Cerebrovascular Diseases最新文献

Introduction: Substance use (SU) has been linked to cerebrovascular disease due to numerous pathophysiologic alterations. This study discusses the age, race, and demographics-related trends in mortality among US adults (≥25 years) with concomitant SU and cerebrovascular disease.

Methods: The CDC WONDER database was used to access the mortality data. Age-adjusted mortality rates (AAMRs) per 100,000 population were calculated. Trends for age, sex, race, state, place of death, census region, and metropolitan status, along with annual percent change (APC) in AAMR, were calculated using the Joinpoint regression analysis.

Results: From 1999 to 2020, 57,838 deaths occurred, with an overall AAMR of 1.23. The highest AAMRs were observed in adults aged 45-64 (1.8), men (1.85), the non-Hispanic American Indian/Alaska Native population (3.23), the District of Columbia (2.78), and nonmetropolitan areas (1.35).

Conclusion: The rising mortality related to SU and cerebrovascular disease with notable sociodemographic and temporal disparities calls for further research and early interventions.

Introduction: Following posterior cerebral artery stroke, infarcts causing quadrantanopia are thought to be smaller than those causing homonymous hemianopia. We investigated whether these two presentations were different due to the varying involvement of the striate, extrastriate cortex, or geniculocalcarine tract.

Methods: Patients with unilateral posterior cerebral artery infarcts on magnetic resonance imaging and visual field defects, as identified by automated visual field perimetry, were included. Infarcts were manually segmented and registered to a standard brain template to facilitate comparison. Infarct volume and infarct involvement with geniculocalcarine fiber tracts were calculated in patients with hemianopia and quadrantanopia.

Results: There were twenty-two patients: 15 patients with homonymous hemianopia (median age 68 [interquartile range, 55-76 years old]) and 7 with superior quadrantanopia (median age 40 [interquartile range, 30-56 years old]). Infarct volume significantly differed between the two groups: hemianopia 34.6 mL (interquartile range, 21.6-56.3 mL) versus superior quadrantanopia 15.5 mL (interquartile range, 7.2-24.1 mL), p = 0.026. There was significantly greater involvement of infarct with the geniculocalcarine tracts in the hemianopia group, 5.7 mL (interquartile range, 2.3-8.2 mL) than the superior quadrantanopia group, 2.0 mL (interquartile range, 1.2-2.7 mL), p = 0.042. Infarct involvement with cuneus and the calcarine cortex also significantly differed between the two groups (p ≤ 0.01).

Conclusion: In posterior cerebral artery infarction, sparing of the superior calcarine cortex, cuneus, and superior paraventricular geniculocalcarine tract differentiated superior quadrantanopia from homonymous hemianopia.

Introduction: Patients with atrial fibrillation (AF) continue to face thrombotic risks even after the left atrial appendages have been occluded, which may manifest as silent cerebral embolisms (SCEs). Half-dose anticoagulation (Hd-OAC) is a pathophysiologically more reasonable therapy in addressing this issue than antithrombotic therapy, but it still lacks strong evidence.

Methods: The trial (NCT05671276) is a multicenter, randomized controlled trial comparing the efficacy of two antithrombotic strategies (Hd-OAC therapy vs. standard antithrombotic therapy) in AF patients after left atrial appendage occlusion (LAAO). The primary endpoint is the incidence of newly detected SCEs on any magnetic resonance imaging conducted during the follow-up period. The secondary endpoints are: (1) more than two new SCEs during the follow-up, their size, and distribution; (2) cognitive function, and (3) a composite endpoint of all-cause mortality, clinical thromboembolic events, and major bleeding events. Follow-up is scheduled at 90 ± 15 days, 180 ± 15 days, and 365 ± 15 days after LAAO.

Conclusions: This trial aimed to determine whether Hd-OAC therapy can reduce the incidence of SCE and protect cognitive function in patients who have successfully undergone LAAO, compared to standard antithrombotic therapy.

Introduction: Patients who experience inhospital strokes may suffer from delays in stroke recognition, delays to acute treatment and management. We aimed to assess evidence for the difference in mortality between patients with inhospital stroke and those with community-onset stroke.

Methods: We searched MEDLINE, EMBASE, and SCOPUS (from inception to October 8, 2024) to identify studies comparing mortality outcomes for inhospital and community-onset stroke patients. We collected data on study characteristics, summarized the quality of evidence, evaluated risk of bias of studies using the Newcastle-Ottawa Scale, and investigated clinical sources of heterogeneity. We performed a random-effects meta-analysis to estimate the pooled odds of mortality of inhospital stroke versus community-onset stroke patients.

Results: Forty-one studies, collectively with 3,038,211 patients, of whom 3% experienced inhospital stroke, were included in the review. Inhospital stroke patients had an approximately 2.3-fold higher odds of inhospital mortality (pooled OR 2.27; 95% CI 1.80-2.86; 32 patient cohorts) and 1.9-fold higher odds of 3-month mortality (pooled OR 1.87; 95% CI 1.43-2.45; 14 patient cohorts) compared to community-onset stroke patients. Meta-analyses stratified by acute treatment received and study characteristics revealed consistently higher odds of death among inhospital stroke patients compared to community-onset stroke patients. Acute treatment received, study setting, geographic region, and components of study quality were significant sources of heterogeneity. Most concerns in study quality were due to potential risks of confounding.

Conclusion: There was a consistently higher odds of inhospital and 3-month mortality among inhospital acute ischemic stroke patients compared to their community-onset counterparts, highlighting the need for targeted interventions to reduce this disparity.

Introduction: It is uncertain whether lowered head position meaningfully improves cerebral perfusion in ischaemic stroke. We performed a prospective, single-arm, single-centre, self-controlled, non-randomised, pre-post-intervention study, testing whether 20-degree head-down (Trendelenburg) positioning in patients with acute stroke improves perfusion of ischaemic brain tissue, as measured by automated quantitative computed tomography perfusion (CTP).

Methods: We enrolled patients aged ≥60, 0-24 h after acute stroke onset, with ≥30 mL anterior circulation CTP lesion volume (delay time [DT] >3 s, MIStar software). CTP was acutely repeated after 5 min of on-table 20-degree Trendelenburg positioning (achieved by a custom-designed foam wedge). Clinical severity (National Institutes of Health Stroke Scale [NIHSS]) and blood pressure were recorded in routine (30° up) and Trendelenburg position. Trendelenburg positioning was maintained for 24 h if lesion volume significantly decreased (≥5 mL) and stroke reperfusion was suboptimal or undetermined.

Results: We enrolled 25 patients {14 (56%) male, age 76 (interquartile range [IQR] 70-85), baseline modified Rankin scale score 0 [IQR 0-0], median pre-CT NIHSS 20 [IQR 13-25]}. All patients had anterior circulation large vessel occlusion (LVO), 15/25 (60%) M1 middle cerebral artery (MCA) occlusion, 6 (24%) proximal M2 MCA, and 4 (16%) ICA. Stroke aetiology was predominantly cardioembolic (15/25 [60%]). Median DT >3 lesion volume was reduced by 18 mL [2-48] following Trendelenburg compared with conventional horizontal CT positioning (114 mL [94-204] vs. 149 mL [76-153]; p = 0.0027). Systolic blood pressure was unaltered (mean 148 mm Hg [±standard deviation 29] vs. 143 [±27]; p = 0.129). Head position did not alter clinical severity (post-CT NIHSS 13 [IQR 9-28] in both positions). A significant lesion volume reduction with Trendelenburg positioning was seen in 15/25 patients (60%); 7 received continued Trendelenburg positioning (6 due to incomplete reperfusion following thrombectomy). Head-down positioning caused no serious adverse events and was mostly well tolerated (6/7 [86%]).

Conclusion: Head-down (Trendelenburg) positioning appears to modestly improve penumbral perfusion in acute LVO ischaemic stroke and is generally well tolerated. Clinical benefits of this approach may be best tested in patients for whom reperfusion is delayed or not achieved.

Introduction: The RESTORE trial was the first randomized controlled trial comparing two systems of medicine in stroke. The trial studied about the safety and efficacy of ayurvedic rehabilitative treatment in comparison with conventional physiotherapy in stroke rehabilitation across North and South India. The results showed that ayurvedic rehabilitative treatment was not superior to conventional physiotherapy for improving sensorimotor recovery in ischemic stroke patients, but it was safe to use. The process evaluation assessed the implementation of the trial and its specific rehabilitation effects.

Methods: A mixed methods approach, incorporating qualitative in-depth interviews and quantitative data derived from case report forms and activity logs, was employed. Thirty-eight interviews of patient-caregiver dyads and health professionals were conducted. Thematic analysis of qualitative data was done with RE-AIM and realist models. The RE-AIM model aimed to evaluate the reach, effectiveness, adoption, implementation, and maintenance of the RESTORE trial. The context-mechanism-outcome configuration was used as the main structure for realist analysis.

Results: Participants in the intervention (ayurvedic rehabilitative treatment) and control (physiotherapy) groups experienced advantages from the therapy, like improved mobility. In addition, the intervention group reported enhanced emotional stability and pain relief compared to the control group. Participants, particularly from South India, found ayurveda therapies more acceptable. In this study, three key reasons were identified for ayurvedic rehabilitative therapy not outperforming conventional physiotherapy. First, a standard ayurveda treatment protocol may not suit every patient as ayurveda emphasizes individualized care. Second, certain treatments like nasya were excluded due to safety concerns for stroke patients, likely affecting outcomes. Lastly, a 1-month duration of ayurveda treatment may be too short to enhance stroke recovery.

Conclusion: This process evaluation suggests the need for further studies with a revised protocol that may lead to an important step in integrating ayurveda and physiotherapy in stroke rehabilitation in India.

Introduction: Good cortical venous outflow has been considered in association with favorable functional outcomes (FFOs) for large vessel occlusion-related stroke patients treated after an intra-arterial endovascular thrombectomy (IA-EVT).

Methods: A diagnostic meta-analysis was performed using the index test of cortical vein opacification score (COVES) on computed tomographic angiography for prediction of 3-month FFOs (reference standard). Literature search for relevant articles was conducted in PubMed, Embase, and Scopus databases from January 1, 2014, to July 8, 2024. The Bayesian analyses were conducted to estimate posttest probabilities (PTPs).

Results: Ten studies and 2,238 patients were enrolled. While excluding studies conducted in duplicated cohorts, four studies defined a favorable COVES as ≥1 and another four studies defined a favorable COVES as ≥3. In studies using a favorable COVES of ≥1, the COVES showed a sensitivity of 0.86 (95% confidence interval [CI], 0.48-0.97), a specificity of 0.47 (95% CI, 0.31-0.64) for predicting 3-month FFOs. With a pretest probability of an FFO of 0.19, the COVES increased the PTP to 0.28. In studies using a favorable COVES of ≥3, the COVES showed a sensitivity of 0.76 (95% CI, 0.58-0.88), a specificity of 0.71 (95% CI, 0.65-0.76) for predicting 3-month FFOs. On a pretest probability of an FFO by 0.19, the COVES increased the PTP to 0.37.

Conclusion: This meta-analysis showed the high sensitivity and moderate specificity of a COVES of ≥3 to select patients who can benefit from an IA-EVT.

Introduction: Approximately one-third of stroke survivors develop post-stroke cognitive impairment (PSCI), yet effective preventive strategies remain limited. The Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet was originally developed to promote cognitive health, but its effect on changes in cognitive function among mild stroke patients remains unclear. In this study, we aimed to explore the effect of MIND intervention on cognitive function among mild stroke patients. By implementing the same protocol in two independent samples, we aimed to examine whether the results are reproducible across different recruitment waves and refine protocols for future large-scale trials.

Methods: The MIND Diet to Improve Cognitive Function in Mild Stroke Patients (MINDICOMS) and MINDICOMS II are two replicate, pilot, two-arm RCTs, each enrolling 60 patients aged 35-70 years with acute ischemic stroke and signs of newly onset cognitive impairment but no dementia. The participants will be randomly assigned to the MIND diet intervention group or a control group. We adapted the MIND diet for the Chinese population, recommending eleven food groups and restricting four food groups. During the 26-week intervention phase, participants in the control group will receive standard medical care along with weekly health education messages. The intervention group will receive a structured MIND diet education program, including in-hospital provision of MIND-compliant meals for 7 days, and post-discharge supplies of nuts, olive or camellia oil, whole grains, and green tea. Personalized dietary guidance and regular feedback from dietitians will be delivered via an online platform. The primary outcome measure is change in global cognitive function measured using a neuropsychological test battery at weeks 0, 13, and 26. Secondary outcomes include changes in domain-specific cognitive function, brain imaging markers, dietary behavior, the ability of daily living, mental health indicators, plasma biomarkers, and the gut microbiota composition.

Conclusion: The MINDICOMS trials will generate preliminary evidence to optimize dietary strategies for cognitive improvement in stroke survivors. The comprehensive set of outcome measures will also offer a unique opportunity to explore potential biological mechanisms and generate new hypotheses for future research.

Introduction: Stroke-associated pneumonia (SAP) is a major infectious complication after stroke and has adverse impact on clinical outcomes. This study investigates whether automatic screening the risk of SAP and giving feedback to medical staff would reduce the incidence of inhospital pneumonia and improve clinical outcomes in patients with acute ischemic stroke (AIS).

Methods: This monocentric retrospective cohort study involved eligible inpatients in neurology department of Beijing Tiantan Hospital from June 2019 to October 2023. A quality improvement program was initiated on July 1, 2021, in which validated risk models were used to screen potential risk of SAP after stroke and feedback was automatically given to medical staff by electric medical records in real time. The primary outcome was occurrence of inhospital pneumonia after stroke. In addition, the following clinical outcomes were used including inhospital urinary tract infection, length of stay (LOS), total medical cost during hospitalization, mRS score at discharge and inhospital mortality. Multivariable logistic regression was performed to evaluate the association between the quality improvement program (after versus before) and clinical outcomes.

Results: A total number of 2,010 AIS patients were included with 652 patients in pre-implementation group and 1,358 patients in post-implementation group. It was shown that the quality improvement program was significantly associated with lower incidence of inhospital pneumonia (adjusted OR 0.421, 95% CI 0.237-0.746, p = 0.003) and better functional outcome (mRS ≤2) (adjusted OR 1.332, 95% CI 1.003-1.769, p = 0.048). In addition, it was illustrated that the program was significantly associated with shorter LOS (≤7 days) (adjusted OR 3.914, 95% CI 2.865-5.347, p < 0.001) and lower total healthcare cost during hospitalization (>15,000 CNY) (adjusted OR 0.479, 95% CI 0.392-0.586, p < 0.001).

Conclusion: SAP risk screening and giving feedback to medical staff is an effective way to reduce inhospital pneumonia, improve functional outcome, and save healthcare cost after stroke.

Introduction: Whether shifting from computed tomography (CT) to magnetic resonance imaging (MRI) as the initial diagnostic approach in emergency assessment may offer an advantage in acute stroke care remains unclear. We sought to evaluate the impact of the MRI-first paradigm on diagnosis, workflow, and clinical outcomes in a comprehensive stroke center.

Methods: In this retrospective analysis of a prospective observational cohort, consecutive patients admitted within 24 h after onset or last known well and with diagnosis of acute ischemic stroke, intracerebral hemorrhage (ICH), or transient ischemic attack (TIA) at the emergency department before (July 2022 to March 2023) and after the implementation of an MRI paradigm (April 2023 to January 2024) were included. We compared the diagnostic performance, workflow metrics, and 3-month modified Rankin Scale (mRS) between CT-first and MRI-first paradigms.

Results: A total of 478 patients in the CT-first group and 488 patients in the MRI-first group with initial diagnosis of acute stroke or TIA were included. The concordance of stroke diagnosis was improved after implementation of MRI-first paradigm {95.9% (95% confidence interval [CI]: 94.1%-97.7%) vs. 91.2% (95% CI: 88.7%-93.8%), p = 0.003}. Despite a lower rate of thrombolysis and slightly prolonged door-to-needle time, fewer cases of stroke mimics were treated by thrombolysis. MRI-first paradigm was associated with favorable shift in mRS (adjusted common odds ratio [cOR] 0.65, 95% CI 0.51-0.84) at 3 months among all patients with final diagnosis of any acute stroke or TIA. MRI-first paradigm was specifically related to favorable outcome (adjusted cOR 0.61, 95% CI: 0.45-0.83) among patients with cerebral ischemia. MRI-first paradigm was not associated with functional outcomes among ICH patients.

Conclusion: Implementing MRI as the first imaging modality in emergency assessment of stroke is feasible and associated with favorable clinical outcomes for cerebral ischemia.