Cerebrovascular Diseases最新文献

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: For patients with acute ischaemic stroke caused by large vessel occlusion (LVO), there is limited evidence regarding the long-term outcomes of endovascular treatment (EVT) compared with best medical treatment (BMT). The objective of this study was to evaluate the long-term efficacy and safety of EVT in LVO stroke patients.

Methods: This study systematically searched electronic databases from January 2015 to August 2024 and included seven eligible trials. These studies reported 1-2 year of follow-up data on functional independence (modified Rankin Scale [mRS] score 0-2), distribution of mRS on shift analysis, quality of life (European Quality of Life 5-Dimensions Questionnaire score), and mortality.

Results: A total of 1,236 patients who received EVT and 1,122 who received BMT were included in the analysis. Compared with BMT, EVT was associated with a significantly greater likelihood of functional independence (odds ratio [OR] 2.55, 95% confidence interval [CI], 1.76-3.70), improved distribution of mRS scores on shift analysis (common OR 1.67, 95% CI, 1.37-2.02), and a better quality of life (beta coefficient 0.13, 95% CI, 0.07-0.19) at 1-2 years of follow-up. Compared with BMT, EVT was also associated with lower rates of all-cause mortality (OR 0.67, 95% CI, 0.56-0.81). Compared with 90-day follow-up, long-term follow-up demonstrated an improvement in functional independence among LVO stroke patients (1.7% vs. 0.2%), whereas the increase in mortality was slower (9.3% vs. 11.3%).

Conclusions: This meta-analysis indicated that LVO stroke patients can achieve long-term benefits following EVT. The findings provide valuable evidence to inform clinical decision-making.

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.

Background: Stroke remains a leading cause of disability and death worldwide. While reperfusion therapies such as tissue plasminogen activator and mechanical thrombectomy have significantly improved stroke management, their effectiveness is limited by ischemia/reperfusion injury, which disrupts the blood-brain barrier (BBB), increases neuroinflammation, and exacerbates secondary neuronal damage. Consequently, there is an urgent need for adjunctive therapies that specifically target these secondary injury mechanisms.

Summary: This review explores novel therapeutic strategies aimed at mitigating neuroinflammation, poststroke edema, and BBB permeability. Key approaches discussed include anti-inflammatory therapies targeting tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), and matrix metalloproteinases (MMPs); neuromodulation by vagus nerve stimulation (VNS); and the inhibition of edema-related molecules such as sulfonylurea receptor 1 (SUR1), aquaporin-4 (AQP4), and both systemic and peripheral hypothermic cooling. While these therapies show promise in preclinical models, their clinical translation is hindered by challenges such as systemic immunosuppression, susceptibility to infection, and limited therapeutic windows. Among these therapies assessed, SUR1 inhibition and remote administration of hypothermia (RAH) are promising candidates for improving stroke outcomes.

Key messages: Secondary injury from BBB disruption, inflammation, and edema remains a major barrier to optimal stroke recovery. Pharmacologic, neuromodulatory, and molecular-targeting strategies, including TNF-α, IL-6, MMP inhibition, VNS, and hypothermia, each offer distinct therapeutic mechanisms, but face critical clinical translation barriers. Among emerging therapies, RAH and SUR1 inhibition represent novel interventions that address many of the translational challenges of other therapies by addressing key mechanisms of neuroinflammation and edema with favorable safety profiles.

Introduction: Antiphospholipid syndrome (APS) is an acquired autoimmune disease characterized by arterial and venous thrombosis. Acute ischemic stroke (AIS) and transient ischemic attack (TIA) are common neurological manifestations in APS patients. Cerebral microbleeds (CMB) are indicators for cerebral small vessel disease and associated with intracerebral hemorrhage (ICH) and AIS. In the present study, we aimed to look at the association and clinical significance of CMB in patients with APS.

Methods: This is a retrospective cohort study that utilized data obtained from health service data of more than 5 million patients. We included patients aged 18 and older diagnosed with APS who underwent brain MRI between January 2014 and April 2020 and an age-matched control group with negative APS laboratory results. APS diagnosis was confirmed by positive laboratory findings from two separate tests conducted at least 12 weeks apart. The first available brain MRI was assessed for the presence of CMB. We compared the prevalence of CMB between patients with APS and controls. Among APS patients, we assessed the association between CMB and future AIS/TIA or ICH during 48-month follow-up using Cox proportional hazards models.

Results: The study included 276 patients, of which 195 were in the APS group and 81 in the control group. Patients with APS exhibited a higher prevalence of CMB (16% vs. 4%, p < 0.01). Among the APS group, those with CMB had a significantly higher risk of subsequent AIS/TIA (hazard ratio = 8.5, 95% confidence interval [CI]: 3.1-23), cumulative incidence 30% (95% CI: 13%-50%). None of the patients with APS had ICH during follow-up.

Conclusion: Patients with APS have a higher prevalence of CMB compared with non-APS individuals, and the presence of CMB in APS patients is associated with an increased risk of AIS/TIA.

Introduction: Women are overrepresented in the unruptured intracranial aneurysm (UIA) population, with an overall two-thirds of patients being female. The reasons behind this female preponderance are still unclear. Therefore, we performed a systematic review of clinical risk factors for UIA, with a specific aim of assessing whether these risk factor associations are sex-dependent.

Methods: We systematically searched 5 electronic medical databases for all relevant literature up to March 2024. Cohort and case-control studies reporting on the lifestyle factors smoking, alcohol use, hypertension, hypercholesterolemia, physical activity, diabetes, and BMI were included.

Results: We found a total of 21 studies, reporting on 347,907 participants and 8,698 UIA cases, that met our inclusion criteria. However, only one study provided its results stratified by sex, making it impossible to perform sex-stratified analyses.

Conclusion: Our findings illustrate the scarcity of sex-stratified results in studies on risk factors for UIAs. Since knowledge on potential sex differences in UIA could help understand the female predominance, we highlight a need for more sex-stratified research in this field.

Introduction: Traditional lipid ratios were considered as robust predictors of cardiovascular disease risk. However, the relationships between traditional lipid ratios and atherosclerosis in the setting of ischemic stroke remain unclear. We aimed to explore the associations between traditional lipid ratios and carotid atherosclerosis in patients with ischemic stroke.

Methods: A total of 1,612 patients with ischemic stroke from 22 hospitals were included in this analysis. Traditional lipid ratios included Castelli's risk index-I (CRI-I), Castelli's risk index-II (CRI-II), and atherogenic coefficient (AC). Logistic regression models were used to assess the relationships between traditional lipid ratios and carotid atherosclerosis.

Results: The multivariable-adjusted odds ratios (ORs) (95% confidence intervals [CIs]) in quartile 4 versus quartile 1 of CRI-I, CRI-II, and AC were 1.65 (1.14-2.38), 1.48 (1.03-2.14), and 1.65 (1.14-2.38) for carotid atherosclerosis. Furthermore, the ORs (95% CIs) for the highest quartile of CRI-I, CRI-II, and AC were 1.51 (1.09-2.09), 1.38 (0.99-1.90), and 1.51 (1.09-2.09) for abnormal mean cIMT and were 1.60 (1.17-2.18), 1.59 (1.17-2.16), and 1.60 (1.17-2.18) for abnormal maximum cIMT, respectively. Restricted cubic spline models indicated that there were dose-response relationships between CRI-I, CRI-II, and AC and carotid atherosclerosis and abnormal cIMT (all P for linearity <0.001). Additionally, CRI-I, CRI-II, and AC offered incremental predictive capacity for carotid atherosclerosis beyond established risk factors, shown by increase in net reclassification improvement and integrated discrimination improvement (all p < 0.05).

Conclusion: Elevated traditional lipid ratios were positively associated with carotid atherosclerosis in patients with ischemic stroke, supporting that these lipid ratios could be promising atherosclerotic predictors.

Introduction: Frailty is increasingly common in individuals after chronic stroke and is associated with poor outcomes. The repercussions of this syndrome on chronic stroke individuals are even worse for physical function. However, it may be reversible, requiring investigations into associated and motor modifiable factors. Thus, this study aimed to investigate whether modifiable variables (level of physical activity and walking speed) are associated with frailty in individuals after chronic stroke, as well as to verify whether these variables contribute to the presence of frailty in these individuals.

Methods: This is a cross-sectional study where individuals with chronic stroke, aged over 18 years, with unilateral involvement, and able to walk with or without assistive devices were included. The dependent variable was frailty, measured with the Clinical Frailty Scale (CFS). The modifiable factors (independent variables) were the level of physical activity, expressed through the adjusted activity score measured by the Human Activity Profile, and the habitual walking speed, measured with the 10-meter walk test, in m/s. A multiple linear regression analysis was performed to verify the association between the modifiable variables and frailty.

Results: Sixty-one individuals, with a mean age of 62.6 ± 15.7 years, 50.8% men, with a mean time of evolution of 46.4 ± 43.0 months were included. The level of physical activity alone explained 59.2% of the frailty variance (R2 = 59.2%; F = 88.1; p < 0.0). Physical activity and walking speed explained 59.9% of the frailty variance (R2 = 67.1%; F = 62.1; p < 0.0).

Conclusion: The level of physical activity and habitual walking speed were significantly associated with the presence of frailty in individuals after chronic stroke. Strategies aiming to increase the level of physical activity and walking speed may be a path to avoid frailty development in these individuals.

Introduction: Individuals with impaired renal function are known to have an increased risk of stroke. However, studies from general populations that include individuals with various comorbidities remain scarce. This study aimed to investigate the association between renal function and stroke incidence according to the entire spectrum of estimated glomerular filtration rate (eGFR) levels in the general Korean population using a nationwide longitudinal analysis.

Methods: We included 2,708,874 participants who underwent health examinations between 2010 and 2011 from the Korean National Health Insurance Service-Health Screening Cohort (NHIS-HEALS) database. An eGFR was calculated to assess renal function and then categorized into clinically relevant ranges as well as deciles. Stroke incidence was defined as a new record of the International Classification of Diseases-10 codes I60-I63, requiring at least two claims with a main or secondary diagnosis within a year and confirmation via brain computed tomography or magnetic resonance imaging within 1 month of diagnosis.

Results: The mean age was 48.63 ± 14.02 years, with 112,913 (4.36%) stroke cases identified over 9.63 years. In the multivariable Cox regression analysis using eGFR ranges and deciles, impaired renal function was significantly associated with an increased stroke incidence. The highest stroke risk occurred in the lowest eGFR range (<30 mL/min/1.73 m2) (hazard ratio [HR], 1.98; 95% confidence interval [CI], 1.83-2.15) and lowest eGFR decile (<67.57 mL/min/1.73 m2) (HR, 1.51; 95% CI, 1.47-1.54), whereas the lowest risk was observed in the highest eGFR range (>120 mL/min/1.73 m2) (HR, 0.32; 95% CI, 0.30-0.34) and eGFR decile (≥113.41 mL/min/1.73 m2) (HR, 0.42; 95% CI, 0.40-0.44). A significant inverse linear trend was confirmed between stroke incidence and both eGFR ranges and deciles. These findings were consistent regardless of age, obesity, and stroke subtypes.

Conclusion: Stroke risk increased linearly with declining eGFR in the general population. Assessment of renal function may be a useful clinical tool for identifying individuals who would benefit most from stroke prevention interventions.