Cerebrovascular Diseases最新文献

Background: Cerebrovascular diseases (CBVDs) are a major cause of mortality and disability, with significant ethnic variations suggesting specific risk factors. Early detection of these risk factors is critical, and retinal imaging offers a non-invasive method to achieve this.

Summary: Retinal phenotypes can serve as early markers for CBVDs. Racial differences in retinal and vascular morphometric characteristics have been described. Examining these characteristics in the context of racial differences could improve early detection and targeted interventions for CBVDs. This review discusses the role of retinal imaging in predicting CBVDs and highlights the importance of ethnicity-specific approaches.

Key messages: Understanding ethnic variations in retinal features can enhance the precision of CBVD prediction and enable personalised treatment strategies.

Introduction: Limited research exists on women's challenges as specialized healthcare professionals in Latin America's stroke field. This survey-based study addresses the potential gender disparities in these professionals' work environments.

Methods: This exploratory study used an online survey to investigate the work environment of women healthcare professionals in stroke across several Latin American countries. Conducted between September and November 2023, it included demographics, relationship status, reproductive history, and gender roles related to healthcare work and/or academic life. Women responders were invited through professional networks and local stroke care organizations. Descriptive analyses were performed, and subgroup comparisons were made using statistical tests such as Chi-square, FisherExact, or Kruskal-Wallis.

Results: A total of 291 responses were gathered from 16 Latin American countries. The average age was 40.01 ± 9.61 years, 34% reported holding leadership positions, with 49.5% having women as supervisors. Furthermore, 41% were married, and 52.9% reported having children. Among those, 29.2% perceived adverse effects of childcare on their academic trajectories, with 71.43% being unable to participate in academic conferences. Only 16.1% held leadership roles in scientific organizations, although 52% were involved in educational endeavors within university settings.

Conclusions: Our survey reveals perceived significant hurdles women healthcare professionals encounter in stroke, notably concerning the influence of maternity on job performance and career development. Furthermore, these results highlight inequalities in leadership roles and career pathways. By shedding light on these obstacles, we aim to increase awareness and advocate for implementing fair policies to create a supportive work environment.

Introduction: Frailty is a clinical syndrome of increased vulnerability to stressors. Frailty is associated with adverse outcomes after stroke, but frailty and transient ischaemic attack (TIA) are less well described.

Methods: We conducted a retrospective analysis of patients referred by the emergency department (ED) to TIA clinic (01/01/2016-12/03/2022) linked to hospital records for electronic follow-up. Only those with Clinical Frailty Scale (CFS) recorded within 2 weeks of clinic were included. Prevalence of frailty was determined based on CFS score ≥4. Hazard ratios (HRs) for mortality were determined through Cox proportional hazard regression, adjusted for prognostic factors. Where repeat CFS data were available, temporal change in frailty was recorded (∼15 months).

Results: Of 1,185 patients included, 53.5% (n = 634) had frailty. Patients with frailty tended to be older (median age 81 vs. 74 years, p < 0.001) and female (53.9% vs. 39.9% p < 0.001). Of 335 diagnosed with TIA following review, 61.2% (n = 205) were frail. Prevalence of frailty by clinic diagnosis was as follows: TIA 61.2% (205/335), stroke 46.7% (128/274), other diagnoses 52.3% (301/575). In TIA patients and the whole cohort (WC), frailty (TIA: HR: 2.69 [95% confidence interval (CI): 1.23-5.87, p = 0.013], WC: 2.58 [95% CI: 1.64-4.08, p < 0.001]), and increasing age [HR: 1.07 95% CI: 1.04-1.12] were predictive of mortality. In stroke patients, only increasing age was predictive of death (HR: 1.11 [95% CI: 1.04-1.19, p = 0.003]). For 414 patients with repeat CFS, the median interval was 15 months and the median change was +1 point (inter-quartile range: 0-2).

Conclusion: Frailty is common in TIA and becomes more common following TIA. The strength of the association of frailty with poor outcome was greater for TIA patients than for those with stroke. Routine assessment of frailty may be a useful addition to TIA services.

Introduction: Stroke mortality has declined, with differential changes by race; stroke is now the 5th leading cause of death overall, but 2nd leading cause of death in Black individuals. Little is known about recent race/ethnic and sex trends in in-hospital mortality after acute ischemic stroke (AIS) and whether system-level factors contribute to possible differences.

Methods: Using the National Inpatient Sample, adults (≥18 years) with a primary diagnosis of AIS from 2006 to 2017 (n = 643,912) were identified. We assessed in-hospital mortality by race/ethnicity (White, Black, Hispanic, Asian/Pacific Islander [API], other), sex, and age. Hospitals were categorized by proportion of White patients served: "≥75% White hospitals," "50-75% White hospitals," and "<50% White hospitals." Using survey adjusted logistic regression, the association between race/ethnicity and odds of mortality was assessed, adjusting for key sociodemographic, clinical, and hospital characteristics (e.g., age, comorbidities, stroke severity, do not resuscitate orders, and palliative care).

Results: Overall, mortality decreased from 5.0% in 2006 to 2.9% in 2017 (p < 0.01). Comparing 2012-2017 to 2006-2011, there was a 68% reduction in mortality odds overall after adjusting for covariates, most prominent in White individuals (69%) and smallest in Black individuals (57%). Compared to White patients, Black and Hispanic patients had lower odds of mortality (adjusted odds ratio [aOR] 0.82, 95% CI 0.78-0.87 and aOR 0.93, 95% CI 0.87-1.00), primarily driven by those >65 years (age × ethnicity interaction p < 0.01). Compared to White men, Black, Hispanic, and API men, and Black women had lower aOR of mortality. The differences in mortality between White and all the other race/ethnic groups combined were most pronounced in ≥75% White hospitals (aOR 0.80, 0.74-0.87) compared to 50-75% White hospitals (aOR 0.85, 0.79-0.91) and <50% White hospitals (aOR 0.88, 0.81-0.95; interaction effect: p < 0.01).

Conclusion: AIS mortality has decreased dramatically in recent years in all race/ethnic subgroups. Overall, while individuals of other race/ethnic subgroups had lower mortality odds compared to White individuals, this effect was significantly lower in hospitals serving predominantly White patients compared to those serving minority populations. Further study is needed to understand these differences and to what extent sociocultural, biological, and system-level factors play a role. Category: Health services, quality improvement, and patient-centered outcomes were the elements used to categorize the study sample.

Introduction: Selecting thrombectomy techniques for acute ischemic stroke due to large vessel occlusion significantly affects outcomes and costs. This study introduces the Bifurcation-Invisible (BI) sign identified on initial microcatheter angiogram in acute middle cerebral artery occlusions before endovascular thrombectomy. We aimed to evaluate whether this sign is associated with better angiographic outcomes using contact aspiration (CA) versus stent retriever (SR).

Methods: In this study, we reviewed 285 cases of acute M1-segment middle cerebral artery (M1-MCA) occlusions treated with SR or CA. Angiographic success was evaluated using modified Thrombolysis In Cerebral Infarction (mTICI) scores after the first attempt, clinical outcomes by 90-day modified Rankin Scale (mRS) scores, and procedural costs were analyzed. Categorical variables were analyzed using χ2 or Fisher's exact test, and continuous variables using Student's t test or Mann-Whitney U test. Subgroup multivariate logistic analysis and interaction tests were conducted, with post hoc analysis applying Bonferroni correction.

Results: BI-positive patients treated with CA had higher first-pass reperfusion rates (mTICI 2b-3: 64.0% vs. 41.3%, p = 0.005; Bonferroni-corrected p = 0.030) and 19.8% lower device costs (p < 0.05) than those treated with SR. BI-positive CA patients had higher first-pass reperfusion rates (mTICI 2b-3: 64.0% vs. 32.1%; p < 0.001; Bonferroni-corrected p = 0.002) and a 39.9% reduction in device costs (p < 0.05) than BI-negative patients. The interaction tests showed significant interactions between the presence of BI and CA for first-pass reperfusion rates (p = 0.007) and device costs (p < 0.001).

Conclusion: The BI sign, a refined version of the branching-site occlusion sign identified via microcatheter angiography, could guide the selection of CA, improving recanalization rates and reducing costs in MCA occlusions.

Introduction: Accurately predicting a patient's prognosis is an important component of decision-making in intracerebral hemorrhage (ICH). We aimed to determine clinicians' ability to predict survival, functional recovery, and return to premorbid activities in patients with ICH.

Methods: Pre-specified secondary analysis of the third intensive care bundle with blood pressure reduction in acute cerebral hemorrhage trial (INTERACT3), an international, multicenter, stepped-wedge cluster randomized controlled trial. Clinician perspectives on prognosis were collected at hospital admission and Day 7 (or before discharge). Prognosis questions were the likelihood of (i) survival at 48 h and 6 months, (ii) favorable functional outcome (recovery walking and self-care), and (iii) return to usual activities at 6 months. Clinician predictions were compared with actual outcomes.

Results: Most clinician participants were from neurosurgery (75%) with a median of 8 working years (IQR 5-14) of experience. Of the 6,305 randomized patients who survived 48 h, 213 (3.4%) were predicted to die (positive predictive value [PPV] 0.99, 95% confidence interval [CI] 0.99-0.99). Of 5,435 patients who survived 6 months, 209 (3.8%) were predicted to die (PPV 0.93, 95% CI: 0.92-0.93). Predictions on the favorable functional outcome (PPV 0.54, 95% CI: 0.52-0.56) and satisfied ability to return to usual activities (PPV 0.50, 95% CI: 0.49-0.52) were poor. Prediction accuracy varied by working years and region of practice.

Conclusions: In patients with ICH, clinician estimates of death are very good but conversely they are poor in predicting higher levels of functional recovery and activities.

Introduction: Selective endovascular brain hypothermia has been proposed as a potential neuroprotective strategy; however, its effectiveness is still not well established. The primary objective of this trial is to investigate the efficacy and safety of selective endovascular brain hypothermia with edaravone dexborneol for endovascular treatment in acute ischemic stroke (AIS).

Methods: The SHE study is a multicenter, single-blind, randomized controlled clinical trial. Patients with acute anterior circulation ischemic stroke who received endovascular treatment within 24 h after stroke onset and achieved successful recanalization will be enrolled and centrally randomized into combined selective endovascular brain hypothermia with edaravone dexborneol or edaravone dexborneol alone groups in a 1:1 ratio (n = 564). Patients allocated to the hypothermia group will receive 300 mL cool saline at 4°C through guiding catheter (30 mL/min) into target vessel within 3 min after recanalization and then receive edaravone dexborneol (edaravone dexborneol 15 mL + NS 100 mL ivgtt bid for 10-14 days) within 24 h after admission. The control group will receive 300 mL 37°C saline (30 mL/min) infused into target vessel through guiding catheter and then receive edaravone dexborneol. All patients enrolled will receive standard care according to current guidelines for stroke management. The primary outcome is the proportion of functional independence, defined as a mRS score of 0-2 at 90 days after randomization.

Conclusion: This is a randomized clinical trial with a large sample size to compare combined selective endovascular brain hypothermia and edaravone dexborneol with edaravone dexborneol alone in patients with acute anterior ischemic stroke. The SHE trial aims to provide further evidence of the benefit of selective endovascular brain hypothermia in AIS patients who received endovascular treatment.

Introduction: Stroke-associated pneumonia (SAP) frequently complicates stroke and is associated with significant mortality. Clinicians often use physiological variables within the National Early Warning Score (NEWS) when diagnosing and prescribing antibiotics for SAP, but little is known of its association with mortality. We investigated the relationship of the NEWS 2 score and its components (respiratory rate, heart rate, temperature, oxygen requirement, oxygen saturation, and alertness level) prior to antibiotic initiation, with time-to-mortality in SAP.

Methods: We included patients with SAP (n = 389) from a single hyperacute stroke unit. Diagnosis of SAP was made if pneumonia occurred within 7 days of hospital admission. Kaplan-Meier survival curves were generated to assess NEWS 2 parameters influencing survival at pre-defined time periods (1 year and 5 years). The association of these parameters on time-to-mortality were analysed using multivariable Cox-regression models to account for a set of pre-specified potential confounders.

Results: The median age was 80 years (71-87 years) and median NIHSS was 7 (IQR 4-17). Mortality within 1 year was 52.4% and 65.8% within 5 years. In the multivariable analyses, time-to-mortality was independently associated with respiratory rate (heart rate [HR] 1.04, 95% confidence intervals [CI] 1.01-1.08, p = 0.009) and total NEWS 2 score (HR 1.13, 95% CI 1.06-1.21, p < 0.001).

Conclusions: In patients with SAP, higher respiratory rate and total NEWS 2 score prior to antibiotic initiation were independently associated with time-to-mortality. Further studies are warranted to identify potential opportunities for intervention and ultimately guide treatment to improve outcomes in SAP patients.

Background: South Asia and Southeast Asia account for more than 40% of the global stroke burden, with differences in stroke risk factors, mortality, and outcomes compared to high-income countries. Sociocultural norms compound the preexisting biological risk differences, resulting in a disproportionate burden of stroke in women in this region. This review summarizes the sex and gender differences across the stroke care continuum in South Asia and Southeast Asia over the past 20 years.

Summary: Despite a higher incidence of stroke in men than women in South and Southeast Asia, women have greater stroke severity and poorer outcomes after stroke. Higher levels of premorbid disability and poor physical health at baseline may be contributory. There is a high prevalence of vascular risk factors such as hypertension, dyslipidemia, cardiac sources of embolism, as well as metabolic syndrome and insulin resistance, among the women in this region. Smoking is uncommon among women; however, other forms of smokeless tobacco, such as tobacco leaf and betel nut chewing, are more prevalent, especially in the rural areas in these countries. Women are more likely to have delayed presentations to the hospital due to untimely recognition of stroke symptoms; however, with regards to door-to-needle times or intravenous thrombolysis (IVT) rates, we found equivocal data. Wide gaps exist in stroke awareness and healthcare-seeking behaviors, with women more commonly opting for public hospitals and low-cost wards, more likely to discontinue treatment, and less likely to adhere to poststroke rehabilitation.

Key findings: This review exposes the gender lacunae in stroke service provision across South Asia and Southeast Asia while acknowledging the many knowledge gaps in our understanding. Although the biological risk differences are non-modifiable, educational, policy, and economic measures to mitigate sociocultural barriers are much needed in the region. Sound epidemiological data are needed from more countries to better understand these differences and bridge this gap. It is imperative to advocate and implement policies and programs for stroke care viable for women, cognizant of the gender and cost bias, as well as the interplay of social and cultural structures specific to the regions.

Introduction: This study aimed to compare the outcomes and safety in patients aged ≥75 years and those aged <75 years who underwent stent-assisted endovascular treatment for unruptured cerebral aneurysms, specifically focusing on perioperative antiplatelet therapy (APT).

Methods: This multicenter retrospective study comprised patients who underwent stent-assisted coiling (SAC) or flow diverter stent (FDS) placement for unruptured cerebral aneurysms. The primary outcome was defined as the composite outcomes of perioperative thromboembolic events, bleeding events, or death.

Results: Among 632 patients, 533 (84.3%) were aged <75 years and 99 (15.6%) were aged ≥75 years. No significant differences were observed in the dual APT duration. The primary outcome occurred in 14.3% of patients aged <75 years and in 14.1% of those aged ≥75 years, with no significant difference (p = 1.0). The composites of the primary outcome, including thromboembolic events, bleeding events, and death differed insignificantly. Similar findings were observed when the primary outcomes for SAC (12.7% vs. 11.5%, p = 0.95) and FDS (17.5% vs. 18.4%, p = 1.0) were analyzed. The 30-day, 1-year, and 2-year cumulative event-free survival rates for the primary outcome were 89.5, 87.2%, and 85.2%, respectively, in patients aged <75 years, and 90.9%, 88.7%, and 87.0%, respectively, in those aged ≥75 years. These trends were similar (log-rank test, p = 0.92).

Conclusion: No significant differences were observed in the rates of the primary outcomes between patients aged <75 years and those aged ≥75 years. Therefore, refraining from stent-assisted treatment for unruptured aneurysms based solely on age might be inappropriate.