Cerebrovascular Diseases最新文献

Introduction: Moyamoya disease (MMD) is a cerebrovascular disease characterized by progressive steno-occlusive lesions in the terminal portion of the internal carotid artery. Despite its unknown etiology, immune dysregulation is regarded as a critical trigger for delineating the pathophysiology of MMD. The gut microbiota produces short-chain fatty (SCFA) and organic acids, influencing immune regulation and vascular remodeling. We aimed to characterize the gut microbiota in patients with MMD.

Methods: Sixteen patients with MMD and sixteen healthy controls were included in this study. We performed 16S rRNA sequencing of fecal samples and analyzed microbiome diversity and composition, and quantified SCFA and organic acid levels using liquid chromatography.

Results: There were no significant differences in α- and b-diversities among feces from the MMD patients and controls. However, 16S rRNA sequencing identified defective Lactococcus lactis (0 ± 0 in the MMD patients vs. 0.026 ± 0.084 in healthy controls, p = 0.0181) and abundant Gordinobacter pamelaeae (0.030±0.039 in the patients vs. 0.001±0.005 in healthy controls, p = 0.003) are strongly linked to MMD. Propionic acid levels were significantly lower in feces of the MMD patients compared to healthy controls (0.83 ± 0.34 mg/g in the MMD patients vs. 1.20 ± 0.55 mg/g in healthy controls, p = 0.028).

Conclusion: Decreased Lactococcus lactis can result in reduced lactic acid and propionic acid levels in the feces of the patients. This imbalance in the gut microbiome and SCFA/organic acid levels could contribute to immune dysregulation underlying the vascular remodeling seen in MMD.

Introduction: Local vasogenic edema following direct revascularization for Moyamoya disease (MMD) is considered to result from an intrinsic vulnerability of blood-brain-barrier (BBB) and is consequently associated with transient focal cerebral hyperperfusion (CHP). However, intraoperative identification of the local vasogenic edema remains challenging. To address this, we implemented a prolonged observation of indocyanine green videoangiography (ICG-VAG) as an extension of routine clinical practice. This approach aimed to investigate intraoperative cortical ICG extravasation following direct revascularization, as an indicator of BBB dysfunction in patients with MMD, providing real-time intraoperative evidence of compromised vascular integrity.

Methods: This prospective observational study included 50 consecutive combined direct/indirect revascularization surgeries performed for MMD at our institution between December 2022 and February 2025. After confirming the patency of the direct anastomosis using ICG-VAG in the early phase, we conducted an additional observation of ICG-VAG in the late phase, approximately five minutes after the initial assessment, to evaluate cortical changes around the anastomotic site. We analyzed the correlation between intraoperative cortical ICG extravasation observed in the late phase of ICG-VAG and postoperative complications, including CHP.

Results: ICG-VAG confirmed patent direct anastomoses in all 50 revascularizations, and postoperative CHP occurred in 16 surgeries (32%) between postoperative days one and seven. Among these cases, intraoperative cortical ICG extravasation was detected in the late phase of ICG-VAG in nine of 50 surgeries (18%). This extravasation presented as focal or patchy leakage of ICG dye near the anastomotic site and/or flow-augmented cortical areas without evident cortical contusion or subarachnoid hemorrhage under the light-field surgical microscope. There were no significant differences in preoperative baseline clinical characteristics between patients with and without cortical ICG extravasation. However, intraoperative cortical ICG extravasation was significantly correlated with postoperative CHP (odds ratio: 12; 95% confidence interval: 2.5-94; P=0.0044) and local vasogenic edema on magnetic resonance imaging (odds ratio: 20; 95% confidence interval: 2.2-444; P=0.015).

Conclusion: Intraoperative cortical ICG extravasation, observed in the late phase of ICG-VAG, may serve as a direct indicator of the intrinsic vulnerability of BBB in patients with MMD. Prolonged ICG-VAG observation could be a simple and effective intraoperative tool to predict postoperative CHP and local vasogenic edema in patients undergoing direct revascularization for MMD, thereby enabling intensive postoperative monitoring for high-risk cases.

Introduction: The posterior circulation is frequently overlooked when managing patients with moyamoya angiopathy (MMA), particularly the non-Asian population. This study aimed to identify the presence of angiopathy in the posterior cerebral artery (PCA), its patterns and the consequences thereof in a paediatric cohort.

Methods: Retrospective clinical data, MRI scans and cerebral angiograms of all patients referred to a single center for cerebral revascularization were analyzed for PCA involvement. Angiographic patterns of PCA involvement were defined. Associated stroke burden was evaluated using general estimation equation regression models adjusting for prespecified potential confounders age at onset, right or left laterality, and involvement of anterior circulation.

Results: PCA involvement was observed in 37% of 122 patients and was identified to be either proximal (proximal P1 segment, P1-Pcomm segment (posterior communicating artery)), or distal (Pcomm-P2 segment and distal P2 segment and beyond). Distal P2 (32%) and involvement of the entire PCA (26%) were most frequently observed. The odds of having any stroke (anterior distribution i.e anterior cerebral artery (ACA), middle cerebrla artery (MCA) or posterior distribution i.e. PCA), was five times higher (odds ratio (OR) 5.0, 95% CI [2.3,10.9], p <0.0001) when PCA was involved compared to without PCA involvement. Distal PCA involvement was observed in 59% of children < 2 years of age. The OR of stroke in the PCA distribution with distal PCA involvement compared to proximal involvement was 4.1, (95% CI [0.9, 19.0], p = 0.07). The OR of anterior distribution stroke with Pcomm involvement versus no Pcomm involvement was 6.2 (95% CI [1.0, 37.2], p = 0.05).

Conclusion: Involvement of the PCA in moyamoya children is highlighted. This may be proximal, distal or along the entire course of the PCA and is strongly associated with overall stroke. The odds of PCA territory strokes is higher with distal PCA involvement while involvement of the Pcomm plays a more important role in anterior stroke. Younger children are at higher risk of PCA stroke.

Objective: This study aimed to investigate the role of novel indicators related to obesity in predicting long-term functional outcomes and the risk of stroke recurrence in participants with first-ever acute ischemic stroke (AIS).

Methods: The area and density of visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), and skeletal muscle (SM) at the third lumbar level, as well as the VAT area (VATA)-to-SM area (SMA) ratio (VSR) and the SAT area-to-SMA ratio (SSR), were assessed using whole-abdominal CT upon admission. The primary endpoint was the recurrence of stroke. The secondary outcomes were all-cause mortality and cardio-cerebrovascular origin death (CCVD) specifically due to cardiovascular and cerebrovascular diseases. Cox's proportional hazards regression model was used to examine the associations between the novel indicators of obesity and clinical outcomes.

Results: A total of 1007 participants were enrolled, with an average follow-up time of 1445 days. The participants in the high VSR group had a higher rate of stroke recurrence (adjusted hazard ratio, 2.06 [95% CI, 1.35-3.14]; p = 0.001). According to the adjusted analysis, high VSR was significantly associated with an increased risk of all-cause mortality (hazard ratio, 2.26 [95% CI, 1.58-3.24]; p < 0.001) and CCVD (hazard ratio, 2.49 [95% CI, 1.65-3.78]; p < 0.001).

Conclusions: A higher VSR was associated with a higher risk of mortality and stroke recurrence in participants with first-ever AIS.

Introduction: The prevalence of comorbid cancer is higher in patients with ischaemic stroke than in the general population, and recent studies have attempted to clarify the relationship between the two. We observed that the evidence for the impact of comorbid cancer on post-stroke clinical outcomes was not established and aimed to investigate it among patients with new-onset acute ischaemic stroke.

Methods: We evaluated 13,345 patients with acute ischaemic stroke who were functionally independent before onset (modified Rankin Scale [mRS] score of 0-2) and admitted to one of the seven stroke centres in Fukuoka, Japan, between June 2007 and September 2019. A total of 13,047 patients were included in the analyses after excluding those with missing potential confounders (n=13) or loss to follow-up (n=298). Comorbid cancer was diagnosed based on previous history or newly identified cancer during hospitalisation for the index stroke. Multivariable-adjusted Poisson regression analyses were conducted to assess the association of comorbid cancer with post-stroke outcomes: clinically assessed poor functional outcomes (mRS score, 3-6), functional dependency (mRS score, 3-5), and mortality (mRS score, 6) at 3 months after stroke onset.

Results: Of 13,047 patients (aged 71.1±12.3 years, 62.8% men) with acute ischaemic stroke, 2,027 (15.6%) had comorbid cancer. Among those with no cancer, 24.0% recorded poor functional outcomes; with non-active cancer, 30.7%; and with active cancer, 46.1%. The risk ratios (95% confidence interval) for poor functional outcome at 3 months increased with active cancer (1.50 [1.37-1.65] vs. no cancer) and recently diagnosed cancer (7 months-4 years: 1.43 [1.28-1.59], ≤6 months: 1.53 [1.36-1.72]) after adjusting for potential confounders. These associations were observed for both 3-month functional dependency and mortality. No significant heterogeneity was observed in these associations across sex, nutritional status, inflammatory status, or coagulation status, except for age and stroke severity. The strongest association with 3-month poor functional outcome was observed for pancreatic cancer, followed by gallbladder and biliary tract, liver, and colon cancers.

Conclusions: Comorbid cancer is likely to be independently associated with unfavourable outcomes in patients with acute ischaemic stroke.

Objective: The impact of body mass index (BMI) on outcomes after mechanical thrombectomy (MT) for large vessel occlusion acute ischemic stroke (LVOS) has been a subject of controversy, mainly due to the so-called "obesity paradox". The obesity paradox refers to the phenomenon where, contrary to expectations, overweight or obese individuals seem to have better clinical outcomes in certain disease states. This study aimed to investigate the relationship between BMI and the clinical prognosis of patients with LVOS treated with endovascular thrombectomy (EVT) combined with or without intravenous alteplase in DIRECT-MT.

Methods: This is a post-hoc analysis of the DIRECT-MT randomized trial. Patients were randomly allocated to undergo EVT after alteplase intravenous thrombolysis (IVT) (IVT+EVT group) or EVT alone (EVT group) at a 1:1 ratio. Among 656 randomized patients, 645 with baseline BMI information were included, The BMI was analyzed as a categorical variable, all patients were categorized according to their BMI into 3 groups: 18.5 ≤ BMI ＜ 24 kg/m2 (normal weight), 24 ≤ BMI＜28 kg/m2 (overweight), BMI ≥ 28 kg/m2 (obese). The primary outcome was the 90-day modified Rankin Scale (mRS) score analyzed as a continuous variable. Multivariable ordinal logistic regression with an interaction term was used to estimate treatment allocation and the BMI subgroups.

Results: A total of 645 patients were enrolled in this study, 373 (57.8%) were normal weight, 208 (32.2%) were overweight and 64 (10.0%) were obese. 175 (46.9%) normal weight patients, 114 (54.8%) overweight patients and 31 (48.4%) obese patients underwent direct EVT. Patients in the three groups were statistically different in age (71 versus 68, 66), time from randomization to groin puncture (31 versus 32, 39.5), time from randomization to revascularization (101.5 versus 92, 116), and time from admission to groin puncture (84 versus 83, 98.5). Other baseline and procedural characteristics were comparable. No significant difference for the ordinal mRS or 90 days mortality was observed by BMI [adjusted common odds ratio (acOR) was 0.92 (95% CI 0.64 to 1.32) for normal weight, 1.36 (95% CI 0.83 to 2.22) for overweight, and 1.09 (95% CI 0.45 to 2.64) for obese] and treatment allocation interaction [the adjusted P value for interaction was 0.335 (normal weight versus overweight), 0.761 (normal weight versus obese) and 0.733 (overweight versus obese)]. For the procedural complications and other clinical and imaging outcomes, no significant differences were observed between the BMI and treatment allocation.

Conclusion: The results demonstrated that BMI had no association with final outcome whether the patient with LVOS underwent EVT alone or plus IVT for Chinese adults. Thus, the obesity paradox does not appear to pertain to EVT alone or plus IVT. Further studies are needed to confirm the finding.

Introduction The indicator of flow diverters (FDs) received approval extension for small (<7 mm) unruptured intracranial aneurysms (UIAs). However, the factors related to aneurysm occlusion remain unclear. Thus, we conducted a multicenter analysis to explore the risk factors for incomplete occlusion (ICO) following FD implantation for small UIAs. Methods We retrospectively reviewed patients from 5 comprehensive hospitals in China with small UIAs treated with either Pipeline or Tubridge between September 2018 and September 2022. Baseline data were prospectively collected at admission. The relationship between baseline characteristics and occlusion status was analyzed and multivariate logistic regression models were performed to identify the independently related factors. Results A total of 565 patients with 565 small UIAs were enrolled. During a mean angiographic follow-up of 10.64 ± 5.99 months, ICO was detected in 116 cases (20.5%). After adjusting for candidate variables, hypertension (adjusted odds ratio [aOR] = 2.274, 95% confidence interval [CI] = 1.462-3.538, p <0.001), coronary disease (aOR = 2.742, 95%CI = 1.148-6.552, p = 0.023), larger aneurysm size (aOR = 1.833, 95%CI = 1.425-2.356, p <0.001), lower size ratio (SR, aOR = 0.380, 95% CI = 0.166-0.869, p = 0.022), and less coil application (aOR = 0.212, 95% CI = 0.061-0.741, p = 0.015) were independently associated with ICO of small UIAs. Conclusion Hypertension, coronary disease, larger aneurysm size, lower SR, and less coil application were independent predictors of ICO for small UIAs after FD implantation. Neurointerventionalists should focus more on blood pressure management and aneurysm morphological assessment in flow-diversion treatment for small UIAs.

Introduction： The role of endovascular thrombectomy (EVT) for acute extra-large ischemic stroke patients with large vessel occlusion (LVO) is uncertain. We aimed to explore the clinical and safety outcomes of medical management (MM) plus EVT (EVT group) versus MM alone (MM group) among acute extra-large ischemic stroke patients with LVO within 24 hours of last known well. Methods： XL STROKE (endovascular thrombectomy for extra-large ischemic stroke) is an investigator-initiated, nationwide, prospective registry with blinded end point assessment performed at approximately 60 sites in China, and will enroll up to 990 acute ischemic stroke patients within 24 hours of last known well. Imaging inclusion criteria are occlusion of the internal carotid artery, or the middle cerebral artery M1 or M2 segments, and Alberta Stroke Program Early Computed Tomography Score of 0 to 2 or an ischemic-core volume ≥85ml. All patients will be dichotomized into EVT group and MM group according to whether they received EVT or not. The primary outcome is the level of disability on the modified Rankin Scale at 90±14 days. Safety outcomes include symptomatic intracranial hemorrhage within 48 hours, and mortality at 90±14 days. Conclusion： Results from XL STROKE registry will provide constructive evidence of improved disability outcomes and safety with EVT for acute extra-large ischemic stroke patients with LVO within 24 hours of last known well. Trial registrations: ClinicalTrials.gov, NCT06210633.