Cerebrovascular Diseases最新文献

Introduction: This research explored the factors influencing early neurological outcomes (ENO) in patients who had vertebrobasilar artery occlusion (VBAO) and received endovascular treatment (EVT), as well as examining the causal influence of ENO on the prognosis of VBAO patients.

Methods: A retrospective review was carried out on patients from 65 Chinese stroke centers, all within 24 h of the estimated occlusion time. ENO includes early neurological improvement (ENI) and early neurological deterioration (END), defined as a decrease or an increase of at least 4 points in NIHSS score between baseline and 24 h after EVT. Death within 24 h after EVT was also considered as END. END was further divided into explained END and unexplained END (unEND). Independent predictors of ENO and the association between ENO and outcomes in patients with VBAO were determined using center-adjusted analyses. The study developed a multivariate logistic regression model to examine the comparative risk of unEND versus explained END on the clinical outcomes in VBAO patients.

Results: A total of 2,257 patients were included. Glasgow Coma Scale (GCS) (OR: 1.16, 95% CI: 1.03-1.30) and successful reperfusion (OR: 1.15, 95% CI: 1.02-1.30) were associated with ENI. Baseline NIHSS (OR: 0.60, 95% CI: 0.53-0.68), successful reperfusion (OR: 0.79, 95% CI: 0.71-0.89), and puncture to reperfusion time (OR: 1.17, 95% CI: 1.03-1.33) were associated with END. When examining 3-month prognostic indexes, both END and ENI were found to be linked to the 3-month outcomes, but in opposite directions. A subgroup analysis of END suggested that unEND typically demonstrated a more favorable prognosis compared to explained END, although the prognosis remained generally unfavorable.

Conclusions: ENO, whether they manifested as early improvement or deterioration, were linked to the prognosis of VBAO patients undergoing EVT. The outcomes after unEND were more favorable than those following explained END.

Introduction: While patients who experience improved cognition following carotid endarterectomy (CEA) typically demonstrate restored brain perfusion after the procedure, it is worth noting that less than 50% of patients in whom postoperative cerebral blood flow (CBF) restoration is achieved actually show improved cognition after postoperatively. This suggests that factors beyond the mere restoration of CBF may play a role in postoperative cognitive improvement. Increased iron deposition in the cerebral cortex may cause neural damage, and quantitative susceptibility mapping (QSM) obtained using magnetic resonance imaging (MRI) quantifies magnetic susceptibility in the cerebral cortex, allowing for the assessment of iron deposition in vivo. The purpose of the present study was to determine whether preoperative cortical magnetic susceptibility as well as postoperative changes in CBF are associated with cognitive improvement after CEA.

Methods: Brain MRI with a three-dimensional gradient echo sequence was preoperatively performed in 53 patients undergoing CEA for ipsilateral internal carotid artery stenosis (≥70%), and QSM with brain surface correction and vein removal was obtained. Cortical magnetic susceptibility was measured in the cerebral hemisphere ipsilateral to surgery on QSM. Preoperatively and at 2 months after the surgery, brain perfusion single-photon emission computed tomography and neuropsychological assessments were conducted. Using these collected data, we evaluated alterations in CBF within the affected hemisphere and assessed cognitive improvements following the operation.

Results: A logistic regression analysis showed that a postoperative greater increase in CBF (95% confidence interval [CI], 1.06-1.90; p = 0.0186) and preoperative lower cortical magnetic susceptibility (95% CI, 0.03-0.74; p = 0.0201) were significantly associated with postoperatively improved cognition. Although sensitivity, specificity, and positive and negative predictive values with the cutoff value lying closest to the upper left corner of a receiver operating characteristic curve for the prediction of postoperatively improved cognition did not differ between postoperative changes in CBF and preoperative cortical magnetic susceptibility, the specificity and the positive predictive value were significantly greater for the combination of postoperative changes in CBF and preoperative cortical magnetic susceptibility (specificity, 95% CI, 93-100%; positive predictive value 95% CI, 68-100%) than for the former parameter alone (specificity, 95% CI, 63-88%; positive predictive value 95% CI, 20-64%).

Conclusion: Preoperative cortical magnetic susceptibility as well as postoperative changes in CBF are associated with cognitive improvement after CEA.

Introduction: Existing randomised controlled trials assessing the safety and efficacy of left atrial appendage occlusion (LAAO) in atrial fibrillation (AF) were of relatively small sample size or included patients who could receive oral anticoagulant treatment after device implantation. We compared the outcomes of patients with newly diagnosed AF who received percutaneous LAAO or direct oral anticoagulant (DOAC) treatment, in a large population from a global federated health network (TriNetX).

Methods: Patients with AF treated with percutaneous LAAO were matched with those treated with DOAC between December 1, 2010, and October 1, 2018. Outcomes were all-cause mortality, ischaemic stroke, and intracranial haemorrhage (ICH) at 5 years.

Results: We included 200 patients with AF, who received either LAAO or DOAC. The risk of all-cause mortality, ischaemic stroke, and ICH at 5 years was not significantly different between the two groups (risk ratio [RR] for all-cause mortality: 1.52, 95% confidence interval (CI): 0.97-2.38, RR for ischaemic stroke: 1.09, 95% CI: 0.51-2.36, and RR for ICH: 1.0, 95% CI: 0.44-2.30).

Conclusion: Patients newly diagnosed with AF, eligible for DOAC, showed similar 5-year risk of death, ischaemic stroke, and ICH when comparing those who underwent percutaneous LAAO to those receiving DOAC. Future randomised controlled trials are needed to confirm the findings and advise changes in guidelines.

Introduction: Chronic subdural hematoma (CSDH) is characterized by the collection of blood beneath the dura mater. Traditional treatments involve surgical drainage of the hematoma, but recurrence rates can be high. A highly vascularized neo-membrane irrigated by the middle meningeal artery (MMA) may be involved in CSDH re-accumulation. We conducted a systematic review and meta-analysis of studies that compared the efficacy and safety of MMA embolization to conventional treatment alone for CSDH.

Methods: A systematic search of PubMed, Embase Ovid, and ClinicalTrials.gov identified observational and randomized clinical studies comparing MMA embolization to conventional treatment for CSDH. The efficacy outcomes were hematoma recurrence and good functional outcome (as defined by a modified Rankin Scale Score [mRS] of 0-2). Safety outcomes were the rate of major complication and mortality. Heterogeneity among studies were evaluated using the I2 statistic. Analyses were conducted using Cochrane Review Manager Software, with risk ratios (RRs) and 95% confidence intervals (95% CI) presented for key outcomes. Absolute risk reduction (95% CI) of 1,000 patients was also calculated using GRADEpro software.

Results: The analysis included data from 13 studies (4 randomized clinical trials [RCTs] and 9 observational studies) with a total number of 2,960 patients (35.3% in the MMA group and 64.7% in the conventional treatment group). Compared to conventional treatment, MMA embolization decreased risk of hematoma recurrence by 59% (13 studies, RR = 0.41, 95% CI: 0.26-0.65; I2 = 49%), for an absolute effect of 116 fewer events/1,000 patients (95% CI: 69-145), with similar risk of major complications (13 studies, RR = 0.88, 95% CI: 0.67-1.15; I2 = 43%) and mortality risk (13 studies, RR = 1.05, 95% CI: 0.67-1.65). In subgroup analyses by study type, pooled results from RCTs showed similar direction effects as those from observational studies for both efficacy and safety outcomes.

Conclusion: MMA embolization in CSDH management is a safe and effective approach for CSDH.

Introduction: There remains a lack of consensus among physicians regarding the blood pressure (BP) management strategy for acute ischemic stroke patients; this study sought to determine current practice patterns and extension of consensus among stroke physicians after publications of several randomized controlled trials (RCTs).

Methods: An online survey of stroke clinicians registered to the Oriental Conference of Interventional Neurovascology (OCIN) platform and Enhanced Control of Hypertension and Thrombectomy Stroke Study (ENCHANTED2/MT) trail collaborators was conducted to investigate the BP management strategy after mechanical thrombectomy (MT). The survey was sent out in March 2024, extracted within 1 month, and then analyzed comprehensively using descriptive statistics.

Results: A total of 351 available responses were collected and analyzed. These participants mostly come from tertiary-level hospitals (90.6%) in 31 provinces in China. During MT, the most popular a BP target was 140-160 mm Hg (36.5%, 128/351) and 120-140 mm Hg (26.8%, 94/351). For patients achieved successful reperfusion, those who achieved expanded treatment in cerebral infarction (eTICI) 3 were expected to maintain BP target of 120-140 mm Hg (56.7%, 199/351) or <120 mm Hg (27.1%, 95/351), while eTICI 2b were wished to 120-140 mm Hg (45.3%, 159/351) or 140-160 mm Hg (38.5%, 135/351). For patients who achieved unsuccessful reperfusion, the most selected BP target was 140-160 mm Hg (40.7%, 143/351). In brief, clinical doctors from China with different experiences have different views on the goals of BP management.

Conclusions: The survey highlights inter-institutional variability among stroke experts regarding the optimal BP target for acute ischemic stroke. While a majority of institutions have established standardized protocols for post-MT BP management, further prospective randomized trials are warranted to determine the optimal BP target.

Introduction: Global burden of stroke mortality tended to be higher among men. A disproportionate stroke burden has been placed upon women, primarily because of life expectancy, putting a more significant burden in this population. The purpose of this study was to address sex differences in stroke epidemiology and treatment in Fortaleza, Brazil.

Methods: Between April 2009 and 2012, data were prospectively gathered from 19 hospitals, following the WHO's Stroke Steps program, stratified by sex assigned at birth.

Results: We included 4,679 patients, 2,403 females. Women mean age was 69.1 (±15.2) years and 66.2 (±13.5) years in males (p < 0.01). Females were more often white, while time to hospital admission and CT scan from symptom onset were similar across sexes. Men more commonly presented with motor, speech, and sensory symptoms, whereas women were more likely to present with reduced consciousness and headaches. Additionally, women had higher rates of diabetes and obesity. Men were more frequently smokers and had higher rates of alcohol misuse, as well as a history of heart attacks or strokes. We utilized univariable logistic regression to assess mRS scores at discharge, in scores 0-2 (lesser disability) and scores 3-6 (more significant disability). The dependent variable regards scores that are above 3. Fewer women than men achieved a modified Rankin Score of ≤2 (77.6% versus 81.7%; p < 0.01). Multivariable analysis identified the female gender as an independent predictor of having a higher mRS score at discharge (OR 1.23; 95% CI [1.01-1.51]; p = 0.04).

Conclusion: Our study, one of the largest South American epidemiological studies on patients admitted with stroke, highlights the sex-specific nuances in stroke outcomes. Our findings underscore that risk factors for stroke vary significantly between men and women, thereby necessitating tailored preventive strategies.

Introduction: Stroke characteristics, subtypes, and risk factors in women may differ from men. Data on sex differences in stroke are scarce in developing countries, especially the South Asian region. We aimed to describe the sex differences in patients with stroke admitted to a tertiary care hospital in Sri Lanka.

Methods: Consecutive patients with stroke enrolled in the Ragama Stroke Registry over 3 years (2020-2023) were studied. Sex differences in demographics, presentation delays, clinical characteristics, stroke subtypes, risk factors, stroke severity, and early functional outcomes were compared using χ2 test, independent sample t test and Wilcoxon rank-sum test. Associations of early functional dependence were studied using multiple logistic regression.

Results: Of 949 patients with stroke, 387 (40.8%) were women, with a median age of 66 (interquartile range [IQR] 57-73) years compared to 63 (IQR 54-70) years in men (p < 0.001). Women had more ischaemic strokes (85.8% vs. 78.6% in men, p = 0.005). Swallowing difficulty (p = 0.039) and bladder involvement (p = 0.001) were more common in women, whereas dysarthria (p = 0.002) and cerebellar signs (p = 0.005) were more common in men. More women had hypertension (74.4% vs. 59.4%, p < 0.001) and diabetes (52.2% vs. 41.6%, p = 0.001), whereas smoking (0.3% vs. 35.1%, p < 0.001), alcohol use (0.3% vs. 55.0%, p < 0.001), and other substance abuse (0.8% vs. 5.2%, p < 0.001) were almost exclusively seen in men. No differences were noted in delays to hospital admission (delay ≥4.5 h: women 45.4% vs. men 41.3%, p = 0.222). There were no sex differences in the rates of CT scanning (women 100% vs. men 99.6%, p = 0.516) or thrombolysis for ischaemic stroke (women 7.8% vs. men 10.2%, p = 0.458), but more men received stroke unit care (women 37.2% vs. men 45.4%, p = 0.012). No differences were noted between sexes in the clinical (Oxfordshire classification, p = 0.671) or aetiological (TOAST criteria, p = 0.364) subtypes of stroke. Stroke severity on admission was similar between sexes (median NIHSS score; women 8.0 vs. men 8.0, p = 0.897). More women had a discharge Barthel index (BI) <60 than men (62.6% vs. 53.5%, p = 0.007), but female sex was not associated with BI <60 on multivariate logistic regression (p = 0.134). There was no difference in in-hospital mortality (women 5.9% vs. men 5.9%, p = 0.963).

Conclusions: Women with stroke in this Sri Lankan cohort were older, had different risk factor profiles and clinical stroke characteristics, and had more ischaemic strokes. Female sex was not independently associated with functional disability on discharge or in-hospital mortality.

Introduction: There are no specific screening recommendations for post-stroke osteoporosis despite evidence that people post-stroke are at heightened risk of fragility fractures. Our objective was to explore the extent of evidence and map the current literature available for osteoporosis screening in the post-stroke population.

Methods: This scoping review searched for articles in MEDLINE, Embase, and CINAHL databases published in English before May 2024, involving osteoporosis screening for adults after stroke. Title and abstract screening as well as full-text review and data extraction was performed by two reviewers. Analysis of the studies is descriptive and narrative.

Results: Eight articles met inclusion criteria: five published articles and three peer-reviewed conference abstracts. Three study designs were utilized: four cross-sectional studies, three cohort studies, and one survey. Four studies investigated post-stroke osteoporosis screening rates, two looked at screening pathways for post-stroke osteoporosis, and two assessed novel osteoporosis screening tools. No post-stroke osteoporosis screening guidelines were found. Across all included studies, reported screening rates for post-stroke osteoporosis were less than 10%.

Conclusions: This scoping review emphasizes the need for osteoporosis screening guidelines and risk assessment tools specific to the post-stroke population.