Cerebrovascular Diseases最新文献

Introduction: Patients with large vessel occlusion (LVO) stroke are often transferred from primary to tertiary stroke centres for endovascular thrombectomy (EVT). We previously showed that ≥33% improvement in National Institute of Health Stroke Scale (NIHSS) score correlated with early recanalization, obviating the need for EVT. We aimed to validate this correlation and assess cost savings if non-invasive imaging was performed prior to digital subtraction angiography (DSA).

Methods: Patients transferred to an Australian tertiary stroke centre for possible EVT between January 2023 and April 2024 and underwent DSA with or without EVT were included. Changes in NIHSS between transfer and arrival, demographic, treatment, and anatomical factors were collected. NIHSS changes were correlated with early recanalization. Real-time costs of in- and out-of-hours neuroimaging and DSA were calculated.

Results: A total of 257 transferred patients with LVO were included (30% female, median age 71 [IQR 61-79]). The median presentation NIHSS was 14 (IQR 10-19). A total of 129 (50%) patients received intravenous thrombolytics. Twenty-seven (11%) patients demonstrated early recanalization and did not require EVT. Threshold of ≥33% NIHSS improvement remained the best trade-off between sensitivity (74%) and specificity (88%) for recanalization. The hyperacute investigation and treatment costs in/out-of-hours per patient were AUD 1,491 and AUD 3,591. Costs if patients with ≥33% NIHSS improvement were non-invasively imaged prior to DSA were AUD 1,471 and AUD 3,548 - savings of AUD 34 per patient overall.

Conclusion: We validated that ≥33% neurological recovery between primary and tertiary stroke centre had the best sensitivity-specificity profile for predicting early recanalization. Modest cost savings occurred using this threshold, but in resource-poor settings, this may be more significant.

Introduction: The quality of stroke care in India is unknown. This multicentric study from the Indian Registry of Stroke Care Quality (RES-Q) provides prospectively entered stroke data from 46 stroke centers across the country. We analyzed demographics, therapeutic interventions, quality metrics, and functional outcomes of ischemic stroke from India.

Methods: It was an analysis of prospectively entered data into the RES-Q from 2022 to 2024. The inclusion criteria were patients ≥18 years of age with an acute ischemic stroke or transient ischemic attack based on the AHA/ASA 2019 criteria within 2 weeks of stroke onset. All demographic, clinical, and radiological details were entered into a predesigned proforma. All quality and performance measures in the hospital were collected.

Results: Approximately 80% of all strokes (n = 7,337) during the study period were ischemic. The median age was 61 years (interquartile range [IQR] 52-71), with 67% being male. The median National Institute of Health Stroke Scale at admission was 7 (IQR 4-12). Brain parenchymal imaging was done for all patients, but vascular imaging was performed for 60% of patients only. The thrombolysis rate was 32% with a median door-to-needle time of 37 min. Endovascular thrombectomy was performed in 6.5% of cases. Swallowing assessment was done in 72% of patients within 24 h of admission and 90% received physiotherapy in the stroke unit.

Conclusion: This landmark dataset marks the first comprehensive nationwide effort to assess stroke care quality in India. Routine quality monitoring through platforms like RES-Q can help standardize care, reduce disparities, and enable hospitals to benchmark performance and implement targeted improvements.

Introduction: Embolic stroke of undetermined source (ESUS) is frequently attributable to atrial fibrillation (AF), yet remains undetected when episodes are brief or asymptomatic. Digital health-enabled cardiac monitoring offers novel pathways for secondary prevention. Implantable loop recorders (ILRs) provide continuous long-term rhythm surveillance, while wearable electrocardiogram (ECG) devices offer greater accessibility but with uncertain diagnostic yield and economic value. We evaluated the cost-effectiveness of ILR versus wearable AF monitoring and usual care in ESUS.

Methods: A cohort-based Markov model simulated 1,000 ESUS patients (mean age 65 years) over a 10-year horizon from the German statutory health insurance perspective. Clinical inputs included AF detection rates (ILR: 15-25%; wearables: 5-10%), risk reduction in ischemic stroke with oral anticoagulation (OAC), and mortality/disability utilities. Costs (EUR 2,024, 3% discount) captured device acquisition, implantation, follow-up, stroke care, and OAC therapy. Outcomes included incremental cost-effectiveness ratio (ICER) and incremental net monetary benefit at willingness-to-pay thresholds of EUR 20,000, EUR 30,000, and EUR 50,000/quality-adjusted life-year (QALY). Deterministic and probabilistic sensitivity analyses, including expected value of perfect information (EVPI), were performed.

Results: ILR yielded 0.23 additional QALYs compared with wearables at an incremental cost of EUR 2,160, resulting in a base-case ICER of EUR 9,391/QALY. In a high-risk subgroup, the ICER decreased to EUR 5,520/QALY. Probabilistic analysis demonstrated >90% probability of cost-effectiveness at EUR 30,000/QALY, with moderate EVPI. These findings align with meta-analytic evidence (RR 3.88 for AF detection; RR 0.75 for stroke reduction) and indicate that prolonged monitoring (≥12 months) maximizes yield.

Conclusion: Digital health-enabled ILR monitoring is likely cost-effective for AF detection after ESUS, particularly in high-risk patients. Wearables may serve as an adjunct but deliver lower value. Results support targeted ILR implementation in post-ESUS care pathways and integration into digital health-driven guideline and reimbursement frameworks.

Background: Traditional medicines are used to meet a variety of health needs by people across India but few data exist for their use by those affected by stroke. We aimed to the prevalence, costs and determinants of traditional medicines used by patients with stroke, and in relation to defined socio-demographic characteristics.

Methods: This study presents a post-hoc analysis of the Family-led Rehabilitation after Stroke in India (ATTEND), a multicentre, prospective, randomised, open blinded endpoint (PROBE) trial conduced at 14 hospitals in India. Data were obtained on the use of non-modern medical treatments and associated financial implications. Multivariable logistic regression was used to identify the predictors of traditional medicine use and reported as odds ratio (aOR) and 95% confidence intervals (CI). Financial impacts and their 95% uncertainty intervals were estimated for all new stroke cases in 2022 (80 INR= 1 USD).

Results: Of 1,250 randomised participants, 968 had sufficient data for analysis [Age 57.7(13.6) years]. The overall prevalence of traditional medicine use was 21.1%. Lower use of traditional medicine was associated with high school/college education (aOR 0.55, 95% CI 0.30,0.98) and mild neurological severity (National Institutes of Health Stroke Scale [NIHSS] score <5; aOR 0.32, 95% CI 0.14, 0.72). There was no significant association with age (aOR 1.76, 95% CI 0.85, 3.64), unemployment (aOR 2.16, 95% CI 0.99, 4.74), pre-stroke dependency (aOR 1.96, 95% CI 0.46, 8.36) and living accommodation (aOR 1.13, 95% CI 0.53, 2.41). We calculated that traditional medicine costs US$ 67 million annually: a higher cost burden among men (US$ 36 million) compared to women (US$ 31 million; 80 INR= 1 USD).

Conclusions: Our study indicates that one in five patients used traditional medicine following acute stroke in India, with significant financial bearings on individuals and their families. There is greater use in those with more severe strokes and with lower education. More evidence is required on the efficacy of traditional medicines and their role in the health care system.

Introduction: Cognitive impairment is a major complication of cerebrovascular diseases (CVDs), significantly affecting patients' quality of life. With limited approved pharmacological interventions, non-pharmacological approaches, such as remote ischemic conditioning (RIC), have emerged as potential therapeutic strategies. This systematic review and meta-analysis aimed to evaluate the efficacy of RIC in improving cognitive function in patients with CVDs.

Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted comprehensive searches across PubMed, Embase, the Cochrane Library (CENTRAL), and Web of Science for relevant studies published up to April 30, 2025. Study quality was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Pooled estimates were calculated using random-effects models, accounting for heterogeneity.

Results: Seven studies, involving 302 participants, met the inclusion criteria. Meta-analysis demonstrated that RIC significantly improved global cognitive performance (standardized mean difference [SMD] 0.65, 95% CI: 0.41-0.90, p < 0.00001). Notable improvements were observed in visuospatial and executive functions (SMD 0.61, 95% CI: 0.33-0.89, p < 0.0001). However, no significant effects were found in other cognitive domains, including naming, attention, language, abstract reasoning, delayed recall, and immediate memory. Heterogeneity across studies varied by outcome.

Conclusion: RIC shows promise for improving visuospatial/executive functions in CVD (SMD = 0.61, p < 0.0001), though effects in other cognitive domains remain inconclusive. Large-scale trials with comprehensive assessments, mechanistic neuroimaging, and extended follow-up are needed to establish sustained clinical benefits.

Introduction: Although guidelines recommend smoking cessation after stroke, smoking cessation may not be adequately prioritized in stroke units. This study evaluated the practices of French stroke neurologists with respect to smoking cessation and sought to identify barriers to their involvement.

Methods: All French stroke units were invited by e-mail to fill an online questionnaire, with reminders sent every 15 days. Questions quantified the implementation in stroke units of practices derived from the Ask, Advise, Assess, Assist, Arrange model of tobacco treatment clinical guidelines on Likert scales, and were summed in an ad hoc total interventionism summary indicator (range 0-45). Associations were analyzed using multivariable mixed models adjusting for workplace clustering.

Results: Between September 2022 and July 2023, responses were received from 453 neurologists (42% of an estimated 190) across 103 stroke units (82% of 126 units). In total 60% of them declared having had no training about smoking cessation care. Most frequent obstacles identified to ideal care were patient reluctance to stop smoking (66%) and limited access to tobacco specialists (55%). Seniority (attending/teaching physician status), high self-rated familiarity with smoking cessation management, and availability of a tobaccologist, were all independently associated with more interventions (adjusted on workplace effect) (Bonferroni-corrected p ≤ 0.02 for all).

Conclusion and perspectives: The survey suggests that most French neurologists provide incomplete smoking cessation care to stroke unit patients. Stroke physician self-assessment/retraining and on-site availability of tobacco specialists seem to be promising interventions.

Introduction: We sought to investigate the dynamic changes in cerebral blood flow (CBF) and heart rate (HR) and their interconnectivity in response to active standing, a physiological model to simulate rapid blood pressure fluctuation, in patients with intracranial atherosclerotic stenosis (ICAS).

Methods: The study was a cross-sectional analysis within a prospective cohort. Transcranial Doppler monitoring was performed in 302 middle cerebral arteries from 182 subjects. All subjects started in the supine position, followed by rapid standing. The CBF velocity and HR trend curves were recorded and compared between the groups.

Results: After the subject stood up, the CBF velocity curve showed a rapid decrease followed by a rebound, while the HR curve showed a rapid increase and dropped back to the baseline. The time to peak CBF velocity rebound was prolonged in the stenotic arteries (19.53 ± 3.8 s) compared with the normal arteries (17.09 ± 3.09 s) (p < 0.001). In patients with ICAS, the maximum HR rangeability was lower (18.1 ± 8.1 vs. 21.3 ± 7.1 bpm, p = 0.013) and the HR variability (HRV) had a trend lower (1.20 ± 0.134 vs. 1.24 ± 0.118, p = 0.07) than the normal controls. The mediating effect analysis showed that the HRV acted as a partial mediating factor of the stenosis on the prolongation of the time to peak CBF velocity rebound, and the proportion of the mediating effect was 12.76%.

Conclusions: The CBF in the intracranial stenotic artery has a blunt response to rapid blood pressure fluctuation, which could be partially mediated by the decrease in HRV, suggesting a new potential heart-brain talk. HR monitoring could be considered in the management of ICAS-related cerebral hypoperfusion.

Introduction: Covert brain infarctions (CBIs) are imaging-detected ischaemic lesions without overt neurological symptoms. Their role in determining short-term outcomes and recurrence risk in acute ischaemic stroke (AIS) remains underexplored. Here, we aimed to evaluate the prevalence, predictors, and impact of CBI on outcomes and recurrence in patients with first-ever AIS in a South Indian cohort.

Methods: This was a single-centre ambispective observational study of patients with first-ever AIS who completed 1-year follow-up. Demographics, vascular risk profiles, imaging findings, including covert infarct location and phenotype, and outcome metrics (functional outcome and recurrence) were studied.

Results: We had 350 subjects in our study cohort. CBI was observed in 132 (37.7%) patients. Most common CBI locations were subcortical supratentorial (50.5%) and cortical supratentorial (27.2%). Frequent phenotypes included combined grey and white matter lesions (40%) and cavitatory lacunes (34.5%). CBI was significantly associated with older age (OR 2.38, p = 0.001), vertebrobasilar territory infarcts (OR 2.26, p = 0.004), watershed infarcts (OR 2.21, p = 0.012), and multiple embolic infarcts (OR 2.91, p = 0.001), but not with vascular risk factors or etiological subtypes. Though patients with CBI showed a trend towards increased recurrence risk in the early phase, functional outcomes at 1 year was favourable.

Conclusions: CBIs are prevalent in over one-third of first-ever AIS cases and are linked to specific infarct patterns and advanced age, rather than classic stroke risk factors. Though not associated with long-term disability, their presence may portend early recurrence. Recognition and characterization of CBI should inform post-stroke monitoring strategies and future preventative trials.

Introduction: Timely early reperfusion therapies improve stroke outcomes, but geographic barriers often limit patient access to these essential treatments. Innovative care models emerged as potential solutions to overcome these accessibility constraints. We introduce a new paradigm in stroke care: the marine mobile stroke units (MSUs).

Methods: This is a prospective study to evaluate the feasibility, image quality, and inter-rater reliability of images produced by portable brain computerized tomography (CT) scanner on a catamaran while exposed to winds, waves, and tides. We performed non-contrast brain portable CT scanning in healthy volunteers hourly, while the catamaran was docked on the river over 7 consecutive days. Six raters (3 neurologists and 3 radiologists) evaluated brain imaging. Twenty-three anatomical regions were assessed and categorized as ganglionic, supra-ganglionic, and posterior fossa. A quality imaging score ranges from 0 (lowest quality) to 5 (highest quality), with scores of 4 or 5 considered adequate image quality. We used Gwet's AC1 to assess inter-rater agreement. Radiation dose, safety data, and axis rotation data from catamaran were also collected.

Results: Of the 168 recruited participants, all completed the study. There were 3,864 anatomical locations included in the analysis. Adequate image quality was demonstrated in 94.9%, 93.0%, and 45.7% of anatomical items at the ganglionic, supra-ganglionic, and posterior fossa regions. Inter-rater agreement was substantial at the ganglionic level (Gwet's AC1 0.62, 95% CI: 0.54-0.70) and the supra-ganglionic level (Gwet's AC1 0.80, 95% CI: 0.74-0.85). The agreement at the posterior fossa level was fair (Gwet's AC1 0.21, 95% CI: 0.13-0.29). No adverse events occurred throughout the duration of the study.

Conclusions: Our study shows the feasibility and safety of a portable brain CT on a catamaran under real-world marine conditions. Our findings pave the way for testing the role of marine MSU for acute stroke management.

Introduction: Acute ischemic stroke (AIS) affects approximately 11.9 million people annually, with large vessel occlusion (LVO) accounting for 10-20% of cases. While endovascular thrombectomy (EVT) is established for AIS with LVO, recent trials have expanded treatment to patients with Alberta Stroke Program Early CT Score (ASPECTS) 3-5. However, the efficacy and safety of EVT in patients with ASPECTS ≤2, representing extremely large infarcts with poor prognoses, remain uncertain due to limited evidence. This study evaluates EVT outcomes in this high-risk population.

Methods: PubMed, Embase, and Web of Science were searched (January 1, 2010-September 20, 2024) for studies comparing EVT plus best medical treatment (BMT) versus BMT alone in AIS patients with ASPECTS ≤2. Outcomes included favorable functional outcome (FFO, mRS 0-2), moderate functional outcome (MFO, mRS 0-3), modified Rankin Scale (mRS) shift, symptomatic intracranial hemorrhage (sICH), any intracranial hemorrhage (ICH), and 90-day mortality. Unadjusted odds ratios (ORs) and risk differences with 95% confidence intervals (CIs) were calculated using a random-effects model. Heterogeneity was assessed with the I2 statistic.

Results: Seven studies involving 718 patients (305 EVT, 413 BMT) were included. EVT significantly improved FFO (11.8% vs. 1.6%; OR 5.39, 95% CI: 2.06-14.13, p = 0.0002), MFO (24.2% vs. 11.5%; OR 2.50, 95% CI: 1.53-4.09, p = 0.0003), and mRS shift (OR 1.64, 95% CI: 1.30-2.06, p < 0.001). However, EVT increased sICH (16.5% vs. 2.4%; OR 5.30, 95% CI: 1.03-27.39, p < 0.001) and any ICH (40.7% vs. 14.9%; OR 3.91, 95% CI: 2.24-6.83, p < 0.001). No significant difference in 90-day mortality was observed (45.5% vs. 50.8%; OR 0.72, 95% CI: 0.34-1.53, p = 0.40), though EVT showed a trend toward reduced mortality.

Conclusion: EVT significantly improves functional outcomes in AIS patients with ASPECTS ≤2; however, the absolute benefits remain modest, given the poor prognosis associated with large infarcts. While EVT increases hemorrhagic complications, it does not increase mortality and may provide meaningful benefits for carefully selected patients. Further large-scale trials are needed to refine EVT guidelines.