Cerebrovascular Diseases最新文献

Introduction: 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 computerized tomography 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 1,007 participants were enrolled, with an average follow-up time of 1,445 days. The participants in the high VSR group had a higher rate of stroke recurrence {adjusted hazard ratio, 2.06 (95% confidence interval [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).

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

Introduction: There is little data on stroke and frailty, especially from South Asia. We aimed to study the prevalence and associations of post-stroke frailty in a cohort of stroke survivors.

Methods: We studied all patients attending a tertiary care stroke clinic over 1 year (September 2023-August 2024). Patients with an index stroke event occurring 1 to 5 years earlier were included. Data on demographic features, stroke characteristics, functional outcome, and frailty were studied. Frailty was assessed with the Clinical Frailty Scale (CFS), stroke severity with the National Institute of Neurological Disorders and Stroke scale (NIHSS), and functional status with the modified Rankin Scale (mRS). Frailty was defined by a CFS score of ≥5 and functional dependence by an mRS score of 3-5. Strokes were categorized as mild (NIHSS score of 1-4), moderate (5-14), or severe (>14). Associations of post-stroke frailty were studied using logistic regression.

Results: A total of 143 patients with stroke (mean age 58 ± 10 years, male 91 [63.6%]) with a mean follow-up of 2.7 (±1.6) years were studied. Of them, 141 (98%) were functionally independent before stroke onset. The majority (115 [80.4%]) had ischemic strokes, and 106 (74%) patients had moderate to severe strokes (admission NIHSS ≥5). On follow-up, 47 patients (33%) were frail (CFS ≥5), with 13 patients (9.1%) having moderate to severe frailty (CFS 6-9). Functional dependence on follow-up was seen in 33 patients (23%). Post-stroke frailty was independently associated with increasing age (p = 0.012), diabetes (p = 0.039), and admission stroke severity (p = 0.001) in a multivariable analysis. Biological sex, stroke type, other vascular risk factors, and duration of follow-up were not associated with post-stroke frailty.

Conclusions: This is the first report on post-stroke frailty in South Asia. One-third of stroke survivors were frail on follow-up. Older age, diabetes and stroke severity were independent predictors of post-stroke frailty.

Background: Cerebral small vessel disease (CSVD) is closely linked to stroke and dementia, marked by structural and functional impairments of small blood vessels in the brain.

Summary: This review focuses on how vascular smooth muscle cells (SMCs) contribute to CSVD progression. SMCs regulate cerebral blood flow, maintain vascular structure, and support glymphatic waste clearance under physiological conditions. However, in the context of CSVD, these cells undergo pathological alterations, such as hypertrophy, degeneration, phenotypic switching, and extracellular matrix abnormalities. These dysregulations are associated with malfunctions in multiple signaling pathways or disrupted mechanical cellular responses. Emerging treatments, such as drugs targeting cyclic nucleotide pathways, show promise in improving blood flow and vascular stability.

Key messages: Despite progress, the molecular mechanisms underlying SMC dysfunction in CSVD remain incompletely understood. A deeper exploration of SMC biology, coupled with clinical translation of preclinical findings, is critical for developing effective therapies to address the escalating burden of CSVD.

Introduction: Organizing acute stroke care effectively reduces disability and mortality. Since the Ministry of Health in Brazil established the National Stroke Policy in 2012, stroke care has improved significantly. However, despite the increase in stroke centers, some hospitals have not fully implemented the recommended structure and protocols. This study aims to evaluate the quality of stroke services in Brazil based on the World Stroke Organization (WSO) Roadmap, marking the first step toward the Certification of Stroke Centers in Latin America.

Method: From 2020 to 2022, we assessed the structure of stroke centers in Brazil via an online survey based on the WSO Roadmap. When multiple responses came from the same hospital, we checked for consistency and contacted the stroke center coordinator if needed. We then compared these findings to the structure of stroke centers available in 2008, before the national stroke plan began.

Results: The number of stroke centers in Brazil increased from 35 in 2008 to 246 in 2022, with 216 centers assessed in this study (102 Essential, 114 Advanced). Advanced centers were mostly private (69%). Of all hospitals, 51% serve public health patients, 75% as Essential centers. The southeast and south region have the highest number of stroke centers (77%). All hospitals provided essential blood tests, CT scans, and thrombolytic therapy, with 97% having pre-hospital emergency services. Neurologists were available 24/7 in 85% of centers (49% on call, 35% on duty, 16% via telemedicine), and 46% of hospitals had stroke units. Nearly 90% had acute neurosurgical care, and 47% offered endovascular thrombectomy 24/7. Advanced centers implemented 85% of the WSO Roadmap items and Essential centers 76%. According to WSO/SIECV Certification, 39 centers were prepared for certification, and 18 were certified (6 private: Advanced, 12 public: 4 Advanced, 8 Essential).

Conclusion: Brazil has significantly improved its stroke care structure, but disparities and areas for further enhancement remain, particularly in equity, resource access, and best practices implementation. Certification programs could help address these issues and improve outcomes for stroke patients.

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 (CON) were included in this study. We performed 16S rRNA sequencing of fecal samples, analyzed microbiome diversity and composition, and quantified SCFA and organic acid levels using liquid chromatography.

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

Conclusion: Decreased L. 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 5 min 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 1 and 7. 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: Adaptive platform trials represent a paradigm shift in stroke research. We examined how patient-partners perceived the design and execution of an international platform trial in acute stroke, ACT-GLOBAL (A multi-faCtorial, mulTi-arm, multi-staGe, randomized, gLOBal Adaptive pLatform trial for stroke), through a series of focus groups with process evaluation methodology.

Methods: Participants were recruited from two comprehensive stroke centers one in Calgary, Canada and one in Sydney, Australia. Four virtual focus groups were attended by a total of 21 patient-partners and 11 clinician-researchers. One focus group had repeat attendees to review a draft consent form and patient information sheet, and one presented a video describing platform trials. Physician facilitators presented the platform trial concept followed by a facilitated discussion. Audio recordings were transcribed and combined with field notes. Exemplar quotes and themes were identified separately for each group and subsequently across groups.

Results: Patients/caregivers perceived acute stroke-focused adaptive platform trials such as ACT-GLOBAL as providing potentially beneficial opportunities to be randomized to multiple treatments, with efficiencies and richer data to improve patient care. Emphasis was given to the importance of gatekeeper processes for the addition of future questions posed by the platform to ensure examined questions would not interfere with routine care, and that safety decisions were ultimately made by nonconflicted parties. They appreciated that deferral of consent would be ideal to allow timely randomization/treatment within the adaptive stroke platform, and for patient safety to be prioritized in enrolment-related decisions with family input whenever feasible. The need to have trial information accessible in digestible chunks, multiple languages, and modalities was emphasized. To facilitate engagement, transparency, trust, and two-way communication was deemed critical to the informed consent process.

Conclusion: Patient-partners were supportive of an adaptive platform trial design. However, they expressed important priorities in their execution while safeguarding patient autonomy and safety. Oversight, multiple modes of delivering patient information, and having feedback evaluation and transparency with ongoing participation were identified as valued components. Deferral of consent was recognized as a pragmatic way to enroll patients. Similar considerations may apply to adaptive platform trials in other neurological/medical emergencies.

Introduction: Stroke causes significant death and disability, with urban-rural disparities in healthcare and limited studies in India, despite its rural majority of 70%. The post hoc study aimed to explore differences in stroke profiles, risk factors, and outcomes between urban and rural participants using data from the Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in India (SPRINT INDIA) trial.

Methods: The SPRINT INDIA trial was a multi-center randomized clinical trial across 31 Indian sites. Data were collected between April 28, 2018, and November 30, 2021. Index stroke patients, aged 18 and older, presenting within 2 days to 3 months of symptom onset, were randomized using a centralized web-based system into intervention or control groups. The intervention included SMS, videos, and an interactive educational workbook for secondary stroke prevention in 11 Indian languages. Baseline data captured in a case report form included participants' urban or rural locations. The primary outcome was a composite endpoint that included recurrent stroke, high-risk transient ischemic attack (TIA), acute coronary syndrome (ACS), and all-cause mortality within 1 year after randomization. The trial is registered by Clinicaltrials.gov (NCT03228979) and Clinical Trials Registry-India (CTRI/2017/09/009600).

Results: The trial enrolled 4,298 sub-acute stroke patients, out of which 3,038 (70.68%) were followed up, of which 1,620 (53.32%) were urban and 1,418 (46.68%) were rural. The primary composite outcome (recurrent stroke, high-risk TIA, ACS, and mortality) was higher in urban areas compared to rural areas (61 [3.8%] vs. 34 [2.4%]; p = 0.018) at 1-year follow-up. All cases of high-risk TIA occurred in urban participants (p < 0.001). Urban participants were more educated (795 [49.1%] vs. rural 394 [27.8%]; p < 0.001), with higher rates of dyslipidemia (335 [20.7%] vs. 247 [17.4%]; p = 0.023), and higher body mass index (25.17 ± 4.31 vs. 24.76 ± 4.23; p = 0.008). Behavioral risk factors of alcohol intake and smoking tobacco were higher in rural patients compared to urban patients (65 [4.6%] vs. 73 [4.5%]; p < 0.001 and 59 [4.2%] vs. 65 [4.0%]; p < 0.001, respectively).

Conclusion: Urban patients show higher stroke recurrence and lifestyle-related conditions, while rural patients face more behavioral risks like smoking and alcohol use. To address these disparities, requires targeted interventions; urban patients would benefit from lifestyle-focused programs, such as dietary improvements and stress management. For rural patients, programs should focus on reducing behavioral risks like smoking and alcohol use through community-based education and accessible cessation support services.

Introduction: There is increasing evidence that middle meningeal artery embolization (MMAE) can be used to treat chronic subdural hematoma (cSDH). The purpose of this study was to demonstrate the efficacy and safety of MMAE treatment through a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs).

Methods: We searched the PubMed, Embase, Cochrane Library, and Web of Science databases to obtain articles related to MMAE from inception to December 3, 2024. The effectiveness outcomes were recurrence, progression, or reoperation of subdural hematoma after treatment, 90-day mRS 0-2, and 90-day mRS 0-3. The safety outcomes were severe deterioration of neurologic function and death within 180 days. The quality of the RCTs was evaluated with the Cochrane risk assessment tool, while the cohort studies were evaluated by the Newcastle-Ottawa Scale (NOS). The random-effect model was used to calculate the effect as risk ratio (RR). The heterogeneity of the results of each study was analyzed by χ2 test.

Results: A total of 892 articles are retrieved. Among those, 4 RCTs and 5 cohort studies met the inclusion criteria. The RCT analysis showed that MMAE plus traditional treatment reduced the risk of recurrence or progression of hematoma compared with traditional treatment alone (5.3% vs. 9.1%; RR: 0.58, 95% CI, 0.39-0.86, p = 0.03). The heterogeneity was very low (I2 = 22%). There was no significant difference between the two groups for the 90-day mRS 0-2 and 0-3 scores (p = 0.73/p = 0.71, respectively). In terms of safety outcomes, the 180-day mortality was 3.5% in the MMAE plus traditional treatment group and 5.0% in the traditional treatment group (p = 0.49 > 0.05). Neurological deterioration was present in 4.6% of patients with MMAE plus traditional treatment compared to 3.9% with traditional treatment (p = 0.44 > 0.05). Across the 5 cohort studies, similar results were obtained for the incidence of recurrence, progression or reoperation of subdural hematoma (12.9% vs. 40.6%; RR: 0.26, 95% CI, 0.07-0.95, p = 0.04), but the heterogeneity was very high (I2 = 89%).

Conclusion: This systematic review and meta-analysis showed that in cSDH patients, MMAE was associated with a reduced rate of recurrence, progression or reoperation of the subdural hematoma compared to traditional treatment with surgery without increasing the incidence of death or adverse events.

Introduction: Detecting atrial fibrillation (AF) in patients with embolic stroke of undetermined source (ESUS) is crucial for effective secondary stroke prevention, particularly in those with left atrial enlargement (LAE), as they have a higher risk of subclinical AF. This study aimed to evaluate and compare the efficacy and safety of a patch-type cardiac monitoring device (PCM) in detecting AF in ESUS patients with LAE.

Methods: This prospective, multicenter, open-label, randomized, controlled, investigator-initiated trial will recruit a total of 370 ESUS patients with LAE and randomize them in a 1:1 ratio into two groups: the intervention group, which will receive continuous monitoring with the PCM for 1 week, and the control group, which will undergo a single 12-lead electrocardiogram. LAE will be defined as a left atrial diameter greater than 40 mm in males and greater than 38 mm in females or a left atrial volume index exceeding 35. The primary endpoint is the proportion of participants with detected AF. Secondary endpoints include AF burden, detection of other arrhythmias, and the incidence of tachycardia, bradycardia, premature atrial contractions, and atrial flutter. A post hoc analysis will explore factors influencing AF detection and aim to develop a predictive model based on clinical and imaging data.

Conclusion: This trial is expected to provide valuable insights into the safety and efficacy of PCM in detecting AF, potentially influencing clinical strategies for AF detection and management in ESUS patients with LAE.