Cerebrovascular Diseases最新文献

Introduction: The fourth INTEnsive ambulance-delivered blood pressure Reduction in hyper-ACute stroke Trial (INTERACT4) is a large-scale, multicenter, prospective, randomized, open-label, blinded endpoint assessment trial, initiated in an ambulance in China, aiming at evaluating the effectiveness and safety of prehospital blood pressure (BP) lowering in patients with suspected acute stroke and elevated BP. A prespecified process evaluation is intended to explore the implementation of the trial intervention, provide support to interpret the trial outcomes and put forward suggestions to scale up the intervention in broader settings in the future.

Methods: This process evaluation is a mixed-methods design, and follows the Normalization Process Theory (NPT) and the UK Medical Research Council (UK MRC) guidance. Fidelity, reach, acceptability, appropriateness, adoption, sustainability, and relevant contextual factors and mechanisms affecting the implementation of prehospital early intensive BP-lowering treatment will be analyzed. Semi-structured interviews with ambulance staff, ward and emergency department clinicians, and nurses are undertaken to explore perceptions of the intervention, contextual factors, and potential suggestions for future implementation in practice. Data from observational records, surveys, conventional monitoring data, on-site records, and case report forms will be analyzed to understand background care and context.

Conclusion: The process evaluation of INTERACT4 will provide insights for the implementation of prehospital early intensive BP-lowering intervention in different health systems and help better explain the trial results for further scale up.

Introduction: Current studies on the association between serum calcium levels and carotid atherosclerosis have yielded inconsistent results. This study aimed to elucidate this relationship through a comprehensive meta-analysis.

Methods: A systematic search of PubMed, Embase, Cochrane Library, Scopus, Web of Science, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Weipu (VIP), and Wanfang databases was conducted, supplemented by manual retrieval, from their inception to October 2023. Two independent researchers conducted literature searches, data extraction, and quality assessment. Meta-analysis was performed using Review Manager 5.3 software on studies that met the inclusion criteria.

Results: The analysis included 9 cross-sectional studies, encompassing a total sample size of 9,720 participants. The meta-analysis revealed a significant statistical difference in serum calcium levels between the carotid atherosclerosis group and the control group (p = 0.03). The standardized mean difference between the two groups was 0.21 (95% CI: 0.02, 0.41) using the control group as a reference.

Conclusions: Our systematic analysis indicates a significant positive correlation between serum calcium levels and carotid atherosclerosis.

Introduction: In patients with acute ischemic stroke (AIS) secondary to intracranial large vessel occlusion, optimal blood pressure (BP) management following endovascular treatment (EVT) has not yet been established. The randomized trial on Hemodynamic Optimization of Cerebral Perfusion after Successful Endovascular Therapy in Patients with Acute Ischemic Stroke (HOPE) (clinicaltrials.gov id: NCT04892511) aims to demonstrate whether hemodynamic optimization using different systolic BP targets following EVT according to the degree of final recanalization, is more effective than currently recommended BP management in improving functional outcomes of patients with AIS.

Methods: HOPE is an investigator-initiated multicenter clinical trial with randomized allocation, open-label treatment, and blinded endpoint evaluation (PROBE). Patients with an anterior circulation AIS within 24 h of symptom onset, treated with EVT, and showing successful recanalization (mTICI ≥2b) at the end of the procedure, are equally allocated (1:1) to hemodynamic optimization according to the study protocol versus BP management according to current guidelines (≤180/105 mm Hg). The protocol includes two different targets of systolic BP depending on the recanalization status (mTICI = 2b: 140-160 mm Hg; mTICI = 2c/3: 100-140 mm Hg). The protocol is applied within the first 72 h and includes BP lowering as well as vasopressor therapies when needed. The primary outcome is the proportion of favorable outcome (modified Rankin Scale [mRS] 0-2) at 90 days. Secondary outcomes include the shift on the mRS score, neurological deterioration, symptomatic intracerebral hemorrhage, and mortality.

Conclusion: The HOPE trial will provide new information on the safety and efficacy of different BP targets following EVT according to the degree of final recanalization in patients with AIS.

Introduction: The treatment of acute ischemic stroke due to large artery vessel occlusion experienced a dramatic development within the last decade. This meta-analysis investigates the effectiveness of bridging therapy (BT) versus mechanical thrombectomy (MT) alone in treating acute ischemic stroke.

Methods: Two independent reviewers assessed two-arm clinical trials from Scopus, PubMed, Web of Science, and the Cochrane Library up to January 2024. Data extraction and quality were evaluated using the ROBINS-2 tool. Our primary outcomes were improvement in NIHSS scores and 90-day modified Rankin Scale (mRS) score.

Results: This meta-analysis, which included 2,638 participants from 8 randomized controlled trials, found that BT resulted in a greater improvement in NIHSS scores from baseline compared to endovascular treatment alone (mean difference [MD] 0.96, 95% confidence interval [CI]: [0.73-1.20], p < 0.00001). Additionally, BT group achieved successful recanalization more frequently before and after thrombectomy. Thrombectomy alone hat a shorter time from stroke onset to groin puncture compared to BT (MD 9.91, 95% CI: [4.31-15.52], p = 0.005). Functional outcomes, mortality rates, symptomatic intracerebral hemorrhage rates, and long-term recovery metrics, such as Barthel index and modified Rankin Scale scores, were comparable between both treatment approaches.

Conclusion: BT is superior to endovascular treatment alone based on NIHSS score improvement and successful reperfusion rates before and after thrombectomy. Despite MT alone demonstrating a shorter time from stroke onset to groin puncture (MD of 9.91 min), it did not contribute to greater NIHSS improvement at 24 h and 7 days. Further trials with larger sample sizes are warranted to enhance precision in clinical guidance.

Introduction: IV thrombolysis (IVT) is established in the unknown or extended time window based on multimodal imaging. Further, increasing evidence exists regarding IVT in patients on oral anticoagulation including direct oral anticoagulants (DOACs). However, data on IVT in ischemic stroke patients on oral anticoagulation with unknown time of stroke onset are sparse.

Methods: This study bases on the longitudinal cohort study Stroke Research Consortium in Northern Bavaria (STAMINA; ClinicalTrials.gov Identifier: NCT04357899). Acute ischemic stroke patients treated with IVT in the unknown or extended time window from January 2015 to December 2019 were included. Patient selection was based on multimodal CT or MRI. Patients on oral anticoagulation (vitamin-K antagonist [VKA] or DOAC within 48 h) were eligible for IVT based on INR measurement (VKA) or plasma levels (DOAC) according to an institutional protocol. Primary outcomes were the incidence of any and symptomatic intracranial hemorrhage.

Results: Of 170 ischemic stroke patients treated with IVT in the unknown or extended time window, 151 had no oral anticoagulation at stroke onset and 19 were on oral anticoagulation (6 on VKA and 13 on DOAC). The risk of symptomatic ICH according to ECASS II criteria was similar between the patients with and without oral anticoagulation (1 [5.3%] vs. 4 [2.7%], p = 0.453). After adjustment for confounding factors, pre-medication with oral anticoagulation was not associated with symptomatic ICH (aOR 1.02 [0.09-11.02], p = 0.988).

Conclusion: IVT for ischemic stroke with unknown onset appeared safe in selected patients on oral anticoagulation with both DOAC and VKA.

Introduction: The objective of this study was to explore the association between net vertebral artery flow volume (NVAFV), calculated through color duplex ultrasonography, and posterior circulation infarction (PCI) in patients with severe intracranial vertebral artery (VA) stenosis.

Methods: 234 patients with severe intracranial VA stenosis (≥70%) were categorized into the PCI group (n = 139) and the non-PCI group (n = 95) based on cranial MRI diagnosis. The correlation between NVAFV and CT perfusion data was analyzed, and the occurrence of PCI under diverse PCI mechanisms was also investigated. Multifactorial logistic regression and stratified analysis was performed to analyze the association between NVAFV and PCI. Lastly, generalized additive models and smooth curve fitting was utilized to outline relationship between NVAFV and PCI.

Results: NVAFV showed a significant correlation with cerebral blood flow, mean transmit time, and time to peak. In the large artery atherosclerosis mechanism, a reduction in NVAFV correlated with a gradual rise in PCI cases (p = 0.002), while this trend lacked significance in the branch artery occlusive disease mechanism (p = 0.993). In the fully adjusted model, each 10 mL/min increase in NVAFV reduced PCI incidence by 11% (OR 0.890, 95% CI 0.840-0.943, p < 0.001), Sensitivity analysis showed similar results; NVAFV presented different PCI risks among various glucose level subgroups, the OR (95% CI) for PCI was 0.788 (0.684, 0.906) in low-glucose group (T1), 0.968 (0.878, 1.066) in moderate-glucose group (T2), and 0.886 (0.801, 0.979) in high-glucose group (T3). Smooth curve fitting demonstrated a linear negative association between NVAFV and PCI.

Conclusion: NVAFV demonstrated an association with PCI in patients with severe intracranial VA stenosis, it can serve as a reference for identifying high-risk populations of PCI; however, it must be considered in combination with glucose.

Introduction: MRI rating criteria for small vessel disease markers include definitions for microbleeds and macrobleeds but do not account for small (<10 mm) hemorrhages with a cystic cavity and/or irregular shape. Such hemorrhages, however, are often present in patients with cerebral amyloid angiopathy (CAA). In this study, we aimed to investigate the frequency, diameter, and volume distribution of these hemorrhages (which we called mesobleeds) in patients with CAA.

Methods: We selected participants with Dutch-type hereditary CAA (D-CAA) and sporadic CAA (sCAA) and scored microbleeds, mesobleeds, and macrobleeds on 3T susceptibility-weighted images MRI. Hemorrhage diameter and volume were calculated in a subset of participants using a semi-automatic tool; their distribution was evaluated on a logarithmic scale.

Results: We included 25 participants with D-CAA (mean age 56 years) and 25 with sCAA (mean age 73 years). In total, 11,007 microbleeds, 602 mesobleeds, and 195 macrobleeds were observed. Eighty-two percent of participants had ≥1 mesobleed. Hemorrhage diameter and volume were calculated in four participants with 272 microbleeds (median diameter 1.52 mm, volume 0.004 mL), 84 mesobleeds (median diameter 5.61 mm, volume 0.06 mL), and 37 macrobleeds (median diameter 19.58 mm, volume 1.33 mL). Mesobleed diameter and volume were larger than microbleeds (optimal cut-off 0.02 mL) but showed overlap with macrobleeds.

Conclusion: Hemorrhages <10 mm with an irregular shape and/or cystic cavity are frequently found in participants with CAA and have a distinct diameter and volume distribution. We propose to name these hemorrhage mesobleeds and to rate them separately from micro- and macrobleeds. Future research is necessary to investigate their pathophysiology and prognostic value.

Introduction: The association between earlobe crease (ELC) and cerebral small vessel disease, including white matter hyperintensities (WMHs) and brain atrophy, is unclear, especially in the setting of acute ischemic stroke (AIS). Here, we aimed to investigate the association between ELC and WMHs as well as brain atrophy among AIS patients.

Methods: A total of 730 AIS patients from China were enrolled. Patients were divided into groups without and with ELC, unilateral and bilateral ELC according to pictures of bilateral ears. Logistic regression models were employed to assess the impact of ELC, bilateral ELC on WMHs, periventricular hyperintensities (PVHs), deep white matter hyperintensities (DWMHs), and brain atrophy, as measured by the Fazekas scale and global cortical atrophy scale, in brain magnetic resonance imaging.

Results: There were 520 (71.2%) AIS patients with WMHs, 445 (61.0%) with PVH, 462 (63.3%) with DWMH, and 586 (80.3%) with brain atrophy. Compared to those without ELC, patients with ELC were significantly associated with an increased risk of PVH (odds ratio [OR] 1.79; 95% confidence interval [CI], 1.15-2.77) and brain atrophy (OR: 6.18; 95% CI: 3.60-10.63) but not WMHs and DWMH. The presence of bilateral ELC significantly increased the odds of WMHs (OR: 1.60; 95% CI: 1.00-2.56), PVH (OR: 1.87; 95% CI: 1.18-2.96), and brain atrophy (OR: 8.50; 95% CI: 4.62-15.66) when compared to individuals without ELC. Furthermore, we discovered that the association between bilateral ELC and WMHs, PVH, and DWMH was significant only among individuals aged ≤68 (median age) years (all p trend ≤0.041). However, this association was not observed in patients older than 68 years.

Conclusions: In Chinese AIS patients, the presence of the visible aging sign, ELC, especially bilateral ELC, showed independent associations with both WMHs and brain atrophy, particularly among those younger than 68 years old.

Introduction: It is unknown whether the influence of age on clinical outcomes post endovascular treatment (EVT) is similar in posterior circulation stroke (PCS) compared to anterior circulation stroke (ACS).

Methods: Data were extracted from the ETIS registry, a nationwide prospective, multicenter, observational registry for stroke EVT procedures in France. We included patients treated with EVT for PCS or ACS between January 2015 and August 2023. The relationship between patient age and clinical outcome variables was studied using regression analysis. Good clinical outcome was defined as modified Rankin scale score ≤2 at 90 days.

Results: The study included 935 patients with PCS and 11,427 patients with ACS. There were no significant differences between PCS and ACS in the influence of age on the likelihood of good clinical outcome. The influence of age on the likelihood of mortality was significantly different. Mortality was higher for PCS between 30 and 85 years, without significant differences in younger or older patients. Elderly patients (≥80 years) with PCS had similar rates of good clinical outcome and mortality compared to patients with ACS from the same age group.

Conclusion: In this comparative analysis assessing the impact of age on EVT outcomes in posterior versus anterior circulation stroke, differences were observed in middle-aged patients, whereas outcomes tended to converge in young and elderly age groups. Elderly PCS patients had similar outcomes as ACS patients from the same age group.