Cerebrovascular Diseases最新文献

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.

Introduction: White matter hyperintensity (WMH) is typically classified into periventricular and deep WMH (PVWMH and DWMH) based on its proximity to the ventricles. While WMH volume has been associated with the cognitive performance and decline in patients with cerebral small vessel disease, the relative contributions of PVWMH and DWMH to the cognitive profile of these patients remain unclear. Therefore, we aimed to determine the differences in association of PVWMH and DWMH with a battery of cognitive tests in a group of middle-aged population at risk for cardiovascular disease.

Methods: Participants in the Genetic Study for Atherosclerosis Risk (GeneSTAR) who had a brain magnetic resonance imaging, a cognitive battery, and were older than 50 years of age were studied. The relative association of PVWMH and DWMH with each of the cognitive measures was tested using multilevel linear regression models adjusting for age, intracranial volume, and cardiovascular risk factors. Adjustment for multiple comparisons was completed by using Benjamini-Hochberg procedure for the primary outcome and q-value of <0.1 was considered significant. Maximal likelihood estimation analysis was used to explore whether age moderated the difference in association of PVWMH and DWMH with the cognitive tests.

Results: A total of 435 participants (age 58.9 ± 6.14 years, 58.38% women, and 39.54% black) were studied. We identified a greater association of PVWMH than DWMH with a worse performance on the grooved peg board test (q-value = 0.06) including the dominant (q-value = 0.098) and nondominant hand (q-value = 0.098) performance as well as the delayed word recall test in its short form (q-value = 0.098). Age did not moderate the differences in the association of PVWMH and DWMH with these cognitive tests.

Conclusions: Our findings indicate a greater effect of PVWMH than DWHM on manipulative manual dexterity and delayed word recall functions suggesting potential injury of the white matter tracts that are relevant to these function by PVWMH. These findings need to be confirmed in future large prospective studies.

Introduction: The adequacy of blood flow from the leptomeningeal collaterals is considered one of the most important factors determining the rate of infarct progression and response to acute stroke treatments in the setting of large vessel occlusions. Several patient-related variables, including age, vascular risk factors, and laboratory parameters, have been proposed to explain the interindividual variability of collateral flow among stroke patients. This study aimed to assess how pre-stroke frailty, an aging-related syndrome characterized by a loss in the physiologic reserve of numerous body functions, affected the degree of leptomeningeal collateral flow in the setting of acute ischemic stroke.

Methods: A consecutive series of patients presenting with proximal middle cerebral artery occlusion were enrolled in this prospective, multicenter observational study. Collateral flow was determined by the regional leptomeningeal collateral (rLMC) score on admission computed tomography angiography images. Pre-stroke frailty was assessed by the Edmonton Frailty Scale (EFS), based on the information obtained from patients or their next of kin. The relationship between collateral flow and frailty was evaluated by bivariate and multivariate analyses taking into consideration the demographic, clinical, and imaging characteristics of the patients.

Results: The study population was comprised of 116 patients (median [interquartile range] age 78 [71-84] years; 60% female). The EFS scores were negatively correlated with the rLMC score (r = -0.264; p = 0.004). A vulnerable or frail (EFS ≥6) status before stroke, higher blood pressure levels at admission, having imaging studies performed at an earlier phase after contrast injection, and presenting with thrombi extending to the proximal half of the M1 portion of the middle cerebral artery were significantly related to poor collateral circulation (rLMC score ≤10). After adjustment for potential confounders in multivariable analyses, a vulnerable/frail status was independently associated with poor leptomeningeal collateral flow (OR: 2.97 [95% CI: 1.15-7.69]; p = 0.025).

Conclusion: Our findings highlight that the leptomeningeal collateral flow is also compromised as part of the diminished physiologic reserve characterizing the frailty status in patients with acute ischemic stroke. Future studies are needed to understand how this interplay contributes to the unfavorable clinical outcomes observed in frail patients after stroke.

Introduction: Cerebral amyloid angiopathy (CAA) has a remarkably variable disease course, even in monogenetic hereditary forms. Our aim was to investigate the prevalence of vascular risk factors and their effect on disease onset and course in Dutch-type hereditary (D-)CAA and sporadic CAA.

Methods: We performed a cohort study in D-CAA to investigate the association between vascular risk factors (hypertension, hypercholesterolemia, smoking, and alcohol use) and age of intracerebral hemorrhage (ICH) onset and time of ICH recurrence with survival analyses. In addition, we performed a systematic review to assess the prevalence of vascular risk factors and their effect on clinical outcome in sporadic CAA. We searched PubMed, Embase, Web of Science, and Cochrane Library from 1987 to 2022 and included cohorts with ≥10 patients. We created forest plots, calculated pooled estimates, and reported variability (heterogeneity plus sampling variability) and risk of bias.

Results: We included 70 participants with D-CAA (47% women, mean age 53 years). Sixteen (23%) had hypertension, 15 (21%) had hypercholesterolemia, 45 (64%) were smokers, and 61 (87%) used alcohol. We found no clear effect of vascular risk factors on age of first ICH (log-rank test hypertension: p = 0.35, hypercholesterolemia: p = 0.41, smoking: p = 0.61, and alcohol use: p = 0.55) or time until ICH recurrence (log-rank test hypertension: p = 0.71, hypercholesterolemia: p = 0.20, and smoking: p = 0.71). We identified 25 out of 1,234 screened papers that assessed the prevalence of risk factors in CAA and 6 that reported clinical outcomes. The pooled prevalence estimates of hypertension was 62% (95% CI: 55-69%), diabetes was 17% (95% CI: 14-20%), dyslipidemia was 32% (95% CI: 23-41%), and tobacco use was 27% (95% CI: 18-36%). One study reported study diabetes and hypertension to be associated with a lower risk of recurrent ICH, whereas another study reported hypertension to be associated with an increased risk. All other studies showed no association between vascular risk factors and clinical outcome. High-quality studies focusing on vascular risk factors were lacking.

Conclusion: In patients with D-CAA and sporadic CAA, the prevalence of vascular risk factors is high. Although this suggests an opportunity for prevention, there is no clear association between these risk factors and CAA-related ICH onset and recurrence.