled in this study. Compared with the control group, Exercise + Education may decrease stroke risk (RR=0.23; 95% CI: 0.07 - 0.73; low strength of evidence (SOE)), followed by Exercise (RR=0.40; 95% CI: 0.28 - 0.57; moderate SOE), Mediterranean diet (RR=0.70; 95% CI: 0.50 - 0.97; low SOE), and Vitamin B6 combined with B12 and folic acid (Vitamin B6 + B12 + folic acid) (RR=0.86; 95% CI: 0.77 - 0.95; moderate SOE). Only Salt substitute showed significantly reduced fatal stroke risk (RR = 0.78; 95% CI: 0.68 - 0.90; high SOE). Exercise + Education (low SOE) and Exercise alone (moderate SOE) showed short-term benefits, while Salt substitute had long-term effects on reducing stroke risk (high SOE). Carotid endarterectomy (moderate SOE) and vitamin C (high SOE) were significantly effective in preventing ischemic stroke; and Salt substitute (high SOE) showed significantly reduced hemorrhagic stroke risk. Vitamin B6 + B12 + folic acid may lower hemorrhagic stroke, fatal hemorrhagic stroke, and transient ischemic attack risks (moderate SOE).

Conclusion: Future studies should prioritize high-quality RCTs with large sample sizes, different follow-up durations and specific stroke types to confirm the efficacy of these non-pharmacological interventions.

Background and purpose Posterior Circulation Acute Stroke Prognosis Early Computed Tomography Scores (PC-ASPECTS) is crucial for diagnosing, treating, and predicting the prognosis of acute ischemic stroke in patients with posterior circulation involvement. However, physicians take longer to score patients' pc-ASPECTS and inter-rater reliability is low among different physicians. To address this issue, we developed an intelligent scoring model using artificial intelligence technology to enhance the accuracy and consistency of these scores. Methods Retrospective clinical and imaging data from multiple stroke centers were used to train and validate a convolutional neural network (CNN)-based model. The model identified early ischemic changes in predefined posterior circulation regions. Performance was evaluated using standard metrics (e.g., AUC, sensitivity, specificity) and compared to manual scoring by clinicians. Results A total of 674 patients with complete data were included in the study, 536 patients (mean age, 56 years ± 12 [SD]; 298 [55.6%] female) were included for model development (training: 300; validation: 129; and internal test set: 107). Another 138 patients (mean age, 59 years ± 14; 90 [65.2%] female) were included in an external test set to evaluate model's performance and generalizability. The PC-ASPECTS intelligent scoring model demonstrated strong discriminative ability across all regions (AUC range: 0.687-0.805). It significantly improved inter-rater consistency (kappa: 0.317 to 0.711) and reduced scoring time compared to clinicians (2-5 seconds vs. 25-90 seconds, p< 0.05). Conclusions The PC-ASPECTS intelligent scoring model developed in this study demonstrated commendable performance. Utilizing this prediction model, the consistency of PC-ASPECTS scoring among clinical physicians was improved and efficiency was significantly enhanced.

Objective: Intracerebral haemorrhage (ICH) is the most severe type of stroke characterised by high morbidity and mortality rates. While prognostic scales aim to predict outcomes based solely on medical information, clinicians' assessments may be influenced by patients' social factors potentially resulting in inequitable care.

Patients and methods: A vignette-based survey presenting five pairs of fictitious ICH cases (10 total) was distributed to professionals involved in ICH patient care. Each pair included identical medical data and a comparable computed tomography scan. Social factors - including family status, employment, home status, and medical history - were varied. Respondents assessed prognosis, recommended management, and identified key factors influencing their decisions. Only healthcare professionals involved in the treatment of neuro-intensive care patients were eligible to participate.

Results: A total of 172 responses were collected, of which 156 were from physicians. Statistically significant differences were observed across all case pairs with regard to prognosis, initial management and further treatment. Cases with less favourable social backgrounds were more likely to result in delayed treatment or recommendations for palliative care. Notably, when participants were asked which factors influenced their decisions, only an average of 10-11% acknowledged that social factors had played a role in their clinical reasoning Conclusions: Social factors seem to influence clinicians' prognostic assessments and management decisions in ICH cases, suggesting unconscious bias is present. These findings highlight the need for strategies to ensure equitable treatment, for example, bias-awareness training.

Introduction Timely thrombolysis is crucial for acute ischemic stroke (AIS) treatment, but delays often persist due to fragmented communication and inefficient workflows. The Smart Stroke Fast Track (SSFT) is a digital workflow platform developed to digitize and streamline acute stroke care. This study evaluates the SSFT's impact on reducing door-to-needle (DTN) time and enhancing workflow efficiency in AIS management. Methods A pre-post implementation study was conducted at Naresuan University Hospital. The SSFT platform is an in-hospital application accessible via mobile, tablet, and desktop, which integrates triage, one-click team alerts, automated rt-PA dose calculation, patient tracking, and a digital checklist. Data from AIS patients treated pre- and post-SSFT implementation were compared. The primary outcome was median DTN time. The secondary outcomes included the proportion of patients treated within 60 and 45 minutes, symptomatic intracerebral hemorrhage (sICH) rate, in-hospital mortality, neurological/functional outcomes, and key workflow time intervals (door-to-physician, door-to-stroke team, door-to-CT, and door-to-laboratory result times). Results Forty patients were included (Pre: 20; Post: 20). Median DTN time significantly decreased from 57.5 minutes (IQR 45-68) to 41.5 minutes (IQR 36.5-52) (p <0.001). Treatment within 60 minutes increased from 60% to 100% (p=0.002); within 45 minutes from 25% to 55% (p=0.053). Significant reductions were observed in key workflow time intervals (all p <0.05). No significant differences were observed in sICH, in-hospital mortality, or neurological/functional outcomes. Conclusion The SSFT platform effectively reduced AIS treatment delays and improved workflow coordination. This digital innovation offers a scalable solution for improving stroke systems in resource-limited settings.

Background Conventional stroke prognostication focuses on fixed timepoints, typically at 3 months. This study aimed to model recovery trajectories across multiple time points and stroke severity levels, and to identify factors associated with differential recovery patterns. Methods We analyzed data from an 11-year prospective stroke registry at one Medical Center, including ischemic stroke patients with documented modified Rankin Scale scores at 1, 3, 6, and 12 months post-stroke. Patients were stratified into severity groups based on NIH Stroke Scale (NIHSS). Generalized estimating equations were used to model functional trajectories and evaluate the impact of baseline clinical characteristics on recovery over time. Results A total of 6,965 patients were included: 3,421 (49.1%) with mild stroke (NIHSS <5), 2,335 (33.5%) with moderate stroke (NIHSS 5-15), and 1,209 (17.4%) with severe stroke (NIHSS >15). Distinct recovery trajectories were identified across severity groups. The majority of functional improvement occurred within the first 3 months, followed by a slower phase of stabilization or plateau across different stroke severity groups. In the mild stroke group, the respective increases of the proportion of favorable outcome were 15.1%, 5.6%, and 0.3%; in the moderate stroke group, 55.1%, 16.3%, and 6.2%; and in the severe stroke group, 78.8%, 27.1%, and 10.7%. Factors including age, sex, treatment with intravenous thrombolysis and/or endovascular thrombectomy, diabetes mellitus, end-stage renal disease, anemia, leukocytosis, prior cerebrovascular events, and white matter hyperintensities, significantly influenced recovery patterns, with varying significances across different severity strata. Notably, a subset of patients exhibited secondary functional decline after initial recovery, underscoring the dynamic and heterogeneous nature of post-stroke functional outcomes. Conclusions Stroke recovery is dynamic and heterogeneous. Patients with different baseline profiles follow distinct trajectories. This trajectory-based approach enhances prognostic accuracy, supports tailored patient counseling, and informs mechanisms of long-term recovery.

Introduction: The optimal timing for initiating direct oral anticoagulants (DOACs) after endovascular therapy (EVT) for acute ischemic stroke (AIS) remains uncertain due to concerns regarding hemorrhagic complications. This study aimed to evaluate the safety and efficacy of early DOAC initiation guided by the "1-2-3-4-day" rule based on stroke severity in patients with non-valvular atrial fibrillation (NVAF) who underwent EVT.

Methods: We analyzed data from the Fukuoka Stroke Registry, a multicenter cohort including patients with AIS with NVAF who underwent EVT between 2013 and 2023. Patients were classified into the early (DOAC initiated within 1-4 days) and non-early groups. The primary outcomes were in-hospital recurrent ischemic stroke and symptomatic intracranial hemorrhage (sICH) occurring more than 24 h after EVT. The secondary outcome was a good functional outcome at 3 months (modified Rankin Scale score of 0-2). Multivariable Poisson regression and inverse probability weighting (IPW) were used for adjustment.

Results: Among the 397 patients analyzed for safety outcomes and 262 for functional outcomes, early DOAC initiation was not associated with increased risk of recurrent ischemic stroke or sICH. The proportion of patients with good functional outcome was significantly higher in the early group than in the non-early group (63.8% vs. 42.2%; adjusted risk ratio, 1.33; 95% CI, 1.06-1.66; p = 0.02). Findings remained consistent across subgroups and sensitivity analyses using IPW.

Conclusions: Early DOAC initiation following EVT based on the "1-2-3-4-day" rule was not associated with increased hemorrhagic risk; rather, it was associated with improved functional outcomes, supporting its feasibility.

Objective: The pathophysiological basis of brain arteriovenous malformations (bAVMs) remains incompletely understood. Early-life factors are hypothesized to influence cerebrovascular development, however, their potential associations with bAVMs have not been systematically evaluated. This study aimed to investigate the associations between eight early-life factors and the risk of bAVMs.

Methods: This prospective cohort study included 329,121 participants aged 40 to 69 years from the UK Biobank with complete covariate data at baseline. Multiple-adjusted logistic regression models were used to explore the associations between eight self-reported early-life factors (breastfed as a baby, part of a multiple birth, maternal smoking around birth, comparative body size at age 10, handedness, childhood sunburn occasions, number of older siblings, and birth weight) and subsequent diagnosis of bAVMs.

Results: A total of 141 patients had diagnosed bAVMs. After multivariable adjustment, three early-life factors were associated with an increased risk of bAVMs: very low birth weight (<1.5 kg vs. 2.5-4.0 kg: odds ratio [OR], 3.27; 95% confidence internal [CI], 1.04-10.67), having one or more older siblings (≥1 person vs. none: OR, 1.83; 95%CI, 1.03-3.24), and frequent childhood sunburn (>10 episodes vs. none: OR, 2.83; 95%CI, 1.13-7.08). No statistically significant associations were observed in other early-life factors. Sensitivity analyses confirmed the robustness of these findings.

Conclusions: In this large prospective cohort, very low birth weight, the presence of older siblings, and repeated childhood sunburn were associated with a higher risk of bAVMs. These findings warrant validation and further investigation into the underlying biological mechanisms.

Introduction: Intracranial hemorrhage (ICrH) is an umbrella term that encompasses any bleeding within the skull. The underlying mechanisms, clinical presentations, and management strategies of ICrH vary considerably based on the anatomical location of the blood. However, the current terminology surrounding ICrH is often ambiguous and inadequate for conveying the precise anatomical origins and extent of the bleeding, contributing to confusion and inconsistency in both clinical practice and research.

Methods: To address these challenges, we identify six key shortcomings in current usage and propose a harmonized terminology for anatomical classification.

Results: We propose the following clarifications: (i) intraparenchymal hemorrhage (IPH) refers to any bleeding within the parenchyma of the brain or the brainstem; (ii) isolated intraventricular hemorrhage (IVH) denotes bleeding within the ventricles, not secondary to intraparenchymal or subarachnoid hemorrhage; (iii) intracerebral hemorrhage (ICH) includes both IPH and IVH; (iv) ICrH encompasses all bleeding within the skull (i.e., intraparenchymal, intraventricular, subarachnoid, subdural and epidural hemorrhages); (v) precise anatomical terminology should be favored over the ambiguous term "hemorrhagic stroke"; and (vi) the term "hemorrhage" indicates an active bleeding process, whereas "hematoma" describes the resulting mass or collection of blood.

Conclusion: We invite stroke physicians and researchers to use this harmonized terminology to standardize and facilitate communication, as well as the interpretation and translation of research findings.

Introduction: Mechanical thrombectomy (MT) is an effective treatment for acute ischemic stroke caused by large vessel occlusion. Prior investigations have shown that a well developed collateral circulation preserves the ischemic penumbra more effectively than inadequate collateral flow. As a result, stroke patients with robust collaterals generally achieve more favorable functional outcomes after MT. However, it remains unclear how long robust collateral flow can preserve the penumbra. This study aimed to determine the onset-to-reperfusion time threshold within which good collaterals improve outcomes.

Methods: We retrospectively analyzed patients with acute ischemic stroke who achieved successful reperfusion (expanded Thrombolysis in Cerebral Infarction ≥ 2b) after MT between 2017 and 2023. Collateral status was graded with the ASITN/SIR scale and categorizing patients into good collateral (grades 2-4) and poor collateral (grades 0-1) group. The primary endpoint was excellent functional outcome, defined as a 90 day modified Rankin Scale (mRS) score of 0-1. We used receiver operating characteristic curve analysis to predict excellent outcomes, determining cut-off points for onset-to-reperfusion time using the Youden index. Additionally, the onset-to-reperfusion time was divided into quartiles based on the distribution of all cases, and excellent outcome rates were compared across these quartiles.

Results: A total of 77 patients were included (good collateral group, 46; Poor collateral group, 31), with a median onset-to-reperfusion time of 310 min (interquartile range, 200-621 min). In the good collateral group, the cutoff time for achieving excellent outcomes was 235 min (sensitivity, 88%; specificity, 62%). The good collateral group showed significantly higher excellent outcome rates than the PC group at the shortest interval (< 200 min).

Conclusion: In patients with good collateral flow who achieved reperfusion after MT, the onset-to-reperfusion time threshold associated with an excellent outcome was 235 min. The 235 min cut off may serve as a practical target for onset to reperfusion timing in patients with favorable collateral circulation undergoing MT.