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Mo J, Chen Z, Wang M, Cheng A, Li J, Pan Y, Jiang Y, Jing J, Wang Y, Pu Y, Li Z. Lipoprotein-associated phospholipase A 2 Activity Levels is Associated with Artery to Artery Embolism in Symptomatic Intracranial Atherosclerotic Disease. J Stroke Cerebrovasc Dis 2024; 33:108012. [PMID: 39277067 DOI: 10.1016/j.jstrokecerebrovasdis.2024.108012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 09/06/2024] [Accepted: 09/11/2024] [Indexed: 09/17/2024] Open
Abstract
BACKGROUND Lipoprotein-associated phospholipase A2 activity (Lp-PLA2-A) is a pivotal enzyme involved in the inflammatory process and atherosclerotic plaque vulnerability. This study aimed to investigate the potential of Lp-PLA2-A as a biomarker for reflecting artery-to-artery embolism (AAE), a critical mechanism with high risk of stroke recurrence in symptomatic intracranial atherosclerotic disease (sICAD). METHODS The current analysis included a cohort of 1,908 patients with sICAD and baseline levels of Lp-PLA2-A from the Third China National Stroke Registry (CNSR-III). The baseline Lp-PLA2-A levels were quantified centrally using an automatic enzyme assay system. Diagnosis of sICAD was made by experienced stroke neurologists based on the presence of a cerebral infarction within the territory of a stenotic (>50%) or occluded artery, or when clinical symptoms were consistent with the diagnosis. Infarct lesions affecting the cortex serve as imaging biomarkers for stroke mechanism involving AAE.The relationship between baseline Lp-PLA2-A quartile levels and the presence of cortical infarction was analyzed using multivariate logistic regression. RESULTS Compared to patients in the first Lp-PLA2-A quartile, those in the second, third and fourth quartiles demonstrated a significantly higher proportion of AAE. The proportion of patients with cortical infarction increased with rising Lp-PLA2-A quartiles, observed at 39.3%, 47.1%, 47.4%, and 50.7% for the first, second, third and fourth quartiles respectively (P for trend=0.004). Compared with the first quartile, the odds ratios (ORs) were 1.38 (95% CI = 1.06-1.79) for the second, 1.33 (95% CI = 1.02-1.72) for the third quartile and 1.48 (95% CI = 1.14-1.92) for the fourth quartile. The association between higher Lp-PLA2-A and increased proportion of cortical infarction was also present in the subgroups defined by age <65 years, male, and high-sensitivity C-reactive protein ≥2 mg/L. In sensitivity analyses, the positive correlation between Lp-PLA2-A levels and proportion of cortical infarction remained consistent. CONCLUSIONS This research highlights the significance of Lp-PLA2-A as a biomarker for reflecting stroke mechanism in sICAD. Additional studies are warranted to explore the potential of targeting Lp-PLA2-associated inflammatory pathways as a pivotal approach in arresting the advancement of intracranial atherosclerotic stenosis and reducing the incidence of embolic strokes.
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Affiliation(s)
- Jinglin Mo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China.
| | - Zimo Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China.
| | - Mengxing Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China.
| | - Aichun Cheng
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China.
| | - Jiejie Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China.
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China.
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China.
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China.
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China; National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100071, China; Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing 100071, China; Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China.
| | - Yuehua Pu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China.
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China; National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing 100071, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100071, China; Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing 100071, China; Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China
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Engel A, Song L, Rauschenbach L, Gümüs M, Santos AN, Dinger TF, Darkwah Oppong M, Li Y, Gembruch O, Ahmadipour Y, Dammann P, Sure U, Jabbarli R. Impact of Carotid Siphon Calcification on the Course and Outcome of Patients With Aneurysmal Subarachnoid Hemorrhage. Stroke 2024; 55:2305-2314. [PMID: 39101226 DOI: 10.1161/strokeaha.124.047594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/25/2024] [Accepted: 07/18/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Carotid siphon calcification (CSC) serves as a marker of atherosclerosis and therefore may influence the outcome after subarachnoid hemorrhage (aSAH). We aimed to analyze the impact of CSC on neurological outcomes, ischemia, and vasospasm. METHODS A total of 716 patients with aSAH were treated between December 2004 and June 2016 in our central European tertiary neurovascular care center in Essen, Germany. CSC was recorded using the Woodcock scale (grades 0-3) on a computed tomography scan. Study end points included an unfavorable outcome at 6 months post-aSAH (modified Rankin Scale score ≥4), vasospasm, and early cerebral ischemia (72 hours) and delayed cerebral ischemia (delayed cerebral ischemia; >72 hours) in the follow-up computed tomography scans. The associations were adjusted for patients' baseline characteristics and secondary complications. Finally, within a subgroup analysis, patients with and without daily aspirin intake after endovascular aneurysm occlusion were compared. RESULTS Increasing grades of CSC were associated with lower rates of vasospasm in the anterior circulation. Severe CSC (grade 3) was independently related to the risk of an unfavorable outcome (adjusted odds ratio [aOR], 4.06 [95% CI, 1.98-8.33]; P<0.001) and early cerebral ischemia (aOR, 1.58 [95% CI, 1.03-2.43]; P=0.035) but not delayed cerebral ischemia (aOR, 1.08 [95% CI, 0.67-1.73]; P=0.763). In the aspirin subgroup analysis, the negative effect of severe CSC on functional outcome remained significant only in aSAH cases without aspirin (aOR, 5.47 [95% CI, 2.38-12.54]; P<0.001). In contrast, there was no association between severe CSC and unfavorable outcomes among individuals with daily aspirin intake (aOR, 0.84 [95% CI, 0.59-4.21]; P=0.603). CONCLUSIONS Our data suggest CSC as a cerebrovascular risk factor resulting in higher rates of early cerebral ischemia and unfavorable outcomes after aSAH. However, by increasing arterial stiffness, CSC might lower the probability of vasospasm, which could explain the missing link between CSC and delayed cerebral ischemia. Additionally, aspirin intake seems to potentially mitigate the negative impact of CSC on aSAH outcome. Further investigations are needed to confirm the observations from the present study.
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Affiliation(s)
- Adrian Engel
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
| | - Li Song
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
| | - Meltem Gümüs
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
| | - Alejandro N Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
| | - Thiemo Florin Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
| | - Yan Li
- Institute for Diagnostic and Interventional Radiology, University Hospital Essen, Germany (Y.L.)
| | - Oliver Gembruch
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
| | - Yahya Ahmadipour
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
- Center for Translational Neuroscience and Behavioral Science (C-TNBS), University of Duisburg-Essen, Germany (A.E., L.S., L.R., M.G., A.N.S., T.F.D., M.D.O., O.G., Y.A., P.D., U.S., R.J.)
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Yu Y, Lou Y, Pan Y, Yan L, Fu W, Hou Z, Cui R, Miao Z, Wang Y, Lou X, Ma N. Residual inflammatory risk predicts long-term outcomes following stenting for symptomatic intracranial atherosclerotic stenosis. Stroke Vasc Neurol 2024; 9:407-417. [PMID: 37640497 PMCID: PMC11420922 DOI: 10.1136/svn-2023-002421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 08/05/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Residual inflammatory risk (RIR) can predict the unfavourable outcomes in patients with minor ischaemic stroke. However, the impact of preprocedural RIR on long-term outcomes in patients with symptomatic intracranial atherosclerotic stenosis (sICAS) who underwent stenting remains understudied. METHODS This retrospective, single-centre cohort study evaluated consecutive patients with severe sICAS who underwent intracranial stenting. Patients were categorised into four groups based on preprocedural high-sensitivity C-reactive protein (hs-CRP) and low-density lipoprotein cholesterol (LDL-C): residual cholesterol inflammatory risk (RCIR, hs-CRP ≥3 mg/L and LDL-C ≥2.6 mmol/L), RIR (hs-CRP ≥3 mg/L and LDL-C <2.6 mmol/L), residual cholesterol risk (RCR, hs-CRP <3 mg/L and LDL-C ≥2.6 mmol/L) and no residual risk (NRR, hs-CRP <3 mg/L and LDL-C <2.6 mmol/L). The long-term clinical outcomes included recurrent ischaemic stroke and death. The long-term imaging outcomes consisted of in-stent restenosis (ISR) and symptomatic ISR (sISR) after stenting. RESULTS In this study, 952 patients were included, with 751 (78.9%) being male. Forty-six cases were categorised into the RCIR group, 211 into the RIR group, 107 into the RCR group and 588 into the NRR group. Patients with RCIR (adjusted HR 6.163; 95% CI 2.603 to 14.589; p<0.001) and RIR (adjusted HR 2.205; 95% CI 1.294 to 3.757; p=0.004) had higher risks of recurrent ischaemic stroke than those with NRR during the 54 months of median follow-up time. Patients with RCIR (adjusted HR 3.604; 95% CI 1.431 to 9.072; p=0.007) were more likely to occur ISR, and patients in the RIR group showed a significant increase in the risk of sISR (adjusted HR 2.402; 95% CI 1.078 to 5.351; p=0.032) compared with those in the NRR group with a median follow-up time of 11.9 months. CONCLUSIONS In patients with sICAS, preprocedural RIR may predict long-term recurrent ischaemic stroke, ISR and sISR following intracranial stenting.
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Affiliation(s)
- Ying Yu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yake Lou
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Long Yan
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Weilun Fu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Zhikai Hou
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Rongrong Cui
- Department of Neurology, Beijing Daxing District People's Hospital, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Xin Lou
- Radiology, Chinese PLA General Hospital, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Uchida K, Yamagami H, Sakai N, Shirakawa M, Beppu M, Toyoda K, Matsumaru Y, Matsumoto Y, Todo K, Hayakawa M, Shindo S, Ota S, Morimoto M, Takeuchi M, Imamura H, Ikeda H, Tanaka K, Ishihara H, Kakita H, Sano T, Araki H, Nomura T, Sakakibara F, Yoshimura S. Endovascular therapy for acute intracranial large vessel occlusion due to atherothrombosis: Multicenter historical registry. J Neurointerv Surg 2024; 16:884-891. [PMID: 37648433 DOI: 10.1136/jnis-2023-020670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/04/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Atherothrombotic stroke-related large vessel occlusion (AT-LVO) is caused by two etiologies, the intracranial artery occlusion due to in situ occlusion (intracranial group) or due to embolism from cervical carotid occlusion or stenosis (tandem group). The prognosis and reocclusion rate of each etiology after endovascular therapy (EVT) is unclear. METHODS We conducted a historical multicenter registry study at 51 Japanese centers to compare the prognoses of AT-LVO between two etiologies. The primary outcome was the incidence of recurrent ischemic stroke or reocclusion of the treated vessels within 90 days after EVT. Each of the primary outcome means the incidence of recurrent ischemic stroke and reocclusion of the treated vessels within 90 days after EVT. RESULTS We analyzed 582 patients (338 in the intracranial group and 244 in the tandem group). Patients in the intracranial group were younger (mean 71.9 vs 74.5, p=0.003), more of them were female and fewer of them were current smokers than those in the tandem group. In the tandem group, the patients' National Institutes of Health Stroke Scale score on admission was higher (13 vs 15, p=0.006), onset to puncture time was shorter (299 [145-631] vs 232 [144-459] minutes, p=0.03) and Alberta Stroke Program Early CT Score (ASPECTS) was lower (8 [7-9] vs 8 [6-9], p=0.0002). The primary outcome was higher in the intracranial group (22.5% vs 8.2%, p<0.0001). However, any ICH and death were not significantly different in the two groups. CONCLUSIONS The incidence of recurrent ischemic stroke or reocclusion after EVT for AT-LVO was higher in the intracranial group.
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Affiliation(s)
- Kazutaka Uchida
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Nobuyuki Sakai
- Neurovascular Research & Neuroendovascular Therapy, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Manabu Shirakawa
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Mikiya Beppu
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yasushi Matsumoto
- Division of Development and Discovery of Interventional Therapy, Tohoku University Hospital, Sendai, Japan
| | - Kenichi Todo
- Stroke Center, Osaka University Graduate School of Medicine, Suita, Japan
| | - Mikito Hayakawa
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Seigo Shindo
- Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
- Department of Neurology, Kumamoto University, Kumamoto, Japan
| | - Shinzo Ota
- Department of Neurosurgery, Brain Attack Center Ota Memorial Hospital, Fukuyama, Japan
| | - Masafumi Morimoto
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgical Hospital, Yokohama, Japan
| | | | - Hirotoshi Imamura
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroyuki Ikeda
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kanta Tanaka
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hideyuki Ishihara
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Japan
| | - Hiroto Kakita
- Department of Neurosurgery, Shimizu Hospital, Kyoto, Japan
| | - Takanori Sano
- Department of Neurosurgery, Japanese Red Cross Ise Hospital, Ise, Japan
| | - Hayato Araki
- Department of Neurosurgery, Araki Neurosurgical Hospital, Hiroshima, Japan
| | - Tatsufumi Nomura
- Neuroendovasucular Therapy Center, Ohkawara Neurosurgical Hospital, Muroran, Japan
| | | | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
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Santulli G, Savino M, Komici K, Mone P, Savino L, Jankauskas SS. A novel imaging marker for asymptomatic cerebrovascular lesions in hypertension. Am J Hypertens 2024:hpae100. [PMID: 39094226 DOI: 10.1093/ajh/hpae100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2024] [Indexed: 08/04/2024] Open
Affiliation(s)
- Gaetano Santulli
- Department of Medicine, Division of Cardiology, Wilf Family Cardiovascular Research Institute, Einstein - Mount Sinai Diabetes Research Center (ES-DRC), Einstein Institute for Neuroimmunology and Inflammation (INI), Albert Einstein College of Medicine, New York, NY, USA
- Department of Molecular Pharmacology, Einstein Institute for Aging Research, Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY, USA
- International Translational Research and Medical Education (ITME) Consortium, Academic Research Unit, and Department of Advanced Biomedical Sciences, "Federico II" University, Naples, Italy
| | - Marco Savino
- Department of Medicine, Division of Cardiology, Wilf Family Cardiovascular Research Institute, Einstein - Mount Sinai Diabetes Research Center (ES-DRC), Einstein Institute for Neuroimmunology and Inflammation (INI), Albert Einstein College of Medicine, New York, NY, USA
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, Campobasso, Italy
| | - Klara Komici
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, Campobasso, Italy
| | - Pasquale Mone
- Department of Medicine, Division of Cardiology, Wilf Family Cardiovascular Research Institute, Einstein - Mount Sinai Diabetes Research Center (ES-DRC), Einstein Institute for Neuroimmunology and Inflammation (INI), Albert Einstein College of Medicine, New York, NY, USA
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, Campobasso, Italy
| | - Luigi Savino
- Department of Medicine, Division of Cardiology, Wilf Family Cardiovascular Research Institute, Einstein - Mount Sinai Diabetes Research Center (ES-DRC), Einstein Institute for Neuroimmunology and Inflammation (INI), Albert Einstein College of Medicine, New York, NY, USA
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, Campobasso, Italy
| | - Stanislovas S Jankauskas
- Department of Medicine, Division of Cardiology, Wilf Family Cardiovascular Research Institute, Einstein - Mount Sinai Diabetes Research Center (ES-DRC), Einstein Institute for Neuroimmunology and Inflammation (INI), Albert Einstein College of Medicine, New York, NY, USA
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Song X, Chen W, Zhao X, Zheng Z, Sang Z, Li R, Wu J. Decreased flow in ischemic stroke with coexisting intracranial artery stenosis and white matter hyperintensities. J Cent Nerv Syst Dis 2024; 16:11795735241266572. [PMID: 39055050 PMCID: PMC11271110 DOI: 10.1177/11795735241266572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 06/10/2024] [Indexed: 07/27/2024] Open
Abstract
Background Stroke patients with coexisting intracranial artery stenosis (ICAS) and white matter lesions (WML) usually have a poor outcome. However, how WML affects stroke prognosis has not been determined. Objective To investigate the quantitative forward flow at the middle cerebral artery in ICAS patients with different degrees of WML using 4D flow. Design Single-center cross-sectional cohort study. Methods Ischemic stroke patients with symptomatic middle cerebral artery (MCA) atherosclerosis were included, and they were divided into 2 groups based on Fazekas scale on Flair image (mild group = Fazekas 0-2, and severe group = Fazekas >2), TOF-MRA and 4D flow were performed to quantify the stenosis degree and forward flow at the proximal of stenosis. The flow parameters were compared between different white matter hyperintensity (WMH) groups, as well as in different MCA stenosis groups, logistic regression was used to validate the association between forward flow and WMH. Results A total of 66 patients were included in this study (mean age 56 years old, 68.2% male). 77.3% of them presented with WMH (Fazekas 1-5). Comparison of flow index between mild and severe WMH groups found a significantly lower forward flow (2.34 ± 1.09 vs 3.04 ± 1.35), higher PI (0.75 ± 0.43 vs 0.66 ± 0.32), and RI (0.49 ± 0.19 vs 0.46 ± 0.15) at ipsilateral infarction MCA in the severe WMH group, all P-values <0.05. After adjusting for other covariates, forward mean flow at ipsilateral infarction MCA is still associated with severe WMH independently, OR = 0.537, 95% CI (0.294, 0.981), P = 0.043. Conclusion Intracranial artery stenosis patients with coexisting severe WMH suffer from significantly decreased flow, which could explain the poor clinical outcome in this population, and also provide some insight into recanalization therapy in the future.
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Affiliation(s)
- Xiaowei Song
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Wenwen Chen
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, China
| | - Xihai Zhao
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, China
- Department of Radiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Zhuozhao Zheng
- Department of Radiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Zhenhua Sang
- Department of Information Technology Service, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Rui Li
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, China
| | - Jian Wu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
- IDG/McGovern Institute for Brain Research at Tsinghua University, Beijing, China
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7
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Zhang F, Yao J, Wu P, Wu Q, Li C, Yang J, Liu Y, Gareev I, Shi H, Wang C. Self-expanding intracranial drug-eluting stent system in patients with symptomatic intracranial atherosclerotic stenosis: initial experience and midterm angiographic follow-up. Neuroradiology 2024:10.1007/s00234-024-03423-x. [PMID: 38977434 DOI: 10.1007/s00234-024-03423-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 06/29/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Symptomatic intracranial atherosclerotic stenosis (ICAS) is a major cause of ischemic stroke worldwide. In patients undergoing endovascular treatment for ICAS, in-stent restenosis (ISR) is associated with ischemic stroke recurrence. OBJECTIVE Intracranial drug-eluting self-expanding stent systems (COMETIU; Sinomed Neurovita Technology Inc., CHN) are new devices for treating ICAS. This study evaluated the perioperative experience and medium-term outcomes of COMETIU in 16 patients. METHODS We prospectively analyzed 16 patients with ICAS (≥ 70% stenosis) who underwent intravascular therapy between September 4, 2022, and February 1, 2023. The primary outcome was the incidence of ISR at 6 months postoperatively. The secondary efficacy outcomes were device and technical success rates. The secondary safety outcomes included stroke or death within 30 days after the procedure and the cumulative annual rate of recurrent ischemic stroke in the target-vessel territory from 31 days to 6 months and 1 year. RESULTS A total of 16 patients with 16 intracranial atherosclerotic lesions were treated with 16 COMETIUs. All procedures were performed under general anesthesia with 100% device and technical success rates, with no cases of periprocedural stroke or death. The mean radiographic follow-up duration was at least 6 months postoperatively, and all patients presented for radiographic and clinical follow-up. There were no reported ischemic or hemorrhagic strokes. Angiographic follow-up for all patients revealed no cases of ISR. CONCLUSION COMETIU is safe and effective for treating ICAS, with minimal risk during the procedure and a low rate of ISR during medium-term follow-up.
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Affiliation(s)
- Feifan Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng road No.23, Harbin, 150000, Heilongjiang, China
| | - Jinbiao Yao
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng road No.23, Harbin, 150000, Heilongjiang, China
| | - Pei Wu
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng road No.23, Harbin, 150000, Heilongjiang, China
| | - Qiaowei Wu
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng road No.23, Harbin, 150000, Heilongjiang, China
| | - Chunxu Li
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng road No.23, Harbin, 150000, Heilongjiang, China
| | - Jinshuo Yang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng road No.23, Harbin, 150000, Heilongjiang, China
| | - Yixuan Liu
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng road No.23, Harbin, 150000, Heilongjiang, China
| | - Ilgiz Gareev
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng road No.23, Harbin, 150000, Heilongjiang, China
| | - Huaizhang Shi
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng road No.23, Harbin, 150000, Heilongjiang, China.
| | - Chunlei Wang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Youzheng road No.23, Harbin, 150000, Heilongjiang, China.
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8
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Ogedegbe G, Teresi JA, Williams SK, Ogunlade A, Izeogu C, Eimicke JP, Kong J, Silver SA, Williams O, Valsamis H, Law S, Levine SR, Waddy SP, Spruill TM. Home Blood Pressure Telemonitoring and Nurse Case Management in Black and Hispanic Patients With Stroke: A Randomized Clinical Trial. JAMA 2024; 332:41-50. [PMID: 38842799 PMCID: PMC11157441 DOI: 10.1001/jama.2024.6609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/29/2024] [Indexed: 06/07/2024]
Abstract
Importance Black and Hispanic patients have high rates of recurrent stroke and uncontrolled hypertension in the US. The effectiveness of home blood pressure telemonitoring (HBPTM) and telephonic nurse case management (NCM) among low-income Black and Hispanic patients with stroke is unknown. Objective To determine whether NCM plus HBPTM results in greater systolic blood pressure (SBP) reduction at 12 months and lower rate of stroke recurrence at 24 months than HBPTM alone among Black and Hispanic stroke survivors with uncontrolled hypertension. Design, Setting, and Participants Practice-based, multicenter, randomized clinical trial in 8 stroke centers and ambulatory practices in New York City. Black and Hispanic study participants were enrolled between April 18, 2014, and December 19, 2017, with a final follow-up visit on December 31, 2019. Interventions Participants were randomly assigned to receive either HBPTM alone (12 home BP measurements/week for 12 months, with results transmitted to a clinician; n = 226) or NCM plus HBPTM (20 counseling calls over 12 months; n = 224). Main Outcomes and Measures Primary outcomes were change in SBP at 12 months and rate of recurrent stroke at 24 months. Final statistical analyses were completed March 14, 2024. Results Among 450 participants who were enrolled and randomized (mean [SD] age, 61.7 [11.0] years; 51% were Black [n = 231]; 44% were women [n = 200]; 31% had ≥3 comorbid conditions [n = 137]; 72% had household income <$25 000/y [n = 234/324]), 358 (80%) completed the trial. Those in the NCM plus HBPTM group had a significantly greater SBP reduction than those in the HBPTM alone group at 12 months (-15.1 mm Hg [95% CI, -17.2 to -13.0] vs -5.8 mm Hg [95% CI, -7.9 to -3.7], respectively; P < .001). The between-group difference in SBP reduction at 12 months, adjusted for primary care physician clustering, was -8.1 mm Hg (95% CI, -11.2 to -5.0; P < .001) at 12 months. The rate of recurrent stroke was similar between both groups at 24 months (4.0% in the NCM plus HBPTM group vs 4.0% in the HBPTM alone group, P > .99). Conclusions and Relevance Among predominantly low-income Black and Hispanic stroke survivors with uncontrolled hypertension, addition of NCM to HBPTM led to greater SBP reduction than HBPTM alone. Additional studies are needed to understand the long-term clinical outcomes, cost-effectiveness, and generalizability of NCM-enhanced telehealth programs among low-income Black and Hispanic stroke survivors with significant comorbidity. Trial Registration Clinical Trials.gov Identifier: NCT02011685.
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Affiliation(s)
- Gbenga Ogedegbe
- Institute for Excellence in Health Equity, NYU Langone Health, New York, New York
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Jeanne A. Teresi
- Division of General Medicine, Columbia University, New York, New York
- Columbia University Stroud Center and New York State Psychiatric Institute, New York
| | - Stephen K. Williams
- Institute for Excellence in Health Equity, NYU Langone Health, New York, New York
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Adebayo Ogunlade
- Institute for Excellence in Health Equity, NYU Langone Health, New York, New York
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Chigozirim Izeogu
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Joseph P. Eimicke
- Division of General Medicine, Columbia University, New York, New York
| | - Jian Kong
- Division of General Medicine, Columbia University, New York, New York
| | | | - Olajide Williams
- Department of Neurology, Columbia University Medical School, New York, New York
| | - Helen Valsamis
- Department of Neurology, NYC Health and Hospitals/Kings County, New York, New York
| | - Susan Law
- Department of Neurology, NYC Health and Hospitals/Kings County, New York, New York
| | - Steven R. Levine
- Department of Neurology, NYC Health and Hospitals/Kings County, New York, New York
- Departments of Neurology and Emergency Medicine and Stroke Center, SUNY Downstate Health Sciences University, New York, New York
| | - Salina P. Waddy
- Division of Clinical Innovation, National Center for Advancing Translational Sciences, Bethesda, Maryland
| | - Tanya M. Spruill
- Institute for Excellence in Health Equity, NYU Langone Health, New York, New York
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
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9
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Fan C, Wu H, Xia B, Tang S, Zhen S, Tao T, Hu J, Chen K, Shi S. A Long-Term Outcome of Symptomatic Middle Cerebral Artery Undergoing Intracranial Angioplasty or Stenting. World Neurosurg 2024:S1878-8750(24)01073-8. [PMID: 38936609 DOI: 10.1016/j.wneu.2024.06.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 06/20/2024] [Accepted: 06/21/2024] [Indexed: 06/29/2024]
Abstract
OBJECTIVE For symptomatic stenosis in the middle cerebral artery (MCA), intracranial angioplasty and stenting are frequently employed. However, limited data exist regarding their long-term impact. Our study demonstrates the long-term advantages in preventing ischemic events through a 5-year follow-up period. METHODS A set of 41 individuals with symptomatic stenosis in the MCA who underwent angioplasty or stenting procedures between October 2004 and April 2018 at various hospitals in Southwest China were prospectively enrolled in the study. The rates of successful revascularization, complications, imaging observations, and clinical outcomes were systematically assessed. RESULTS A total of 41 individuals successfully underwent stenting, respectively. After stenting, the extent of stenosis was decreased from 71.8% (56-87.8%) to 24.9% (0-45%). The mean follow-up period is 36.9 ± 13.68 months (range, 11-67 months). There was no deterioration of neurological function or a new ischemic event. A DSA or CT angiography was conducted after the procedure and demonstrated no in-stent restenosis. No patient experienced restenosis below 50% during the mean follow-up period. The morbidity and mortality rates of the case series were 7.3% and 2.4%, respectively. CONCLUSIONS In the treatment of symptomatic MCA atherosclerotic stenoses, intracranial angioplasty and stenting are demonstrated to be technically feasible and safe. Its early and long-term efficacy on ischemic event prevention is acceptable, with a reduced level of restenosis, although the representative sample is tiny.
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Affiliation(s)
- Chaojun Fan
- Department of Neurology, The Sixth people's Hospital of Yibin, Yibin, China
| | - Hongchen Wu
- Neuroloy Department, Songshan General Hospital, Chongqing, China
| | - Bingxuan Xia
- Department of Neurology, The Sixth people's Hospital of Yibin, Yibin, China
| | - Shuping Tang
- Department of Neurology, The Sixth people's Hospital of Yibin, Yibin, China
| | - Shengming Zhen
- Department of Neurology, The Sixth people's Hospital of Yibin, Yibin, China
| | - Tianhua Tao
- Department of Neurology, The Sixth people's Hospital of Yibin, Yibin, China
| | - Jun Hu
- Department of Neurology, First affiliated Hospital of Army Medical University, Chongqing, China
| | - Kangning Chen
- Department of Neurology, First affiliated Hospital of Army Medical University, Chongqing, China
| | - Shugui Shi
- Neuroloy Department, Songshan General Hospital, Chongqing, China.
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10
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Garzon-Mancera ND, Khasiyev F, Del Brutto VJ, Spagnolo Allende AJ, Wright CB, Elkind M, Rundek T, Del Brutto OH, Gutierrez J. Validation of bedside manual versus automated measurements of brain arterial diameters from MR angiography. J Neuroimaging 2024. [PMID: 38809240 DOI: 10.1111/jon.13217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/06/2024] [Accepted: 05/14/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND AND PURPOSE Brain arterial luminal diameters are reliably measured with automated imaging software. Nonautomated imaging software alternatives such as a Picture Archiving Communication System are more common bedside tools used for manual measurement. This study is aimed at validating manual measurements against automated methods. METHODS We randomly selected 600 participants from the Northern Manhattan Study (NOMAS) and 260 participants from the Atahualpa Project studied with 1.5 Tesla MR angiography. Using the Radiant measuring tool, three independent readers (general practitioner, neurology resident, and vascular neurologist) measured manually the diameter of arterial brain vessels. The same vessels were also measured by LKEB Automated Vessel Analysis (LAVA). We calculated the intraclass correlation coefficient (ICC) of each rater's diameters versus those obtained with LAVA. RESULTS The ICC between diameters obtained by the general practitioner or the neurology resident compared to LAVA was excellent for both internal carotid arteries (ICA) and Basilar Arteries (BA) (ICC > .80 in all comparisons) in NOMAS. In the Atahualpa Project, ICC between diameters obtained by a vascular neurologist and LAVA was good for both ICA and BA (ICC > .60 in all comparisons). The ICCs for the measurements of the remaining arteries were moderate to poor. CONCLUSION Results suggest that manual measurements of ICA and BA diameters, but not MCA or ACA, are valid and could be used to identify dilated brain arteries at the bedside and for eventual selection of patients with dolichoectasia into clinical trials.
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Affiliation(s)
| | - Farid Khasiyev
- Department of Neurology, St. Louis University Hospital, St. Louis, Missouri, USA
| | | | | | | | - Mitchell Elkind
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA
| | - Tatjana Rundek
- School of Medicine, University of Miami Miller, Miami, Florida, USA
| | - Oscar H Del Brutto
- School of Medicine and Research Center, Universidad Espiritu Santi, Samborondón, Ecuador
| | - Jose Gutierrez
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA
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11
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Wu L, Zhang B, Li C, Zhuang Z, Liu K, Chen H, Zhu S, Zhu J, Dai Z, Huang H, Jiang Y. PSCK9 inhibitors reduced early recurrent stroke in patients with symptomatic intracranial atherosclerotic stenosis. J Neurol Neurosurg Psychiatry 2024; 95:529-535. [PMID: 38212060 DOI: 10.1136/jnnp-2023-332392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 12/22/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Symptomatic intracranial atherosclerotic stenosis (ICAS) is prone to cause early recurrent stroke (ERS). Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors lower low-density lipoprotein cholesterol (LDL-C) levels and prevent cardiovascular events. This multicentre, hospital-based prospective cohort study was designed to investigate whether PCSK9 inhibitors would prevent ERS in patients with symptomatic ICAS. METHODS From 1 October 2020 to 30 September 2022, consecutive patients with acute ischaemic stroke attributed to ICAS admitted within 1 week after onset were enrolled and followed up for 1 month. Patients were divided into two groups, the PCSK9 inhibitors group receiving PCSK9 inhibitors add-on therapy, and the control group receiving statins and/or ezetimibe. The primary outcome was ERS. Cox proportional hazard models and Kaplan-Meier survival curve were used to estimate the association between PCSK9 inhibitors and ERS. RESULTS At the end of follow-up, the LDL-C levels were further lowered by PCSK9 inhibitors add-on therapy (n=232, from 3.06±1.16 mmol/L to 2.12±1.19 mmol/L) than statins and/or ezetimibe treatment (n=429, from 2.91±1.05 mmol/L to 2.64±0.86 mmol/L, p<0.001). The Kaplan-Meier survival curves showed that PCSK9 inhibitors add-on therapy significantly reduced ERS (5.59%, 24/429, vs 2.16%, 5/232; log-rank test, p=0.044). The multivariate Cox regression analysis revealed that, after adjusting for confounders with a p value less than 0.05 in univariate analysis or of particular importance, the HR was 0.335 (95% CI 0.114 to 0.986, p=0.047), compared with the control group. CONCLUSIONS In our study, PCSK9 inhibitors add-on therapy further reduced LDL-C levels and ERS in patients with symptomatic ICAS.
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Affiliation(s)
- Li Wu
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Bo Zhang
- Department of Neurology, Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Chenghao Li
- Department of Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Zhuolin Zhuang
- Department of Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Kang Liu
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Hualin Chen
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Shuanggen Zhu
- Department of Neurology, Shenzhen Longhua District Central Hospital, The Affiliated Hospital of Guangdong Medical University, Shenzhen, Guangdong, China
| | - Juehua Zhu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Zheng Dai
- Department of Neurology, Wuxi People's Hospital, Wuxi, Jiangsu, China
| | - Huameng Huang
- Department of Neurology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Yongjun Jiang
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
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12
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Zitek H, Hejcl A, Sadeh M, Charbel FT, Sames M. Occipital artery to vertebral artery bypass for treatment of bilateral vertebral artery occlusion with QMRA as an adjunct to diagnostic assessment. Acta Neurochir (Wien) 2024; 166:203. [PMID: 38713241 PMCID: PMC11076335 DOI: 10.1007/s00701-024-06099-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/22/2024] [Indexed: 05/08/2024]
Abstract
PURPOSE Stroke, the second leading cause of death globally, often involves ischemia in the vertebrobasilar territory. This condition is underexplored, despite significant morbidity and mortality risks. The purpose of this study is to present a case of occipital artery to V3 segment vertebral artery bypass, emphasizing the role of quantitative magnetic resonance angiography (qMRA) in assessing flow and guiding surgical intervention. METHODS A 66-year-old man with bilateral vertebral artery occlusion presented acute symptoms. qMRA was employed to evaluate flow dynamics and determine the feasibility of a flow augmentation bypass surgery. The occipital artery to left vertebral artery bypass (OA-to-VA) was performed, utilizing an inverted hockey-stick incision and an antegrade inside-out technique. The patency of the bypass was confirmed using both Doppler probe and Indocyanine green. RESULTS Postoperative assessments, including computed tomography angiography (CTA) and qMRA, demonstrated the patency of the bypass with improved flow in the basilar artery and left vertebral artery. The patient's condition remained stable postoperatively, with residual peripheral palsy of the left facial nerve. CONCLUSION In conclusion, the presented case illustrates the efficacy of the OA-to-VA bypass in addressing symptomatic bilateral vertebral artery occlusion. The study underscores the pivotal role of qMRA in pre- and postoperative assessments, providing noninvasive flow quantification for diagnostic considerations and long-term follow-up in patients with vertebrobasilar insufficiency.
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Affiliation(s)
- Hynek Zitek
- Department of Neurosurgery, Purkinje University, Masaryk Hospital, Usti nad Labem, Czech Republic.
| | - Ales Hejcl
- Department of Neurosurgery, Purkinje University, Masaryk Hospital, Usti nad Labem, Czech Republic
| | - Morteza Sadeh
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Fady T Charbel
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Martin Sames
- Department of Neurosurgery, Purkinje University, Masaryk Hospital, Usti nad Labem, Czech Republic
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13
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Musmar B, Salim H, Abdelgadir J, Spellicy S, Adeeb N, Liu J, Jabbour P, Hasan D, Zomorodi A. Balloon-mounting stent versus balloon angioplasty for intracranial arterial stenosis: A systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2024; 33:107631. [PMID: 38331010 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/01/2024] [Accepted: 02/05/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Intracranial artery atherosclerotic stenosis (ICAS) is a major cause of stroke, especially in Asian countries. Current treatment options, including balloon-mounted stent (BMS) and balloon angioplasty (BA), lack sufficient evidence to determine a preferred approach. This systematic review and meta-analysis aimed to compare the efficacy and safety of BMS and BA in treating ICAS. METHODS Following PRISMA 2020 guidelines, we conducted a comprehensive search in PubMed, Web of Science, and Scopus up to December 1, 2023. Eligible studies compared BMS with BA in patients diagnosed with ICAS. Primary outcomes included the success rate and occurrence of stroke (ischemic or hemorrhagic). Secondary outcomes were perforator occlusion, in-stent thrombosis, death, and restenosis. Statistical analysis was conducted using R software version 4.3.1, employing a random-effects model. RESULTS Five high-quality studies involving 707 patients (515 males, 192 females) were included. BMS had a significantly higher success rate compared to BA (Risk Ratio [RR]: 1.13; CI: 1.03 to 1.24, p < 0.01; I2 = 14 %). The overall risk for stroke (ischemic and hemorrhagic) was significantly higher in BMS (RR: 2.97; CI: 1.32 to 6.67, p < 0.01; I2 = 0 %). However, no significant difference was found between BMS and BA regarding ischemic stroke (RR: 2.33; CI: 0.80 to 6.74, p = 0.12; I2 = 0 %). Additionally, no significant differences were observed in terms of perforator occlusion, in-stent thrombosis, dissection, minor and major strokes, and mortality rates. BMS was associated with a lower risk of restenosis (RR: 0.31; 95 % CI: 0.12 to 0.83, p = 0.02; I2 = 0 %). CONCLUSION Our results indicate that BMS might be associated with higher success and lower restenosis rates than BA in the treatment of ICAS but with an increased overall risk of stroke. No significant differences were observed in ischemic stroke, perforator occlusion, in-stent thrombosis, dissection, minor and major strokes, and mortality rates. The choice of treatment should consider these findings, alongside the technical challenges and desired angiographic outcomes. Future randomized controlled trials are necessary to further elucidate these results.
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Affiliation(s)
- Basel Musmar
- Department of Neurosurgery, Duke University Hospital, Durham, NC, USA.
| | - Hamza Salim
- Department of Neurosurgery, Louisiana State University, Shreveport, LA 70803, USA
| | - Jihad Abdelgadir
- Department of Neurosurgery, Duke University Hospital, Durham, NC, USA
| | - Samantha Spellicy
- Department of Neurosurgery, Duke University Hospital, Durham, NC, USA
| | - Nimer Adeeb
- Department of Neurosurgery, Louisiana State University, Shreveport, LA 70803, USA
| | - Jian Liu
- Department of Neurosurgery, Duke University Hospital, Durham, NC, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - David Hasan
- Department of Neurosurgery, Duke University Hospital, Durham, NC, USA
| | - Ali Zomorodi
- Department of Neurosurgery, Duke University Hospital, Durham, NC, USA
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14
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Regenhardt RW, Nolan NM, Das AS, Mahajan R, Monk AD, LaRose SL, Migdady I, Chen Y, Sheriff F, Bai X, Dmytriw AA, Patel AB, Snider SB, Vaitkevicius H. Transcranial Doppler cerebrovascular reactivity: Thresholds for clinical significance in cerebrovascular disease. J Neuroimaging 2024; 34:348-355. [PMID: 38553906 PMCID: PMC11220496 DOI: 10.1111/jon.13197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND AND PURPOSE Thresholds for abnormal transcranial Doppler cerebrovascular reactivity (CVR) studies are poorly understood, especially for patients with cerebrovascular disease. Using a real-world cohort with cerebral arterial stenosis, we sought to describe a clinically significant threshold for carbon dioxide reactivity (CO2R) and vasomotor range (VMR). METHODS CVR studies were performed during conditions of breathing room air normally, breathing 8% carbon dioxide air mixture, and hyperventilation. The mean and standard deviation (SD) of CO2R and VMR were calculated for the unaffected side in patients with unilateral stenosis; a deviation of 2 SDs below the mean was chosen as the threshold for abnormal. Receiver operating characteristic (ROC) curves for both sides for patients with unilateral and bilateral stenosis were evaluated for sensitivity (Sn) and specificity (Sp). RESULTS A total of 133 consecutive CVR studies were performed on 62 patients with stenosis with mean±SD age 55±16 years. Comorbidities included hypertension (60%), diabetes (15%), stroke (40%), and smoking (35%). In patients with unilateral stenosis, mean±SD CO2R for the unaffected side was 1.86±0.53%, defining abnormal CO2R as <0.80%. Mean±SD CO2R for the affected side was 1.27±0.90%. The CO2R threshold predicted abnormal acetazolamide single-photon emission computed tomography (SPECT) (Sn = .73, Sp = .79), CT/MRI perfusion abnormality (Sn = .42, Sp = .77), infarction on MRI (Sn = .45, Sp = .76), and pressure-dependent exam (Sn = .50, Sp = .76). For the unaffected side, mean±SD VMR was 39.5±15.8%, defining abnormal VMR as <7.9%. For the affected side, mean±SD VMR was 26.5±17.8%. The VMR threshold predicted abnormal acetazolamide SPECT (Sn = .46, Sp = .94), infarction on MRI (Sn = .27, Sp = .94), and pressure-dependent exam (Sn = .31, Sp = .90). CONCLUSIONS In patients with multiple vascular risk factors, a reasonable threshold for clinically significant abnormal CO2R is <0.80% and VMR is <7.9%. Noninvasive CVR may aid in diagnosing and risk stratifying patients with stenosis.
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Affiliation(s)
- Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Neal M Nolan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alvin S Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Rahul Mahajan
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew D Monk
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- NovaSignal, Los Angeles, California, USA
| | - Sarah L LaRose
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ibrahim Migdady
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Neurocritical Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Yimin Chen
- Department of Neurology, Foshan Sanshui District People's Hospital, Foshan, China
| | - Faheem Sheriff
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, El Paso, Texas, USA
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Adam A Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel B Snider
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Henrikas Vaitkevicius
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Status Epilepticus Division, Marinus Pharmaceuticals, Radnor, Pennsylvania, USA
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15
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Zhang J, Huang X, Wang G, Wang X, Zhang T, Wang D, Qi L, Liang J, Li B, Chu J, Li K, Sun L, Song Y, Zhao W, Zheng M, Meng Y, Yin H, Wang W, Han J. Efficacy and Safety of Tirofiban Before Stenting for Symptomatic Intracranial Atherosclerotic Stenosis: A Randomized Clinical Trial. Neurology 2024; 102:e209217. [PMID: 38489544 DOI: 10.1212/wnl.0000000000209217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 12/21/2023] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Acute stent thrombosis (AST) is not uncommon and even catastrophic during intracranial stenting angioplasty in patients with symptomatic high-grade intracranial atherosclerotic stenosis (ICAS). The purpose of this study was to investigate whether adjuvant intravenous tirofiban before stenting could reduce the risk of AST and periprocedural ischemic stroke in patients receiving stent angioplasty for symptomatic ICAS. METHODS A prospective, multicenter, open-label, randomized clinical trial was conducted from September 9, 2020, to February 18, 2022, at 10 medical centers in China. Patients intended to receive stent angioplasty for symptomatic high-grade ICAS were enrolled and randomly assigned to receive intravenous tirofiban or not before stenting in a 1:1 ratio. The primary outcomes included the incidence of AST within 30 minutes after stenting, periprocedural new-onset ischemic stroke, and symptomatic intracranial hemorrhage. The outcomes were analyzed using logistic regression analysis to obtain an odds ratio and 95% confidence interval. RESULTS A total of 200 participants (122 men [61.0%]; median [interquartile ranges] age, 57 [52-66] years) were included in the analysis, with 100 participants randomly assigned to the tirofiban group and 100 participants to the control (no tirofiban) group. The AST incidence was lower in the tirofiban group than that in the control group (4.0% vs 14.0%; adjusted odds ratio, 0.25; 95% CI 0.08-0.82; p = 0.02). No significant difference was observed in the incidence of periprocedural ischemic stroke (7.0% vs 8.0%; p = 0.98) or symptomatic intracranial hemorrhage between the 2 groups. DISCUSSION This study suggests that adjuvant intravenous tirofiban before stenting could lower the risk of AST during stent angioplasty in patients with symptomatic high-grade ICAS. TRIAL REGISTRATION INFORMATION URL: chictr.org.cn; Unique identifier: ChiCTR2000031935. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that for patients with symptomatic high-grade ICAS, pretreatment with tirofiban decreases the incidence of acute stent thrombosis. This study is Class II due to the unequal distribution of involved arteries between the 2 groups.
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Affiliation(s)
- Jun Zhang
- From the Departments of Neurology (J.Z., L.S., Y.S., W.Z., M.Z., Y.M., H.Y., W.W., J.H.) and Clinical Pharmacy (X.H.), The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan; Department of Neurology (G.W.), Binzhou People's Hospital; Department of Neurology (X.W.), Linyi People's Hospital; Department of Neurology (T.Z.), The First Hospital of Zibo; Department of Neurology (D.W.), Weifang Hospital of Traditional Chinese Medicine; Department of Neurology (L.Q.), Liaocheng People's Hospital; Department of Neurology (J.L.), Yucheng People's Hospital, Dezhou; Department of Neurology (B.L.), Yantai Yuhuangding Hospital; Department of Neurology (J.C.), Jining First People's Hospital; and Department of Neurology (K.L.), Heze Municipal Hospital, China
| | - Xin Huang
- From the Departments of Neurology (J.Z., L.S., Y.S., W.Z., M.Z., Y.M., H.Y., W.W., J.H.) and Clinical Pharmacy (X.H.), The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan; Department of Neurology (G.W.), Binzhou People's Hospital; Department of Neurology (X.W.), Linyi People's Hospital; Department of Neurology (T.Z.), The First Hospital of Zibo; Department of Neurology (D.W.), Weifang Hospital of Traditional Chinese Medicine; Department of Neurology (L.Q.), Liaocheng People's Hospital; Department of Neurology (J.L.), Yucheng People's Hospital, Dezhou; Department of Neurology (B.L.), Yantai Yuhuangding Hospital; Department of Neurology (J.C.), Jining First People's Hospital; and Department of Neurology (K.L.), Heze Municipal Hospital, China
| | - Guoqing Wang
- From the Departments of Neurology (J.Z., L.S., Y.S., W.Z., M.Z., Y.M., H.Y., W.W., J.H.) and Clinical Pharmacy (X.H.), The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan; Department of Neurology (G.W.), Binzhou People's Hospital; Department of Neurology (X.W.), Linyi People's Hospital; Department of Neurology (T.Z.), The First Hospital of Zibo; Department of Neurology (D.W.), Weifang Hospital of Traditional Chinese Medicine; Department of Neurology (L.Q.), Liaocheng People's Hospital; Department of Neurology (J.L.), Yucheng People's Hospital, Dezhou; Department of Neurology (B.L.), Yantai Yuhuangding Hospital; Department of Neurology (J.C.), Jining First People's Hospital; and Department of Neurology (K.L.), Heze Municipal Hospital, China
| | - Xianjun Wang
- From the Departments of Neurology (J.Z., L.S., Y.S., W.Z., M.Z., Y.M., H.Y., W.W., J.H.) and Clinical Pharmacy (X.H.), The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan; Department of Neurology (G.W.), Binzhou People's Hospital; Department of Neurology (X.W.), Linyi People's Hospital; Department of Neurology (T.Z.), The First Hospital of Zibo; Department of Neurology (D.W.), Weifang Hospital of Traditional Chinese Medicine; Department of Neurology (L.Q.), Liaocheng People's Hospital; Department of Neurology (J.L.), Yucheng People's Hospital, Dezhou; Department of Neurology (B.L.), Yantai Yuhuangding Hospital; Department of Neurology (J.C.), Jining First People's Hospital; and Department of Neurology (K.L.), Heze Municipal Hospital, China
| | - Tao Zhang
- From the Departments of Neurology (J.Z., L.S., Y.S., W.Z., M.Z., Y.M., H.Y., W.W., J.H.) and Clinical Pharmacy (X.H.), The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan; Department of Neurology (G.W.), Binzhou People's Hospital; Department of Neurology (X.W.), Linyi People's Hospital; Department of Neurology (T.Z.), The First Hospital of Zibo; Department of Neurology (D.W.), Weifang Hospital of Traditional Chinese Medicine; Department of Neurology (L.Q.), Liaocheng People's Hospital; Department of Neurology (J.L.), Yucheng People's Hospital, Dezhou; Department of Neurology (B.L.), Yantai Yuhuangding Hospital; Department of Neurology (J.C.), Jining First People's Hospital; and Department of Neurology (K.L.), Heze Municipal Hospital, China
| | - Dong Wang
- From the Departments of Neurology (J.Z., L.S., Y.S., W.Z., M.Z., Y.M., H.Y., W.W., J.H.) and Clinical Pharmacy (X.H.), The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan; Department of Neurology (G.W.), Binzhou People's Hospital; Department of Neurology (X.W.), Linyi People's Hospital; Department of Neurology (T.Z.), The First Hospital of Zibo; Department of Neurology (D.W.), Weifang Hospital of Traditional Chinese Medicine; Department of Neurology (L.Q.), Liaocheng People's Hospital; Department of Neurology (J.L.), Yucheng People's Hospital, Dezhou; Department of Neurology (B.L.), Yantai Yuhuangding Hospital; Department of Neurology (J.C.), Jining First People's Hospital; and Department of Neurology (K.L.), Heze Municipal Hospital, China
| | - Lifeng Qi
- From the Departments of Neurology (J.Z., L.S., Y.S., W.Z., M.Z., Y.M., H.Y., W.W., J.H.) and Clinical Pharmacy (X.H.), The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan; Department of Neurology (G.W.), Binzhou People's Hospital; Department of Neurology (X.W.), Linyi People's Hospital; Department of Neurology (T.Z.), The First Hospital of Zibo; Department of Neurology (D.W.), Weifang Hospital of Traditional Chinese Medicine; Department of Neurology (L.Q.), Liaocheng People's Hospital; Department of Neurology (J.L.), Yucheng People's Hospital, Dezhou; Department of Neurology (B.L.), Yantai Yuhuangding Hospital; Department of Neurology (J.C.), Jining First People's Hospital; and Department of Neurology (K.L.), Heze Municipal Hospital, China
| | - Jiye Liang
- From the Departments of Neurology (J.Z., L.S., Y.S., W.Z., M.Z., Y.M., H.Y., W.W., J.H.) and Clinical Pharmacy (X.H.), The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan; Department of Neurology (G.W.), Binzhou People's Hospital; Department of Neurology (X.W.), Linyi People's Hospital; Department of Neurology (T.Z.), The First Hospital of Zibo; Department of Neurology (D.W.), Weifang Hospital of Traditional Chinese Medicine; Department of Neurology (L.Q.), Liaocheng People's Hospital; Department of Neurology (J.L.), Yucheng People's Hospital, Dezhou; Department of Neurology (B.L.), Yantai Yuhuangding Hospital; Department of Neurology (J.C.), Jining First People's Hospital; and Department of Neurology (K.L.), Heze Municipal Hospital, China
| | - Bing Li
- From the Departments of Neurology (J.Z., L.S., Y.S., W.Z., M.Z., Y.M., H.Y., W.W., J.H.) and Clinical Pharmacy (X.H.), The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan; Department of Neurology (G.W.), Binzhou People's Hospital; Department of Neurology (X.W.), Linyi People's Hospital; Department of Neurology (T.Z.), The First Hospital of Zibo; Department of Neurology (D.W.), Weifang Hospital of Traditional Chinese Medicine; Department of Neurology (L.Q.), Liaocheng People's Hospital; Department of Neurology (J.L.), Yucheng People's Hospital, Dezhou; Department of Neurology (B.L.), Yantai Yuhuangding Hospital; Department of Neurology (J.C.), Jining First People's Hospital; and Department of Neurology (K.L.), Heze Municipal Hospital, China
| | - Jianfeng Chu
- From the Departments of Neurology (J.Z., L.S., Y.S., W.Z., M.Z., Y.M., H.Y., W.W., J.H.) and Clinical Pharmacy (X.H.), The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan; Department of Neurology (G.W.), Binzhou People's Hospital; Department of Neurology (X.W.), Linyi People's Hospital; Department of Neurology (T.Z.), The First Hospital of Zibo; Department of Neurology (D.W.), Weifang Hospital of Traditional Chinese Medicine; Department of Neurology (L.Q.), Liaocheng People's Hospital; Department of Neurology (J.L.), Yucheng People's Hospital, Dezhou; Department of Neurology (B.L.), Yantai Yuhuangding Hospital; Department of Neurology (J.C.), Jining First People's Hospital; and Department of Neurology (K.L.), Heze Municipal Hospital, China
| | - Kai Li
- From the Departments of Neurology (J.Z., L.S., Y.S., W.Z., M.Z., Y.M., H.Y., W.W., J.H.) and Clinical Pharmacy (X.H.), The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan; Department of Neurology (G.W.), Binzhou People's Hospital; Department of Neurology (X.W.), Linyi People's Hospital; Department of Neurology (T.Z.), The First Hospital of Zibo; Department of Neurology (D.W.), Weifang Hospital of Traditional Chinese Medicine; Department of Neurology (L.Q.), Liaocheng People's Hospital; Department of Neurology (J.L.), Yucheng People's Hospital, Dezhou; Department of Neurology (B.L.), Yantai Yuhuangding Hospital; Department of Neurology (J.C.), Jining First People's Hospital; and Department of Neurology (K.L.), Heze Municipal Hospital, China
| | - Lili Sun
- From the Departments of Neurology (J.Z., L.S., Y.S., W.Z., M.Z., Y.M., H.Y., W.W., J.H.) and Clinical Pharmacy (X.H.), The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan; Department of Neurology (G.W.), Binzhou People's Hospital; Department of Neurology (X.W.), Linyi People's Hospital; Department of Neurology (T.Z.), The First Hospital of Zibo; Department of Neurology (D.W.), Weifang Hospital of Traditional Chinese Medicine; Department of Neurology (L.Q.), Liaocheng People's Hospital; Department of Neurology (J.L.), Yucheng People's Hospital, Dezhou; Department of Neurology (B.L.), Yantai Yuhuangding Hospital; Department of Neurology (J.C.), Jining First People's Hospital; and Department of Neurology (K.L.), Heze Municipal Hospital, China
| | - Yun Song
- From the Departments of Neurology (J.Z., L.S., Y.S., W.Z., M.Z., Y.M., H.Y., W.W., J.H.) and Clinical Pharmacy (X.H.), The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan; Department of Neurology (G.W.), Binzhou People's Hospital; Department of Neurology (X.W.), Linyi People's Hospital; Department of Neurology (T.Z.), The First Hospital of Zibo; Department of Neurology (D.W.), Weifang Hospital of Traditional Chinese Medicine; Department of Neurology (L.Q.), Liaocheng People's Hospital; Department of Neurology (J.L.), Yucheng People's Hospital, Dezhou; Department of Neurology (B.L.), Yantai Yuhuangding Hospital; Department of Neurology (J.C.), Jining First People's Hospital; and Department of Neurology (K.L.), Heze Municipal Hospital, China
| | - Wei Zhao
- From the Departments of Neurology (J.Z., L.S., Y.S., W.Z., M.Z., Y.M., H.Y., W.W., J.H.) and Clinical Pharmacy (X.H.), The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan; Department of Neurology (G.W.), Binzhou People's Hospital; Department of Neurology (X.W.), Linyi People's Hospital; Department of Neurology (T.Z.), The First Hospital of Zibo; Department of Neurology (D.W.), Weifang Hospital of Traditional Chinese Medicine; Department of Neurology (L.Q.), Liaocheng People's Hospital; Department of Neurology (J.L.), Yucheng People's Hospital, Dezhou; Department of Neurology (B.L.), Yantai Yuhuangding Hospital; Department of Neurology (J.C.), Jining First People's Hospital; and Department of Neurology (K.L.), Heze Municipal Hospital, China
| | - Meimei Zheng
- From the Departments of Neurology (J.Z., L.S., Y.S., W.Z., M.Z., Y.M., H.Y., W.W., J.H.) and Clinical Pharmacy (X.H.), The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan; Department of Neurology (G.W.), Binzhou People's Hospital; Department of Neurology (X.W.), Linyi People's Hospital; Department of Neurology (T.Z.), The First Hospital of Zibo; Department of Neurology (D.W.), Weifang Hospital of Traditional Chinese Medicine; Department of Neurology (L.Q.), Liaocheng People's Hospital; Department of Neurology (J.L.), Yucheng People's Hospital, Dezhou; Department of Neurology (B.L.), Yantai Yuhuangding Hospital; Department of Neurology (J.C.), Jining First People's Hospital; and Department of Neurology (K.L.), Heze Municipal Hospital, China
| | - Yao Meng
- From the Departments of Neurology (J.Z., L.S., Y.S., W.Z., M.Z., Y.M., H.Y., W.W., J.H.) and Clinical Pharmacy (X.H.), The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan; Department of Neurology (G.W.), Binzhou People's Hospital; Department of Neurology (X.W.), Linyi People's Hospital; Department of Neurology (T.Z.), The First Hospital of Zibo; Department of Neurology (D.W.), Weifang Hospital of Traditional Chinese Medicine; Department of Neurology (L.Q.), Liaocheng People's Hospital; Department of Neurology (J.L.), Yucheng People's Hospital, Dezhou; Department of Neurology (B.L.), Yantai Yuhuangding Hospital; Department of Neurology (J.C.), Jining First People's Hospital; and Department of Neurology (K.L.), Heze Municipal Hospital, China
| | - Hao Yin
- From the Departments of Neurology (J.Z., L.S., Y.S., W.Z., M.Z., Y.M., H.Y., W.W., J.H.) and Clinical Pharmacy (X.H.), The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan; Department of Neurology (G.W.), Binzhou People's Hospital; Department of Neurology (X.W.), Linyi People's Hospital; Department of Neurology (T.Z.), The First Hospital of Zibo; Department of Neurology (D.W.), Weifang Hospital of Traditional Chinese Medicine; Department of Neurology (L.Q.), Liaocheng People's Hospital; Department of Neurology (J.L.), Yucheng People's Hospital, Dezhou; Department of Neurology (B.L.), Yantai Yuhuangding Hospital; Department of Neurology (J.C.), Jining First People's Hospital; and Department of Neurology (K.L.), Heze Municipal Hospital, China
| | - Wei Wang
- From the Departments of Neurology (J.Z., L.S., Y.S., W.Z., M.Z., Y.M., H.Y., W.W., J.H.) and Clinical Pharmacy (X.H.), The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan; Department of Neurology (G.W.), Binzhou People's Hospital; Department of Neurology (X.W.), Linyi People's Hospital; Department of Neurology (T.Z.), The First Hospital of Zibo; Department of Neurology (D.W.), Weifang Hospital of Traditional Chinese Medicine; Department of Neurology (L.Q.), Liaocheng People's Hospital; Department of Neurology (J.L.), Yucheng People's Hospital, Dezhou; Department of Neurology (B.L.), Yantai Yuhuangding Hospital; Department of Neurology (J.C.), Jining First People's Hospital; and Department of Neurology (K.L.), Heze Municipal Hospital, China
| | - Ju Han
- From the Departments of Neurology (J.Z., L.S., Y.S., W.Z., M.Z., Y.M., H.Y., W.W., J.H.) and Clinical Pharmacy (X.H.), The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan; Department of Neurology (G.W.), Binzhou People's Hospital; Department of Neurology (X.W.), Linyi People's Hospital; Department of Neurology (T.Z.), The First Hospital of Zibo; Department of Neurology (D.W.), Weifang Hospital of Traditional Chinese Medicine; Department of Neurology (L.Q.), Liaocheng People's Hospital; Department of Neurology (J.L.), Yucheng People's Hospital, Dezhou; Department of Neurology (B.L.), Yantai Yuhuangding Hospital; Department of Neurology (J.C.), Jining First People's Hospital; and Department of Neurology (K.L.), Heze Municipal Hospital, China
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16
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Rehman S, Nadeem A, Akram U, Sarwar A, Quraishi A, Siddiqui H, Malik MAJ, Nabi M, Ul Haq I, Cho A, Mazumdar I, Kim M, Chen K, Sepehri S, Wang R, Balar AB, Lakhani DA, Yedavalli VS. Molecular Mechanisms of Ischemic Stroke: A Review Integrating Clinical Imaging and Therapeutic Perspectives. Biomedicines 2024; 12:812. [PMID: 38672167 PMCID: PMC11048412 DOI: 10.3390/biomedicines12040812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/28/2024] [Accepted: 04/01/2024] [Indexed: 04/28/2024] Open
Abstract
Ischemic stroke poses a significant global health challenge, necessitating ongoing exploration of its pathophysiology and treatment strategies. This comprehensive review integrates various aspects of ischemic stroke research, emphasizing crucial mechanisms, therapeutic approaches, and the role of clinical imaging in disease management. It discusses the multifaceted role of Netrin-1, highlighting its potential in promoting neurovascular repair and mitigating post-stroke neurological decline. It also examines the impact of blood-brain barrier permeability on stroke outcomes and explores alternative therapeutic targets such as statins and sphingosine-1-phosphate signaling. Neurocardiology investigations underscore the contribution of cardiac factors to post-stroke mortality, emphasizing the importance of understanding the brain-heart axis for targeted interventions. Additionally, the review advocates for early reperfusion and neuroprotective agents to counter-time-dependent excitotoxicity and inflammation, aiming to preserve tissue viability. Advanced imaging techniques, including DWI, PI, and MR angiography, are discussed for their role in evaluating ischemic penumbra evolution and guiding therapeutic decisions. By integrating molecular insights with imaging modalities, this interdisciplinary approach enhances our understanding of ischemic stroke and offers promising avenues for future research and clinical interventions to improve patient outcomes.
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Affiliation(s)
- Sana Rehman
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Arsalan Nadeem
- Department of Medicine, Allama Iqbal Medical College, Lahore 54700, Pakistan;
| | - Umar Akram
- Department of Medicine, Allama Iqbal Medical College, Lahore 54700, Pakistan;
| | - Abeer Sarwar
- Department of Medicine, Fatima Memorial Hospital College of Medicine and Dentistry, Lahore 54000, Pakistan; (A.S.); (H.S.)
| | - Ammara Quraishi
- Department of Medicine, Dow University of Health Sciences, Karachi 74200, Pakistan;
| | - Hina Siddiqui
- Department of Medicine, Fatima Memorial Hospital College of Medicine and Dentistry, Lahore 54000, Pakistan; (A.S.); (H.S.)
| | | | - Mehreen Nabi
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Ihtisham Ul Haq
- Department of Medicine, Amna Inayat Medical College, Sheikhupura 54300, Pakistan;
| | - Andrew Cho
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Ishan Mazumdar
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Minsoo Kim
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Kevin Chen
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Sadra Sepehri
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Richard Wang
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Aneri B. Balar
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Dhairya A. Lakhani
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Vivek S. Yedavalli
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
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Lin H, Shen H, Wang N, Wu T. Monocyte to high-density lipoprotein ratio as an independent predictor of intracranial atherosclerotic stenosis-related emergency large vessel occlusion. Clin Neurol Neurosurg 2024; 239:108228. [PMID: 38460429 DOI: 10.1016/j.clineuro.2024.108228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 02/19/2024] [Accepted: 03/02/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVE To evaluate the correlation between the monocyte-to-high-density lipoprotein cholesterol ratio (MHR) and intracranial atherosclerotic stenosis-related emergent large vessel occlusion (ICAS-ELVO) in acute ischemic stroke patients with endovascular thrombectomy. METHODS Included in this study were 215 patients who underwent endovascular thrombectomy. They were randomly assigned to training and testing datasets. The patients in training dataset (n=128) were divided into ICAS group (n=65) and embolism group (n=63). MHR was compared between the two groups. According to the cut-off value, patients in testing dataset (n=87) were divided into low-MHR group (n=54) and high-MHR group (n=33). MHR was compared between the two groups. RESULTS In training dataset, the proportion of male patients, diabetic patients and smokers in ICAS group was significantly higher than that in embolism group [(50 (76.9%) vs. 30 (47.6%), P=0.001; 29 (44.6%) vs. 14(22.2%), P=0.007; 37(56.9%) vs. 14 (22.2%), P=0.001; 37 (56.9%) vs. 14 (22.2%), P=0.001], while the mean age and the proportion of patients with coronary heart disease (CHD), stroke and atrial fibrillation were significantly lower [(64.74±9.13 vs. 71.38±13.34, P=0.001; 6 (9.2%) vs. 14 (22.2%), P=0.043; 12 (18.5%) vs. 22 (34.9%), P=0.035; 5 (7.7%)vs. 56 (88.9%), P<0.001)]. The laboratory test results showed that monocyte count was significantly higher and high-density lipoprotein level was significantly lower in ICAS group than those in embolism group (0.61±0.26 vs. 0.45±0.13, P=0.001; 1.17±0.28 vs. 1.37±0.27, P=0.001). MHR in ICAS group was significantly higher than that in embolism group (0.55±0.26 vs. 0.34±0.11, P=0.001). In training set, MHR was found to be an independent predictor for the occurrence of ICAS-ELVO with an adjusted OR of 2.39 (95%CI 1.29-4.48, P=0.006). ROC curve analysis showed that the area under the curve (AUC) of MHR was 0.8 (95% CI, 0.72-0.87, p < 0.001), with a sensitivity of 0.60 and a specificity of 0.873. The optimal cut-off value of the MHR level was 0.46. In testing dataset, the rate of ICAS-ELVO in higher quartile was significantly higher than that in the lower quartile (81.8% vs. 33.3%, P<0.001). Patients with a low MHR had a higher rate of cerebral hemorrhagic than those with a high MHR. CONCLUSION MHR was associated with ICAS-ELVO in acute ischemic stroke patients with endovascular thrombectomy, and the higher level of MHR does benefit to differentiate ICAS from intracranial embolism, suggesting that MHR may prove to be an independent predictor for ICAS-ELVO.
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Affiliation(s)
- Huangbin Lin
- Department of Neurology, The Fourth People's Hospital Affiliated to Tongji University, Shanghai, China.
| | - Hongjian Shen
- Neurovascular Center, Department of Neurology, Changhai Hospital, Naval Medical University, Shanghai, China.
| | - Nuo Wang
- Department of Neurology, Changhai Hospital, Naval Medical University, Shanghai, China.
| | - Tao Wu
- Neurovascular Center, Department of Neurology, Changhai Hospital, Naval Medical University, Shanghai, China.
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18
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Bhatia R, Padma Srivastava MV, Sarkar R, Fatima S, Longkumer I, Garg A, Gupta P, Pandian JD, Khurana D, Sylaja PN, Jain S, Arora D, Dhasan A, Sharma M. STENOSIS: Long-term single versus dual antiplatelet therapy in patients with ischaemic stroke due to intracranial atherosclerotic disease - a randomised trial. BMJ Neurol Open 2024; 6:e000532. [PMID: 38501127 PMCID: PMC10946378 DOI: 10.1136/bmjno-2023-000532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 10/10/2023] [Indexed: 03/20/2024] Open
Abstract
Rationale Intracranial atherosclerotic disease (ICAD) is a pathological process that causes progressive stenosis and cerebral hypoperfusion, leading to stroke occurrence and recurrence around the world. The exact duration of dual antiplatelet therapy (DAPT) for ICAD is unclear in view of long-term risk of bleeding complications. Aim The current study aims to study the efficacy and safety of long-term DAPT (up to 12 months) in patients with ICAD. Sample size Using 80% power and an alpha error of 5 %, presuming a 10%-15% drop-out rate, a total of 2200 patients will be recruited for the study. Methodology This is a prospective, randomised, double-blind, placebo controlled trial. Study outcomes The primary outcomes include recurrent ischaemic stroke (IS) or transient ischaemic attack and any intracranial haemorrhage (ICH), major or minor systemic bleeding at the end of 12 months. Secondary outcomes include composite of any stroke, myocardial infarction or death at the end of 12 months. The safety outcomes include any ICH, major or minor bleeding as defined using GUSTO (Global Use of Streptokinase and tPA for occluded Coronary Arteries) classification at the end of 12 months and 1 month after completion of the drug treatment phase. Discussion The study will provide level I evidence on the duration of DAPT among patients with IS due to ICAD of more than or equal to 50%.
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Affiliation(s)
- Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - MV Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Risha Sarkar
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Saman Fatima
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Imnameren Longkumer
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Garg
- Department of Neuroimaging and Interventional Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Pooja Gupta
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Dheeraj Khurana
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - PN Sylaja
- Department of Neurology, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, India
| | - Shweta Jain
- Department of Neurology, Christian Medical College, Ludhiana, India
| | - Deepti Arora
- Department of Neurology, Christian Medical College, Ludhiana, India
| | - Aneesh Dhasan
- Department of Neurology, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, India
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Hirano Y, Miyawaki S, Sakaguchi Y, Koizumi S, Hongo H, Saito N. A bibliometric analysis of the 100 most-cited clinical articles in the research of intracranial artery stenosis and intracranial atherosclerosis. Surg Neurol Int 2024; 15:74. [PMID: 38628533 PMCID: PMC11021113 DOI: 10.25259/sni_1030_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 01/19/2024] [Indexed: 04/19/2024] Open
Abstract
Background Intracranial arterial stenosis (ICAS), caused by intracranial atherosclerosis, is one of the major causes of ischemic stroke. This study identified the top 100 most-cited publications on ICAS through a bibliometric analysis. Methods Two independent authors conducted a search in the Web of Science database for clinical articles on ICAS published between 1993 and 2022. The top 100 most-cited articles were then extracted. For each article, the analysis covered the title, author, country of origin/affiliation, journal, total number of citations, number of citations per year, and type of study. Results The top 100 most-cited papers in the ICAS were authored by 565 authors from 12 countries and published in 29 journals. In terms of the 5-year trend, the largest number of papers were published between 2003 and 2007 (n = 31). The median number of citations for the 100 papers was 161 (range 109-1,115). The journal with the highest proportion of the 100 most published articles was Stroke, accounting for 41% of articles and 37% of the citations. According to country of origin, the United States of America accounted for the largest number of articles, followed by China, Japan, and South Korea, with these four countries together accounting for 81% of the total number of articles and 88% of the citations. Trends in the past five years included the use of terms such as acute ischemic stroke and mechanical thrombectomy. Conclusion The findings of this study provide novel insight into this field and will facilitate future research endeavors.
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Affiliation(s)
- Yudai Hirano
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Japan
| | - Satoru Miyawaki
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Japan
| | - Yusuke Sakaguchi
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Japan
| | - Satoshi Koizumi
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Japan
| | - Hiroki Hongo
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Japan
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20
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Xi Z, Guangxin D, He Z, Zhibin C, Yun L, Tingzheng Z, Yun X, Jingwei L. Safety and effectiveness assessment of endovascular recanalization for non-acute middle cerebral artery occlusion. CNS Neurosci Ther 2024; 30:e14426. [PMID: 37641873 PMCID: PMC10915976 DOI: 10.1111/cns.14426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/18/2023] [Accepted: 08/12/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Endovascular treatment for patients with symptomatic nonacute middle cerebral artery occlusion remains clinically challenging, and proof of a beneficial effect on functional outcome is lacking. We aim to evaluate the effectiveness and safety of endovascular recanalization for patients with symptomatic nonacute middle cerebral artery occlusion. METHODS Ninety-eight patients with symptomatic atherosclerotic nonacute middle cerebral artery occlusion were divided into drug treatment groups (42) and endovascular treatment groups (56). The rate of recanalization, peri-procedural complications, and follow-up results were evaluated. RESULTS Among the 56 patients who received endovascular treatment, 53 (94.6%) achieved successful recanalization. The rate of peri-procedural complications was 7.1% (4/56), and the death rate was 1.8% (1/56). Any stroke within 90 days was 7.1% (4/56). Among the 42 patients in drug treatment group, any stroke within 90 days was 19.0% (8/42), death rate was 0. CONCLUSION Among patients with symptomatic nonacute middle cerebral artery occlusion with a short length of occlusion and a moderate-to-good collateral circulation, endovascular treatment seems to be safe. And endovascular treatment could reduce the recurrence rate of stroke.
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Affiliation(s)
- Zhang Xi
- Department of Neurology, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology, Drum Tower HospitalNanjing UniversityNanjingChina
- Jiangsu Province Stroke Center for Diagnosis and TherapyNanjingChina
| | - Duan Guangxin
- Department of Neurology, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology, Drum Tower HospitalNanjing UniversityNanjingChina
- Jiangsu Province Stroke Center for Diagnosis and TherapyNanjingChina
| | - Zhang He
- Department of Neurology, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology, Drum Tower HospitalNanjing UniversityNanjingChina
- Jiangsu Province Stroke Center for Diagnosis and TherapyNanjingChina
| | - Chen Zhibin
- Department of Neurology, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology, Drum Tower HospitalNanjing UniversityNanjingChina
- Jiangsu Province Stroke Center for Diagnosis and TherapyNanjingChina
| | - Luo Yun
- Department of Neurology, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology, Drum Tower HospitalNanjing UniversityNanjingChina
- Jiangsu Province Stroke Center for Diagnosis and TherapyNanjingChina
| | - Zhang Tingzheng
- Department of Neurology, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology, Drum Tower HospitalNanjing UniversityNanjingChina
- Jiangsu Province Stroke Center for Diagnosis and TherapyNanjingChina
| | - Xu Yun
- Department of Neurology, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology, Drum Tower HospitalNanjing UniversityNanjingChina
- Jiangsu Province Stroke Center for Diagnosis and TherapyNanjingChina
| | - Li Jingwei
- Department of Neurology, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology, Drum Tower HospitalNanjing UniversityNanjingChina
- Jiangsu Province Stroke Center for Diagnosis and TherapyNanjingChina
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21
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Sun X, Yang M, Sun D, Peng G, Deng Y, Zhao X, Liu L, Ma N, Gao F, Mo D, Yu W, Wang Y, Wang Y, Miao Z. Balloon Angioplasty for Symptomatic Intracranial Artery Stenosis (BASIS): protocol of a prospective, multicentre, randomised, controlled trial. Stroke Vasc Neurol 2024; 9:66-74. [PMID: 37202152 PMCID: PMC10956109 DOI: 10.1136/svn-2022-002288] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 04/20/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND The superiority of balloon angioplasty plus aggressive medical management (AMM) to AMM alone for symptomatic intracranial artery stenosis (sICAS) on efficacy and safety profiles still lacks evidence from randomised controlled trials (RCTs). AIM To demonstrate the design of an RCT on balloon angioplasty plus AMM for sICAS. DESIGN Balloon Angioplasty for Symptomatic Intracranial Artery Stenosis (BASIS) trial is a multicentre, prospective, randomised, open-label, blinded end-point trial to investigate whether balloon angioplasty plus AMM could improve clinical outcome compared with AMM alone in patients with sICAS. Patients eligible in BASIS were 35-80 years old, with a recent transient ischaemic attack within the past 90 days or ischaemic stroke between 14 days and 90 days prior to enrolment due to severe atherosclerotic stenosis (70%-99%) of a major intracranial artery. The eligible patients were randomly assigned to receive balloon angioplasty plus AMM or AMM alone at a 1:1 ratio. Both groups will receive identical AMM, including standard dual antiplatelet therapy for 90 days followed by long-term single antiplatelet therapy, intensive risk factor management and life-style modification. All participants will be followed up for 3 years. STUDY OUTCOMES Stroke or death in the next 30 days after enrolment or after balloon angioplasty procedure of the qualifying lesion during follow-up, or any ischaemic stroke or revascularisation from the qualifying artery after 30 days but before 12 months of enrolment, is the primary outcome. DISCUSSION BASIS trail is the first RCT to compare the efficacy and safety of balloon angioplasty plus AMM to AMM alone in sICAS patients, which may provide an alternative perspective for treating sICAS. TRIAL REGISTRATION NUMBER NCT03703635; https://www. CLINICALTRIALS gov.
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Affiliation(s)
- Xuan Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Yang
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guangge Peng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Yiming Deng
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wengui Yu
- Department of Neurology, Comprehensive Stroke & Cerebrovascular Center, University of California Irvine, Irvine, California, USA
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
- National Center for Neurological Diseases, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Beijing Laboratory of Oral Health, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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22
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Ma L, Wang F, Feng H, Yan S, Xu JC, Cheng YS, Fang C. Endovascular treatment of symptomatic severe intracranial atherosclerotic stenosis with a novel intracranial dedicated drug-eluting stent: a more effective treatment approach. Front Neurol 2024; 15:1304524. [PMID: 38585365 PMCID: PMC10995922 DOI: 10.3389/fneur.2024.1304524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/08/2024] [Indexed: 04/09/2024] Open
Abstract
Background Endovascular treatment of severe intracranial atherosclerotic stenosis (ICAS) using coronary drug-eluting stents (DESs) significantly reduces the risk of in-stent restenosis (ISR) and stroke recurrence. However, there are few reports regarding the treatment of ICAS with intracranial dedicated DES. Herein, we present our experience with the feasibility, safety, and medium-term follow-up outcomes of a novel intracranial DES, named NOVA stent, in patients with symptomatic severe ICAS (≥70%). Methods From December 2021 to May 2022, patients with symptomatic severe ICAS who underwent implantation of the NOVA stent in our institution were retrospectively analyzed for procedural results, perioperative complications, imaging and clinical follow-up outcomes. Results Twenty-four patients, 16 (66.7%) with anterior circulation lesions and 8 (33.3%) with posterior circulation lesions, were enrolled. All patients with intracranial ICA (n = 6), middle cerebral artery (n = 10), basilar artery (n = 3), intracranial vertebral artery (n = 3), and the vertebrobasilar junction (n = 2) stenosis were treated successfully using NOVA stents. The severity of stenosis ranged from 75 to 96% (mean 85.9%) before treatment and this was reduced to 0 to 20% (mean 8.6%) immediately after stent placement. Symptomatic distal embolism occurred in one case; however, there were no other perioperative complications. The mean follow-up duration was 12.2 ± 1.06 months. No symptomatic ischemic events occurred during follow-up. Follow-up cerebral angiography was performed in 22 of 24 patients (91.7%), and significant ISR occurred in one patient (4.2%). Conclusion Our results demonstrate that implantation of the novel intracranial DES NOVA in severe ICAS is feasible, safe, and effective in selected cases, reducing the incidence of ISR, and showing excellent midterm clinical outcomes, providing a promising option for ICAS treatment.
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Affiliation(s)
- Lin Ma
- Department of Interventional Radiology, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Fei Wang
- Department of Neurosurgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Hao Feng
- Department of Interventional Radiology, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shuo Yan
- Department of Interventional Radiology, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Ji-Chong Xu
- Department of Interventional Radiology, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Ying-Sheng Cheng
- Department of Interventional Radiology, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Chun Fang
- Department of Interventional Radiology, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
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Wabnitz AM, Turan TN. Optimal Medical Management of Atherosclerotic Intracranial Stenosis. Stroke 2024; 55:335-343. [PMID: 38252762 DOI: 10.1161/strokeaha.123.043633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Reducing the high risk of recurrent stroke in patients with symptomatic intracranial atherosclerotic stenosis (sICAS) has proven to be challenging, but aggressive medical management, with intensive risk factor control and antithrombotic therapy, has been shown to be beneficial. High-intensity statins are recommended for patients with atherosclerotic stroke, including sICAS. Ezetimibe and PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors are beneficial for those who fail to reach low-density lipoprotein targets or those with statin intolerance. The treatment target for sICAS is low-density lipoprotein <70 mg/dL. In neurologically stable patients, blood pressure should be treated to goal <140/90 mm Hg with the use of thiazide diuretics, angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers preferentially. For those with diabetes, treat to goal hemoglobin A1C ≤7% for most patients through combination of diet, insulin, and hypoglycemic drugs. Some degree of physical activity (eg, walking, stationary biking with arms or legs, etc) should be encouraged in all patients with sICAS who are not severely disabled. A minimum of 10 minutes of moderate-intensity aerobic activity 4 times a week is recommended for patients who are capable of exercise. For all patients with severe sICAS (70%-99% stenosis), dual antiplatelet therapy for up to 90 days followed by single antiplatelet agent is recommended.
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Affiliation(s)
- Ashley M Wabnitz
- Department of Neurology, Medical University of South Carolina, Charleston
| | - Tanya N Turan
- Department of Neurology, Medical University of South Carolina, Charleston
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24
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Jiang X, Liang W, Zhao Z, Zhao B, Yan L, Mang J. Angiographic Pattern of M1 Stenosis Predicts Territorial Stroke in Patients Receiving Aggressive Medication without Stenting. World Neurosurg 2024; 182:e536-e545. [PMID: 38101545 DOI: 10.1016/j.wneu.2023.11.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE To evaluate the relationship between different angiographic patterns of middle cerebral artery M1 segment stenosis and related territorial stroke in patients receiving aggressive medical treatment without stenting. METHODS We retrospectively reviewed our patient registry database to identify ICAS patients diagnosed by digital subtraction angiography between January 2017 and December 2020 and identified 3 different angiographic patterns (normal, shift, and dilation) in 124 patients with M1 stenosis. The association between these patterns and recurrent ischemic stroke in the M1 territory was analyzed. RESULTS The rates of recurrent M1 territorial stroke and transient ischemic attack in the normal group, shift group, dilation group and shift-dilation group were 34.5%, 35.0%, 78.3%, and 44.4% respectively. In patients with the shift pattern, the rate of recurrent stroke is significantly higher at a deflection angle ≥9.32° than at a deflection angle <9.32°(P < 0.05). In patients with dilation pattern, the rate of recurrent stroke is significantly higher than patients with non-dilation pattern (72.3% vs. 36.8%, P < 0.05). CONCLUSIONS Angiographic patterns of M1 stenosis may predict recurrent territorial strokes, thus providing a surrogate marker to identify high-risk patients for potential endovascular treatment.
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Affiliation(s)
- Xinzhao Jiang
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China; Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
| | - Wenzhao Liang
- Department of Geriatric and General Medicine, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Zhongyu Zhao
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Bingyang Zhao
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Lei Yan
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Jing Mang
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China.
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25
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Al Kasab S, Nguyen TN, Derdeyn CP, Yaghi S, Amin-Hanjani S, Kicielinski K, Zaidat OO, de Havenon A. Emergent Large Vessel Occlusion due to Intracranial Stenosis: Identification, Management, Challenges, and Future Directions. Stroke 2024; 55:355-365. [PMID: 38252763 DOI: 10.1161/strokeaha.123.043635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/12/2023] [Indexed: 01/24/2024]
Abstract
This comprehensive literature review focuses on acute stroke related to intracranial atherosclerotic stenosis (ICAS), with an emphasis on ICAS-large vessel occlusion. ICAS is the leading cause of stroke globally, with high recurrence risk, especially in Asian, Black, and Hispanic populations. Various risk factors, including hypertension, diabetes, hyperlipidemia, smoking, and advanced age lead to ICAS, which in turn results in stroke through different mechanisms. Recurrent stroke risk in patients with ICAS with hemodynamic failure is particularly high, even with aggressive medical management. Developments in advanced imaging have improved our understanding of ICAS and ability to identify high-risk patients who could benefit from intervention. Herein, we focus on current management strategies for ICAS-large vessel occlusion discussed, including the use of perfusion imaging, endovascular therapy, and stenting. In addition, we focus on strategies that aim at identifying subjects at higher risk for early recurrent risk who could benefit from early endovascular intervention The review underscores the need for further research to optimize ICAS-large vessel occlusion treatment strategies, a traditionally understudied topic.
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Affiliation(s)
- Sami Al Kasab
- Department of Neurology (S.A.K.), Medical University of South Carolina, Charleston
- Department of Neurosurgery (S.A.K., K.K.), Medical University of South Carolina, Charleston
| | | | - Colin P Derdeyn
- Department of Radiology, Carver College of Medicine, Iowa City (C.P.D.)
| | - Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (S.Y.)
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, OH (S.A.-H.)
| | - Kimberly Kicielinski
- Department of Neurosurgery (S.A.K., K.K.), Medical University of South Carolina, Charleston
| | - Osama O Zaidat
- Department of Neurology, Mercy Health, Toledo, OH (O.O.Z.)
| | - Adam de Havenon
- Department of Neurology, Center for Brain and Mind Health, Yale University, New Haven, CT (A.d.H.)
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Hoh BL, Chimowitz MI. Focused Update on Intracranial Atherosclerosis: Introduction, Highlights, and Knowledge Gaps. Stroke 2024; 55:305-310. [PMID: 38252758 PMCID: PMC10832349 DOI: 10.1161/strokeaha.123.045513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Affiliation(s)
- Brian L Hoh
- Department of Neurosurgery, University of Florida (B.L.H.)
| | - Marc I Chimowitz
- Department of Neurology, Medical University of South Carolina (M.I.C.)
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Toudou-Daouda M, Chausson N, Smadja D, Alecu C. Detection of moderate to severe middle cerebral artery atherosclerotic stenosis in stroke patients: Transcranial color-coded duplex sonography versus computed tomography angiography. ULTRASOUND (LEEDS, ENGLAND) 2024; 32:43-52. [PMID: 38314017 PMCID: PMC10836233 DOI: 10.1177/1742271x231195723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 05/01/2023] [Indexed: 02/06/2024]
Abstract
Background Intracranial atherosclerotic stenosis is a common cause of ischemic cerebrovascular events and is associated with a high risk of stroke recurrence. This study aimed to assess the diagnostic accuracy of transcranial color-coded duplex sonography for moderate-to-severe middle cerebral artery stenosis in stroke patients. Methods A retrospective analysis was carried out, including 31 patients aged ⩾18 years hospitalized for ischemic cerebrovascular event in whom middle cerebral artery stenosis ⩾30% was identified on computed tomography angiography. Transcranial color-coded duplex sonography findings were compared to the degree of stenosis blindly identified on the computed tomography angiography used as the reference method. Results Overall, 27 patients had M1 stenosis and the other 4 had M2 stenosis. To detect M2 stenosis ⩾ 50% and ⩾ 70%, stenotic to pre-stenotic ratio ⩾ 2 and ⩾ 3 had a sensitivity of 100%, respectively. To detect M1 stenosis ⩾ 70%, peak systolic velocity ⩾ 300 cm/s had a sensitivity of 53.8% and specificity of 85.7% with area under the receiver-operating characteristic curve of 0.753 (95% confidence interval: 0.568-0.938; p = 0.026), and stenotic to pre-stenotic ratio ⩾ 3 had a sensitivity of 84.6% and a specificity of 78.6% (area under the curve = 0.854; 95% confidence interval: 0.707-1; p = 0.002). Middle cerebral artery/anterior cerebral artery velocity ratio < 0.7 had a sensitivity of 57.1% and specificity of 90% to detect dampened pre-stenotic flow in middle cerebral artery secondary to downstream M1 stenosis ⩾ 70% (area under the curve = 0.800; 95% confidence interval: 0.584-1; p = 0.040). Conclusion This study showed that stenotic to pre-stenotic ratio ⩾ 3 was more sensitive than peak systolic velocity ⩾ 300 cm/s to screen M1 stenosis ⩾ 70%. Middle cerebral artery/anterior cerebral artery ratio < 0.7 was a good indirect sign to detect dampened pre-stenotic flow due to M1 stenosis ⩾ 70%.
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Affiliation(s)
- Moussa Toudou-Daouda
- Department of Neurology, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France
| | - Nicolas Chausson
- Department of Neurology, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France
| | - Didier Smadja
- Department of Neurology, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France
| | - Cosmin Alecu
- Department of Neurology, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France
- Department of Neurology, Centre Hospitalier Universitaire de Nice, Nice, France
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Chen LH, Spagnolo-Allende A, Yang D, Qiao Y, Gutierrez J. Epidemiology, Pathophysiology, and Imaging of Atherosclerotic Intracranial Disease. Stroke 2024; 55:311-323. [PMID: 38252756 PMCID: PMC10827355 DOI: 10.1161/strokeaha.123.043630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Intracranial atherosclerotic disease (ICAD) is one of the most common causes of stroke worldwide. Among people with stroke, those of East Asia descent and non-White populations in the United States have a higher burden of ICAD-related stroke compared with Whites of European descent. Disparities in the prevalence of asymptomatic ICAD are less marked than with symptomatic ICAD. In addition to stroke, ICAD increases the risk of dementia and cognitive decline, magnifying ICAD societal burden. The risk of stroke recurrence among patients with ICAD-related stroke is the highest among those with confirmed stroke and stenosis ≥70%. In fact, the 1-year recurrent stroke rate of >20% among those with stenosis >70% is one of the highest rates among common causes of stroke. The mechanisms by which ICAD causes stroke include plaque rupture with in situ thrombosis and occlusion or artery-to-artery embolization, hemodynamic injury, and branch occlusive disease. The risk of stroke recurrence varies by the presumed underlying mechanism of stroke, but whether techniques such as quantitative magnetic resonance angiography, computed tomographic angiography, magnetic resonance perfusion, or transcranial Doppler can help with risk stratification beyond the degree of stenosis is less clear. The diagnosis of ICAD is heavily reliant on lumen-based studies, such as computed tomographic angiography, magnetic resonance angiography, or digital subtraction angiography, but newer technologies, such as high-resolution vessel wall magnetic resonance imaging, can help distinguish ICAD from stenosing arteriopathies.
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Affiliation(s)
- Li Hui Chen
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Antonio Spagnolo-Allende
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Dixon Yang
- Department of Neurology, Rush University, Chicago, IL, USA
| | - Ye Qiao
- Department of Radiology, Johns Hopkins University, Baltimore, MD, USA
| | - Jose Gutierrez
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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29
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Charles JH, Desai S, Jean Paul A, Hassan A. Multimodal imaging approach for the diagnosis of intracranial atherosclerotic disease (ICAD): Basic principles, current and future perspectives. Interv Neuroradiol 2024; 30:105-119. [PMID: 36262087 PMCID: PMC10956456 DOI: 10.1177/15910199221133170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 09/29/2022] [Indexed: 02/05/2023] Open
Abstract
PURPOSE To review the different imaging modalities utilized in the diagnosis of Intracranial Atherosclerotic Disease (ICAD) including their latest development and relevance in management of ICAD. METHODS A review of the literature was conducted through a search in google scholar, PubMed/Medline, EMBASE, Scopus, clinical trials.gov and the Cochrane Library. Search terms included, "imaging modalities in ICAD," "ICAD diagnostic," "Neuroimaging of ICAD," "Evaluation of ICAD". A summary and comparison of each modality's basic principles, advantages and disadvantages were included. RESULTS A total of 144 articles were identified and reviewed. The most common imaging used in ICAD diagnoses were DSA, CTA, MRA and TCD. They all had proven accuracy, their own benefits, and limitations. Newer modalities such as VWI, IVUS, OCT, PWI and CFD provide more detailed information regarding the vessel walls, plaque characteristics, and flow dynamics, which play a tremendous role in treatment guidance. In certain clinical scenarios, using more than one modality has been shown to be helpful in ICAD identification. The rapidly evolving software related to imaging studies, such as virtual histology, are very promising for the diagnostic and management of ICAD. CONCLUSIONS ICAD is a common cause of recurrent ischemic stroke. Its management can be both medical and/or procedural. Many different imaging modalities are used in its diagnosis. In certain clinical scenario, a combination of two more modalities can be critical in the management of ICAD. We expect that continuous development of imaging technique will lead to individualized and less invasive management with adequate outcome.
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Affiliation(s)
| | - Sohum Desai
- Department of Endovascular Surgical Neuroradiology, Valley Baptist Medical Center, Harlingen, Texas, USA
| | - Axler Jean Paul
- School of Medicine, State University of Haiti, Port Au Prince, Haiti
| | - Ameer Hassan
- Department of Endovascular Surgical Neuroradiology, Valley Baptist Medical Center, Harlingen, Texas, USA
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30
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de Havenon A, Turan TN. Past, Present, and Future of Intracranial Atherosclerosis Treatment. Stroke 2024; 55:471-473. [PMID: 38152957 PMCID: PMC10842205 DOI: 10.1161/strokeaha.123.044270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Affiliation(s)
- Adam de Havenon
- Department of Neurology, Yale University School of Medicine, New Haven, CT (A.d.H.)
| | - Tanya N Turan
- Department of Neurology, Medical University of South Carolina, Charleston (T.N.T.)
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Dunn L, Wang Y, Kass-Hout T, Chiu D. Randomized Secondary Prevention Trials in Participants With Symptomatic Intracranial Atherosclerotic Stenosis. Stroke 2024; 55:324-334. [PMID: 38252760 PMCID: PMC11008430 DOI: 10.1161/strokeaha.123.043632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Intracranial atherosclerotic stenosis is a prevalent cause of ischemic stroke worldwide. Its association with silent cerebral infarcts and its contribution to cognitive impairment and dementia emphasize the critical need for disease prevention and effective management strategies. Despite extensive research on secondary stroke prevention treatment over the past several decades, intracranial atherosclerotic stenosis continues to exhibit a notably higher recurrent stroke rate compared with other causes. This review focuses on randomized secondary prevention trials involving antithrombotic therapy, endovascular treatment, open surgical therapy, and remote ischemic conditioning. It aims to provide an insightful overview of the major findings from each trial and their implications for future research efforts.
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Affiliation(s)
- Lauren Dunn
- Department of Neurology, Ochsner Health System, New Orleans, LA
| | - Yan Wang
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | | | - David Chiu
- Department of Neurology, Houston Methodist Hospital, Houston, TX
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32
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Chan BPL, Wong LYH, Tan BYQ, Yeo LLL, Venketasubramanian N. Dual Antiplatelet Therapy for the Acute Management and Long-term Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack, An Updated Review. J Cardiovasc Dev Dis 2024; 11:48. [PMID: 38392262 PMCID: PMC10889184 DOI: 10.3390/jcdd11020048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/18/2024] [Accepted: 01/24/2024] [Indexed: 02/24/2024] Open
Abstract
To improve the efficacy over antiplatelet monotherapy, dual antiplatelet therapy (DAPT) has been increasingly adopted in the management of non-cardioembolic stroke. For minor ischemic stroke and high-risk transient ischemic attack, the aspirin-clopidogrel combination is now recommended for acute short-term treatment, whereas aspirin-ticagrelor combination may be considered in selected patients, especially those with resistance to clopidogrel. For long-term stroke prevention, aspirin-dipyridamole combination has been used as an alternative to antiplatelet monotherapy, and aspirin or clopidogrel combined with cilostazole may be prescribed for added protection in high-risk patients. In this paper, we review the development of DAPT from a historical perspective and describe the findings from major clinical trials published up until the end of 2023. Using the 2021 American Heart Association guideline for secondary stroke prevention as a basis for our recommendations, we further discuss areas of controversy and more recent developments to provide an updated review for clinicians to consider in their daily practice.
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Affiliation(s)
- Bernard P L Chan
- Division of Neurology, National University Hospital, National University Health System, Singapore 119228, Singapore
| | - Lily Y H Wong
- Division of Neurology, National University Hospital, National University Health System, Singapore 119228, Singapore
| | - Benjamin Y Q Tan
- Division of Neurology, National University Hospital; and Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Leonard L L Yeo
- Division of Neurology, National University Hospital; and Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
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33
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Jiang Y, Song X, Hou D, Zhao X, Chen W, Li R, Zheng Z, Sang Z, Wu J. Morning blood pressure surge and intracranial atherosclerotic plaque characteristics: a high-resolution magnetic resonance vessel wall imaging study. Br J Radiol 2024; 97:210-220. [PMID: 38263837 PMCID: PMC11027336 DOI: 10.1093/bjr/tqad011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/01/2023] [Accepted: 10/16/2023] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVE To investigate the relationship between morning blood pressure surge (MBPS) and intracranial atherosclerotic plaque burden and vulnerability. METHODS A total of 267 ischaemic stroke patients were retrospectively analysed. Sleep-trough and prewaking MBPS were calculated from ambulatory blood pressure monitoring (ABPM). Plaque characteristics, including intraplaque haemorrhage (IPH), maximum wall thickness (max WT), and stenosis degree, were obtained from high-resolution MR vessel wall imaging (HR-vwMRI). Linear and logistic regression were used to detect the association. RESULTS Subjects with the top tertile of sleep-trough MBPS (≥15.1 mmHg) had a lower prevalence (9.1% vs. 19.6%, P = .029) of severe stenosis (≥70%) than others. Subjects within the top tertile of prewaking MBPS (≥7.6 mmHg) had a lower percentage of IPH (27.3% vs. 40.4%, P = .035) than others. After adjusting for stroke risk factors (age, sex, diabetes, hyperlipidaemia, hyperhomocysteinaemia, smoking, and family stroke history) and 24-h mean systolic blood pressure, 10 mmHg sleep-trough MBPS increment was associated with 0.07mm max WT reduction, and the top tertile MBPS group was associated with a lower chance of severe stenosis (odd ratio = 0.407, 95% CI, 0.175-0.950). Additionally, an increased prewaking MBPS is associated with a lower incidence of IPH, with OR = 0.531 (95% CI, 0.296-0.952). Subgroup analysis demonstrated that the positive findings could only be seen in non-diabetic subjects. CONCLUSION Increment of MBPS is negatively associated with intracranial atherosclerotic plaque burden and vulnerability, and this relationship remains significant in the non-diabetic subgroup. ADVANCES IN KNOWLEDGE This study provided evidence that MBPS was associated with the intracranial atherosclerotic plaque burden and vulnerability on HR-vwMRI.
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Affiliation(s)
- Yuhan Jiang
- School of Medicine, Tsinghua University, Beijing 100084, China
| | - Xiaowei Song
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Duoduo Hou
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Xihai Zhao
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing 100084, China
- Department of Radiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Wenwen Chen
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing 100084, China
| | - Rui Li
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing 100084, China
| | - Zhuozhao Zheng
- Department of Radiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Zhenhua Sang
- Department of Information Technology Service, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Jian Wu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
- IDG/McGovern Institute for Brain Research at Tsinghua University, Beijing 100084, China
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34
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Fanning JP, Campbell BCV, Bulbulia R, Gottesman RF, Ko SB, Floyd TF, Messé SR. Perioperative stroke. Nat Rev Dis Primers 2024; 10:3. [PMID: 38238382 DOI: 10.1038/s41572-023-00487-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 01/23/2024]
Abstract
Ischaemic or haemorrhagic perioperative stroke (that is, stroke occurring during or within 30 days following surgery) can be a devastating complication following surgery. Incidence is reported in the 0.1-0.7% range in adults undergoing non-cardiac and non-neurological surgery, in the 1-5% range in patients undergoing cardiac surgery and in the 1-10% range following neurological surgery. However, higher rates have been reported when patients are actively assessed and in high-risk populations. Prognosis is significantly worse than stroke occurring in the community, with double the 30-day mortality, greater disability and diminished quality of life among survivors. Considering the annual volume of surgeries performed worldwide, perioperative stroke represents a substantial burden. Despite notable differences in aetiology, patient populations and clinical settings, existing clinical recommendations for perioperative stroke are extrapolated mainly from stroke in the community. Perioperative in-hospital stroke is unique with respect to the stroke occurring in other settings, and it is essential to apply evidence from other settings with caution and to identify existing knowledge gaps in order to effectively guide patient care and future research.
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Affiliation(s)
- Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Anaesthesia & Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
- The George Institute for Global Health, Sydney, New South Wales, Australia.
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Bruce C V Campbell
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Richard Bulbulia
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | | | - Sang-Bae Ko
- Department of Neurology and Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Thomas F Floyd
- Department of Anaesthesiology & Pain Management, Department of Cardiovascular and Thoracic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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35
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Aoki J, Kimura K. Cilostazol addition to aspirin may worsen the short-term outcome in patients with large artery disease: ADS subanalysis. J Neurol Sci 2024; 456:122854. [PMID: 38154248 DOI: 10.1016/j.jns.2023.122854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/26/2023] [Accepted: 12/17/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Our previous acute dual study (ADS) reported that dual antiplatelet therapy (DAPT) using cilostazol and aspirin did not reduce the rate of neurological deterioration in non-cardioembolic stroke patients. In this post-hoc analysis, we investigated whether the impact of dual antiplatelet therapy (DAPT) may depend on neurological severity, as represented by large artery disease. METHODS Neurological deterioration was defined as neurological progression with an increment of the National Institutes of Health Stroke Scale (NIHSS) score of ≥2. NIHSS score subgroups were divided into that of 0-1, 2-4, 5-10, and >10. RESULTS Among 1014 patients, 203 (20%) had the large artery disease, and 811 (80%) did not. In the total cohort, the rate of neurological deterioration was 10.8% in the DAPT group and 8.3% in the aspirin group (P = 0.197). When we focused on the large artery disease group, DAPT group had a higher rate of neurological deterioration as 18.3% compared to 8.2% in the aspirin group (P = 0.036). Among patients with NIHSS score of 0-1 and 2-4, the rates of neurological deterioration were not different between the two group (both, P = 1.000). However, when NIHSS score elevated to 5-10, 45% in the DAPT group and 9.1% in the aspirin group deteriorated (P = 0.013). Among the patients with NIHSS score of >10, 60% in the DAPT group and none (0%) in the aspirin group had the neurological deterioration (P = 0.045). CONCLUSION DAPT with aspirin and cilostazol was associated with higher rate of neurological deterioration when patients have large artery disease and not mild neurological deficits.
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Affiliation(s)
- Junya Aoki
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan.
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan
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36
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Liu Y, Zhao H, Dong Q, Cao W. Long-term recurrence of ischemic events in patients with intracranial atherosclerotic stenosis stratified by symptoms and pathogenesis. J Neurol Sci 2024; 456:122838. [PMID: 38171070 DOI: 10.1016/j.jns.2023.122838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/28/2023] [Accepted: 12/07/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Intracranial atherosclerotic stenosis (ICAS) can cause either transient ischemic attack (TIA) or acute ischemic stroke (AIS). Pathogenesis of ICAS-AIS can be divided into artery-to-artery embolism(A-A), hypoperfusion(HP), and parent-artery atherosclerosis occluding penetrating artery(POPA). However, the prognosis of each type remains uncertain. Our study aimed to investigate potential disparities in the recurrent risk among these four subtypes of symptomatic ICAS. METHODS From a prospective, single-center cohort study of acute cerebrovascular diseases from January 2017 to November 2021, we recruited 120 ICAS patients and classified them into four groups based on diffusion weighted imaging. Patients were retrospectively followed up for recurrence in December 2022. The primary outcome was recurrent cerebral vascular events (RCVE) in the same territory. RESULTS Among 120 recruited patients, POPA(33%) was the most common subtype, followed by A-A(32%), HP(29%), and TIA(6%). Cumulative recurrent rate was 31.2% with median months of follow-up as 27(20-45.5). There was no significant difference in the risk of RCVE in the same territory among four subgroups within three months. However, when considering the risk after three months, TIA(57%) had the highest risk of RCVE, followed by A-A(26%), while HP(4%) and POPA(8%) had lower risks (P = 0.001). Cox regression model indicated that symptom and pathogenesis was an independent risk factor for RCVE in long-term prognosis (P = 0.022), after adjusting for a history of hypertension and cerebral infarction. CONCLUSIONS Distinctive symptoms and pathogenesis of ICAS exhibit varying risks of RCVE in long-term prognosis. The differentiation in recurrent risk may provide valuable insights for guiding secondary prevention strategies.
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Affiliation(s)
- Yimeng Liu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Hongchen Zhao
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China; State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China; National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China.
| | - Wenjie Cao
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China; State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China; National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China.
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Yang P, Wan S, Wang J, Hu Y, Ma N, Wang X, Zhang Y, Zhang L, Zhu X, Shen F, Zheng Q, Wang M, Leng X, Fiehler J, Siddiqui AH, Miao Z, Xiang J, Liu J. Hemodynamic assessment for intracranial atherosclerosis from angiographic images: a clinical validation study. J Neurointerv Surg 2024; 16:204-208. [PMID: 37185108 DOI: 10.1136/jnis-2023-020073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/04/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Intracranial atherosclerotic stenosis (ICAS) is one of the leading causes of ischemic stroke. Conventional anatomical analysis by CT angiography, MRI, or digital subtraction angiography can provide valuable information on the anatomical changes of stenosis; however, they are not sufficient to accurately evaluate the hemodynamic severity of ICAS. The goal of this study was to assess the diagnostic performance of the pressure ratio across intracranial stenoses (termed as fractional flow (FF)) derived from cerebral angiography for the diagnosis of hemodynamically significant ICAS defined by pressure wire-derived FF. METHODS This retrospective study represents a feasible and reliable method for calculating the FF from cerebral angiography (AccuFFicas). Patients (n=121) who had undergone wire-based measurement of FF and cerebral angiography were recruited. The accuracy of the computed pressure ratio was evaluated using wire-based FF as the reference standard. RESULTS The mean value of wire-based FF was 0.78±0.19, while the computed AccuFFicas had an average value of 0.79±0.18. Good correlation (Pearson's correlation coefficient r=0.92, P<0.001) between AccuFFicas and FF was observed. Bland-Altman analysis showed that the mean difference between AccuFFicas and FF was -0.01±0.07, indicating good agreement. The area under the curve (AUC) of AccuFFicas in predicting FF≤0.70, FF≤0.75, and FF≤0.80 was 0.984, 0.986, and 0.962, respectively. CONCLUSION Angiography-based FF computed from cerebral angiographic images could be an effective computational tool for evaluating the hemodynamic significance of ICAS.
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Affiliation(s)
- Pengfei Yang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Shu Wan
- Brain Center, Zhejiang Hospital, Hangzhou, China
| | - Jun Wang
- Department of Neurology, Chinese PLA General Hospital, Beijing, China
| | - Yumeng Hu
- ArteryFlow Technology Co., Ltd, Hangzhou, China
| | - Ning Ma
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Beijing, China
| | - Xiaohui Wang
- Department of Neurology, Chinese PLA General Hospital, Beijing, China
| | - Yongwei Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lei Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xuan Zhu
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Fang Shen
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qian Zheng
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Ming Wang
- Brain Center, Zhejiang Hospital, Hangzhou, China
| | | | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Zhongrong Miao
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Beijing, China
| | | | - Jianmin Liu
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
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Heo J, Lee H, Lee IH, Lim IH, Hong SH, Shin J, Nam HS, Kim YD. Combined use of anticoagulant and antiplatelet on outcome after stroke in patients with nonvalvular atrial fibrillation and systemic atherosclerosis. Sci Rep 2024; 14:304. [PMID: 38172278 PMCID: PMC10764735 DOI: 10.1038/s41598-023-51013-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 12/29/2023] [Indexed: 01/05/2024] Open
Abstract
This study aimed to investigate whether there was a difference in one-year outcome after stroke between patients treated with antiplatelet and anticoagulation (OAC + antiplatelet) and those with anticoagulation only (OAC), when comorbid atherosclerotic disease was present with non-valvular atrial fibrillation (NVAF). This was a retrospective study using a prospective cohort of consecutive patients with ischemic stroke. Patients with NVAF and comorbid atherosclerotic disease were assigned to the OAC + antiplatelet or OAC group based on discharge medication. All-cause mortality, recurrent ischemic stroke, hemorrhagic stroke, myocardial infarction, and bleeding events within 1 year after the index stroke were compared. Of the 445 patients included in this study, 149 (33.5%) were treated with OAC + antiplatelet. There were no significant differences in all outcomes between groups. After inverse probability of treatment weighting, OAC + antiplatelet was associated with a lower risk of all-cause mortality (hazard ratio 0.48; 95% confidence interval 0.23-0.98; P = 0.045) and myocardial infarction (0% vs. 3.0%, P < 0.001). The risk of hemorrhagic stroke was not significantly different (P = 0.123). OAC + antiplatelet was associated with a decreased risk of all-cause mortality and myocardial infarction but an increased risk of ischemic stroke among patients with NVAF and systemic atherosclerotic diseases.
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Affiliation(s)
- JoonNyung Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
- Department of Radiology, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyungwoo Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
- Department of Radiology, Yonsei University College of Medicine, Seoul, South Korea
| | - Il Hyung Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
- Department of Radiology, Yonsei University College of Medicine, Seoul, South Korea
| | - In Hwan Lim
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
- Department of Radiology, Yonsei University College of Medicine, Seoul, South Korea
| | - Soon-Ho Hong
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
- Department of Radiology, Yonsei University College of Medicine, Seoul, South Korea
| | - Joonggyeong Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.
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Shen R, Tong X, Zhao C, Qiao H, Ning Z, Li J, Zhao H, Yuan C, Zhao X. Atherosclerotic plaque characteristics in extracranial carotid artery may indicate closer association with white matter hyperintensities than intracranial arteries: A CARE-II study. Eur J Radiol 2024; 170:111208. [PMID: 37988960 DOI: 10.1016/j.ejrad.2023.111208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 11/16/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE This study aimed to investigate the associations of atherosclerotic plaque characteristics in intracranial and extracranial carotid arteries with severity of white matter hyperintensities (WMHs) in symptomatic patients using magnetic resonance (MR) imaging. METHOD Patients with cerebrovascular symptoms and carotid plaque were recruited from the cross-sectional, multicenter study of CARE-II. Luminal stenosis of intracranial and extracranial carotid arteries, carotid plaque compositional features, and WMHs were evaluated by brain structural and vascular MR imaging. The atherosclerotic plaque characteristics in intracranial and extracranial carotid arteries were compared between patients with and without moderate-to-severe WMHs (Fazekas score > 2), and their associations with severity of WMHs were analyzed using logistic regression. RESULTS Of the recruited 622 patients (mean age, 58.7 ± 10.9 years; 422 males), 221 (35.5 %) had moderate-to-severe WMHs with higher prevalence of moderate-to-severe luminal stenosis (17.0 % vs. 10.4 %), intraplaque hemorrhage (15.7 % vs. 9.0 %), thin/ruptured fibrous cap (30.2 % vs. 20.4 %), calcification (44.4 % vs. 22.2 %) and lipid-rich necrotic core (63.8 % vs. 51.1 %) in carotid artery compared to those without (all P < 0.05). Multivariate logistic regression showed that carotid calcification (OR, 1.854; 95 % CI, 1.187-2.898; P = 0.007) was independently associated with moderate-to-severe WMHs after adjusting for confounding factors. No significant association was found between intracranial atherosclerotic stenosis and moderate-to-severe WMHs (P > 0.05). CONCLUSION Carotid atherosclerotic plaque features, particularly presence of calcification, were independently associated with severity of WMHs, but such association was not found in intracranial atherosclerotic stenosis, suggesting that carotid atherosclerotic plaque characteristics may have closer association with severity of WMHs compared to intracranial atherosclerosis.
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Affiliation(s)
- Rui Shen
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Xinyu Tong
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Chenyang Zhao
- Department of Radiology, the Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China
| | - Huiyu Qiao
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Zihan Ning
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Jin Li
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Huilin Zhao
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chun Yuan
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Xihai Zhao
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China.
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Liu Y, Li S, Tian X, Leung TW, Liu L, Liebeskind DS, Leng X. Cerebral haemodynamics in symptomatic intracranial atherosclerotic disease: a narrative review of the assessment methods and clinical implications. Stroke Vasc Neurol 2023; 8:521-530. [PMID: 37094991 PMCID: PMC10800270 DOI: 10.1136/svn-2023-002333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/07/2023] [Indexed: 04/26/2023] Open
Abstract
Intracranial atherosclerotic disease (ICAD) is a common cause of ischaemic stroke and transient ischaemic attack (TIA) with a high recurrence rate. It is often referred to as intracranial atherosclerotic stenosis (ICAS), when the plaque has caused significant narrowing of the vessel lumen. The lesion is usually considered 'symptomatic ICAD/ICAS' (sICAD/sICAS) when it has caused an ischaemic stroke or TIA. The severity of luminal stenosis has long been established as a prognostic factor for stroke relapse in sICAS. Yet, accumulating studies have also reported the important roles of plaque vulnerability, cerebral haemodynamics, collateral circulation, cerebral autoregulation and other factors in altering the stroke risks across patients with sICAS. In this review article, we focus on cerebral haemodynamics in sICAS. We reviewed imaging modalities/methods in assessing cerebral haemodynamics, the haemodynamic metrics provided by these methods and application of these methods in research and clinical practice. More importantly, we reviewed the significance of these haemodynamic features in governing the risk of stroke recurrence in sICAS. We also discussed other clinical implications of these haemodynamic features in sICAS, such as the associations with collateral recruitment and evolution of the lesion under medical treatment, and indications for more individualised blood pressure management for secondary stroke prevention. We then put forward some knowledge gaps and future directions on these topics.
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Affiliation(s)
- Yuying Liu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Shuang Li
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Xuan Tian
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Thomas W Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - David S Liebeskind
- Department of Neurology, Neurovascular Imaging Research Core, University of California Los Angeles, Los Angeles, California, USA
| | - Xinyi Leng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
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Tang Y, Li T, Liu W, He Y, Zhu L, Wang ZL, He Y. Comparison of drug-coated balloon with conventional balloon for angioplasty in symptomatic intracranial atherosclerotic stenosis. J Neurointerv Surg 2023; 15:e369-e374. [PMID: 36604174 DOI: 10.1136/jnis-2022-019685] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/23/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Drug-coated balloon (DCB) angioplasty has been studied for reducing the occurrence of restenosis after treatment for intracranial atherosclerotic stenosis (ICAS), but no comparison has been published of the use of drug-coated and non-coated balloons in angioplasty for ICAS. We aim to compare the safety and efficacy of DCB angioplasty with conventional balloon (CB) angioplasty for the treatment of symptomatic ICAS. METHODS One hundred cases with symptomatic ICAS treated with DCB (n=49) and CB (n=51) angioplasty were retrospectively analyzed. 1:1 propensity score matching (PSM) was completed to eliminate bias in the patients selected for further analysis. The periprocedural events and follow-up outcomes between the two groups were compared. RESULTS There were 32 cases in each group after PSM. Technical success (<50% residual stenosis) was achieved in 30 cases (93.8%) in the DCB group and in 28 cases (87.5%) in the CB group. The rates of stroke or mortality within 30 days were 3.1% in the DCB group and 6.3% in the CB group (p=1). The incidence of restenosis in the DCB group (6.3%) was significantly lower than that in the CB group (31.3%) (p=0.01). CONCLUSIONS Compared with CB angioplasty, DCB angioplasty can effectively reduce the incidence of restenosis. Further studies are needed to validate the role of DCB angioplasty in the management of symptomatic ICAS.
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Affiliation(s)
- Yao Tang
- Cerebrovascular and Neurosurgery Department of Stroke Center, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Tianxiao Li
- Cerebrovascular and Neurosurgery Department of Interventional Center, Zhengzhou University People's Hospital, Henan Provincial People's Hospital; Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, Henan, China
| | - Wenbo Liu
- Cerebrovascular and Neurosurgery Department of Stroke Center, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Yanyan He
- Cerebrovascular and Neurosurgery Department of Interventional Center, Zhengzhou University People's Hospital, Henan Provincial People's Hospital; Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, Henan, China
| | - Liangfu Zhu
- Cerebrovascular and Neurosurgery Department of Interventional Center, Zhengzhou University People's Hospital, Henan Provincial People's Hospital; Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, Henan, China
| | - Zi-Liang Wang
- Cerebrovascular and Neurosurgery Department of Interventional Center, Zhengzhou University People's Hospital, Henan Provincial People's Hospital; Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, Henan, China
| | - Yingkun He
- Cerebrovascular and Neurosurgery Department of Interventional Center, Zhengzhou University People's Hospital, Henan Provincial People's Hospital; Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, Henan, China
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Li A, Ye Z, Zhou W, Qin C. Short-term outcome of stenting with Enterprise stents for symptomatic intracranial atherosclerotic disease at a single center. Interv Neuroradiol 2023; 29:731-737. [PMID: 36259331 PMCID: PMC10680965 DOI: 10.1177/15910199221133166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/29/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate the safety and efficacy of stenting for symptomatic intracranial atherosclerotic severe stenosis or occlusion with Enterprise stents. METHODS Fifty-three consecutive patients with symptomatic intracranial atherosclerotic severe (70%-99%) stenosis or occlusion who underwent endovascular treatment with Enterprise stents between September 2019 and March 2022 were retrospectively analyzed. Primary outcomes included technical stenting success rates, the incidence of complications within 30 days of the procedure, and the in-stent restenosis rates during the follow-up period. These outcomes were further categorized based on lesion location and operation time. RESULTS Fifty-seven lesions in 53 patients aged 61.0 ± 10.0 years were treated with Enterprise stents with a technical success rate of 100%. Seven patients (12.3%) had severe complications within 30 days of the procedure: five had a symptomatic ischemic stroke, one had a symptomatic intracerebral hemorrhage, and one had a subarachnoid hemorrhage related to the procedure. No deaths were observed. The rate of in-stent restenosis was 18.2%, with a mean vascular imaging follow-up period of 6.7 months. The 30-day complication and in-stent restenosis rates did not differ significantly between patients with different lesion locations and operation times (P > 0.05). CONCLUSION This retrospective study suggests that percutaneous transluminal angioplasty and stenting with Enterprise stents is an effective treatment for symptomatic intracranial arterial stenosis or occlusion with a high technical success rate. It also indicates that stenting during the early nonacute stage after stroke may not increase the incidence of perioperative complications for symptomatic intracranial atherosclerotic stenosis when following strict inclusion criteria.
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Affiliation(s)
- Aiping Li
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
- Department of Neurology, Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, Hunan, China
| | - Ziming Ye
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Wensheng Zhou
- Department of Neurology, Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, Hunan, China
| | - Chao Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
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Suo Y, Jing J, Meng X, Li Z, Pan Y, Yan H, Jiang Y, Liu L, Zhao X, Wang Y, Li H, Wang Y. Intracranial arterial stenosis and recurrence in stroke patients with different risk stratifications by Essen stroke risk score. Neurol Res 2023; 45:1069-1078. [PMID: 37724803 DOI: 10.1080/01616412.2023.2257415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 07/29/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVES We sought to investigate whether the prognostic value of intracranial arterial stenosis (ICAS) is consistent across different risk stratifications using the Essen Stroke Risk score (ESRS). METHODS We derived data from the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events trial. Patients without complete baseline brain imaging data were excluded. Participants were categorized into different risk groups based on ESRS (low risk, 0-2, and high risk ≥ 3). The main outcome was stroke recurrence within 3 and 12 months. Hazard ratios (HRs) and 95% confidence intervals (95%CIs) of ICAS, and other factors associated with stroke recurrence within 3 and 12 months were estimated using the Cox regression method. RESULTS During the 3-month follow-up, 54 patients (7.9%) had recurrent stroke in the low-risk group, and 39 patients (9.6%) had recurrent stroke in the high-risk group. ICAS was associated with a higher risk of stroke within 3 months (HR = 2.761; 95%CI = 1.538-4.957; P < 0.001) in the low-risk group, but not in the high-risk group (HR = 1.501; 95%CI = 0.701-3.213; P = 0.296). ICAS was independently associated with higher recurrent risk in the low-risk group (HR = 2.540; 95%CI = 1.472-4.381; P < 0.001), but not in the high-risk group (HR = 1.951; 95%CI = 0.977-3.893; P = 0.058) within 12 months. CONCLUSION ICAS was an independent predictor of both 3- and 12-month stroke recurrence in low-risk but not high-risk patients with minor ischemic stroke or transient ischemic attack according to ESRS stratification.
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Affiliation(s)
- Yue Suo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongyi Yan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Tiantan Neuroimaging Center of Excellence, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
- Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, China
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Tan BY, Zheng Y, Lim MJR, Koh YY, Tan YK, Goh C, Myint MZ, Sia CH, Tan J, Nor FEM, Soon B, Chan BP, Leow AS, Ho JS, Yeo LL, Sharma VK. Comparison of short-term outcomes between patients with extracranial carotid and/or intracranial atherosclerotic disease. Clin Neurol Neurosurg 2023; 235:108024. [PMID: 37922680 DOI: 10.1016/j.clineuro.2023.108024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/16/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To directly compare the 90-day outcomes of patients with symptomatic intracranial atherosclerotic disease (ICAD), extracranial carotid atherosclerotic disease (ECAD), and ICAD with concomitant ECAD. METHODS From 2017-2021, patients who had (1) a transient ischemic attack or ischemic stroke within 30 days of admission as evaluated by a stroke neurologist and (2) ipsilateral ICAD and/or ECAD were prospectively enrolled. The cohort was divided into three groups: ICAD, ECAD, and ICAD with concomitant ECAD. The primary outcome assessed was 90-day ischemic stroke recurrence. Secondary outcomes included 90-day myocardial infarction (MI), all-cause mortality, and major adverse cardiovascular events (MACE, including cardiovascular death, nonfatal MI, and/or nonfatal ischemic stroke). RESULTS Of 371 patients included in the analysis, 240 (64.7%) patients had ICAD only, 93 (25.0%) patients had ECAD only, and 38 (10.3%) patients had ICAD with concomitant ECAD. On multivariate time-to-event analysis adjusting for potential confounders and with ICAD as the reference comparator, the risk of 90-day clinical outcomes was highest among patients with ICAD and concomitant ECAD, with adjusted hazard ratios of 4.54 (95% CI=1.45, 14.2; p = 0.006), 9.32 (95% CI=1.58, 54.8; p = 0.014), and 8.52 (95% CI=3.54, 20.5; p < 0.001) for 90-day ischemic stroke, MI, and MACE, respectively. CONCLUSIONS Patients with ICAD and concomitant ECAD have a poorer prognosis and are at significantly higher risk for 90-day ischemic stroke, MI, and MACE. Further research should focus on the evaluation of coronary atherosclerotic disease and more intensive medical therapy in this population.
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Affiliation(s)
- Benjamin Yq Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yilong Zheng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Ying Ying Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ying Kiat Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Claire Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - May Zin Myint
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Cardiology, National University Health System, Singapore
| | - Jaclyn Tan
- Division of Neurosurgery, National University Health System, Singapore
| | | | - Betsy Soon
- Department of Diagnostic Imaging, National University Health System, Singapore
| | - Bernard Pl Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Aloysius St Leow
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Jamie Sy Ho
- Department of Medicine, National University Health System, Singapore
| | - Leonard Ll Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Vijay Kumar Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Yang A, Nguyenhuy M, Seevanayagam S. Intracranial Atherosclerosis Increases the Risk of Postoperative Stroke After Cardiac Surgery: A Review and Meta-Analysis. Heart Lung Circ 2023; 32:1417-1425. [PMID: 38016908 DOI: 10.1016/j.hlc.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/18/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Postoperative stroke is a devastating complication of cardiac surgery with high morbidity, mortality, and health care cost. Extracranial carotid atherosclerosis (ECAS) is a known risk factor for stroke; however, the impact of intracranial atherosclerosis (ICAS) remains unclear. To our knowledge, this is the first literature review of ICAS in cardiac surgery. We aimed to assess the prevalence, association with postoperative stroke, and perioperative management of ICAS in cardiac surgery. METHOD A search was performed to identify studies reporting rates of ICAS and stroke after cardiac surgery. Data extraction and primary outcomes for meta-analysis included the prevalence of preoperative ICAS and the association between ICAS and stroke. Risk ratios (RRs) and 95% confidence intervals (CIs) were pooled by random-effects modelling. RESULTS Seventeen studies were reviewed and seven were included in the meta-analysis, comprising 4,936 patients. Prevalence of intracranial atherosclerosis (ICAS) among cardiac surgery patients was 21% (95% CI 13%-32%). Patients with ICAS were more likely to develop postoperative stroke (RR 3.61; 95% CI 2.30-5.67; p<0.001). ICAS was more closely associated with stroke than ECAS. Preoperative brain perfusion single-photon emission computed tomography with acetazolamide challenge, staged intracerebral revascularisation, or conversion to off-pump coronary artery bypass grafting are described management options for ICAS. CONCLUSION Patients with ICAS are 3.61 times more likely to develop stroke after cardiac surgery. Known predictors for ICAS can be used to develop risk stratification screening tools. Further research with diverse cohorts is required to develop evidence-based guidelines for screening and management of ICAS in cardiac surgery.
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Affiliation(s)
- Amy Yang
- Brian F. Buxton Department of Cardiac and Thoracic Aortic Surgery, Austin Health, Melbourne, Vic, Australia.
| | | | - Siven Seevanayagam
- Brian F. Buxton Department of Cardiac and Thoracic Aortic Surgery, Austin Health, Melbourne, Vic, Australia
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Dalakoti M, Leow MKS, Khoo CM, Yang H, Ling LH, Muthiah M, Tan E, Lee J, Dan YY, Chew N, Seow WQ, Soong PL, Gan L, Gurung R, Ackers-Johnson M, Hou HW, Sachaphibulkij K, MacAry P, Low G, Ang C, Yeo TJ, Djohan AH, Li T, Yeung W, Soh R, Sia CH, Panday V, Loong SSE, Tan BYQ, Yeo LLL, Teo L, Chow P, Foo R. Platform for the interdisciplinary study of cardiovascular, metabolic and neurovascular diseases (PICMAN) protocol. Sci Rep 2023; 13:20521. [PMID: 37993612 PMCID: PMC10665389 DOI: 10.1038/s41598-023-47407-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 11/13/2023] [Indexed: 11/24/2023] Open
Abstract
Through extensive multisystem phenotyping, the central aim of Project PICMAN is to correlate metabolic flexibility to measures of cardiometabolic health, including myocardial diastolic dysfunction, coronary and cerebral atherosclerosis, body fat distribution and severity of non-alcoholic fatty liver disease. This cohort will form the basis of larger interventional trials targeting metabolic inflexibility in the prevention of cardiovascular disease. Participants aged 21-72 years with no prior manifest atherosclerotic cardiovascular disease (ASCVD) are being recruited from a preventive cardiology clinic and an existing cohort of non-alcoholic fatty liver disease (NAFLD) in an academic medical centre. A total of 120 patients will be recruited in the pilot phase of this study and followed up for 5 years. Those with 10-year ASCVD risk ≥ 5% as per the QRISK3 calculator are eligible. Those with established diabetes mellitus are excluded. Participants recruited undergo a detailed assessment of health behaviours and physical measurements. Participants also undergo a series of multimodality clinical phenotyping comprising cardiac tests, vascular assessments, metabolic tests, liver and neurovascular testing. Blood samples are also being collected and banked for plasma biomarkers, 'multi-omics analyses' and for generation of induced pluripotent stem cells (iPSC). Extensive evidence points to metabolic dysregulation as an early precursor of cardiovascular disease, particularly in Asia. We hypothesise that quantifiable metabolic inflexibility may be representative of an individual in his/her silent, but high-risk progression towards insulin resistance, diabetes and cardiovascular disease. The platform for interdisciplinary cardiovascular-metabolic-neurovascular diseases (PICMAN) is a pilot, prospective, multi-ethnic cohort study.
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Affiliation(s)
- Mayank Dalakoti
- Department of Cardiology, National University Heart Centre, Singapore, Singapore.
- Department of Medicine, Ng Teng Fong General Hospital, Singapore, Singapore.
- National University of Singapore Cardiovascular Disease Translational Research Program, Singapore, Singapore.
| | - Melvin Khee Shing Leow
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Chin Meng Khoo
- Department of Medicine, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hayang Yang
- National University of Singapore Cardiovascular Disease Translational Research Program, Singapore, Singapore
| | - Lieng Hsi Ling
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mark Muthiah
- Department of Medicine, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Eunice Tan
- Department of Medicine, National University Health System, Singapore, Singapore
| | - Jonathan Lee
- Department of Medicine, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yock Young Dan
- Department of Medicine, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nicholas Chew
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- National University of Singapore Cardiovascular Disease Translational Research Program, Singapore, Singapore
| | - Wei Qiang Seow
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University of Singapore Cardiovascular Disease Translational Research Program, Singapore, Singapore
| | - Poh Loong Soong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University of Singapore Cardiovascular Disease Translational Research Program, Singapore, Singapore
| | - Louis Gan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University of Singapore Cardiovascular Disease Translational Research Program, Singapore, Singapore
| | - Rijan Gurung
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University of Singapore Cardiovascular Disease Translational Research Program, Singapore, Singapore
| | - Matthew Ackers-Johnson
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University of Singapore Cardiovascular Disease Translational Research Program, Singapore, Singapore
| | - Han Wei Hou
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Karishma Sachaphibulkij
- Center for Life Sciences, National University of Singapore-Cambridge Cell Phenotyping Centre, Singapore, Singapore
| | - Paul MacAry
- Center for Life Sciences, National University of Singapore-Cambridge Cell Phenotyping Centre, Singapore, Singapore
| | - Gwen Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University of Singapore Cardiovascular Disease Translational Research Program, Singapore, Singapore
| | - Christy Ang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University of Singapore Cardiovascular Disease Translational Research Program, Singapore, Singapore
| | - Tee Joo Yeo
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andie Hartanto Djohan
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Tony Li
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Wesley Yeung
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Rodney Soh
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Ching Hui Sia
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University of Singapore Cardiovascular Disease Translational Research Program, Singapore, Singapore
| | - Vinay Panday
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Shaun S E Loong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University of Singapore Cardiovascular Disease Translational Research Program, Singapore, Singapore
| | - Benjamin Y Q Tan
- Department of Medicine, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Leonard L L Yeo
- Department of Medicine, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Lynette Teo
- Department of Radiology, National University Health System, Singapore, Singapore
| | - Pierce Chow
- Duke-NUS Medical School, Singapore, Singapore
| | - Roger Foo
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University of Singapore Cardiovascular Disease Translational Research Program, Singapore, Singapore
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47
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Derdeyn CP, Wall M. Counterpoint: stenting for idiopathic intracranial hypertension should be trialed. J Neurointerv Surg 2023; 15:1063-1064. [PMID: 37344173 DOI: 10.1136/jnis-2023-020404] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 06/23/2023]
Affiliation(s)
- Colin P Derdeyn
- Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Michael Wall
- Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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48
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Schirmer CM, Bulsara KR, Al-Mufti F, Haranhalli N, Thibault L, Hetts SW. Antiplatelets and antithrombotics in neurointerventional procedures: Guideline update. J Neurointerv Surg 2023; 15:1155-1162. [PMID: 37188504 DOI: 10.1136/jnis-2022-019844] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/22/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Antiplatelet and antithrombotic medication management before, during, and after neurointerventional procedures has significant practice variation. This document updates and builds upon the 2014 Society of NeuroInterventional Surgery (SNIS) Guideline 'Platelet function inhibitor and platelet function testing in neurointerventional procedures', providing updates based on the treatment of specific pathologies and for patients with specific comorbidities. METHODS We performed a structured literature review of studies that have become available since the 2014 SNIS Guideline. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS The management of antiplatelet and antithrombotic agents before, during, and after endovascular neurointerventional procedures continues to evolve. The following recommendations were agreed on. (1) It is reasonable to resume anticoagulation after a neurointerventional procedure or major bleeding episode as soon as the thrombotic risk exceeds the bleeding risk in an individual patient (Class I, Level C-EO). (2) Platelet testing can be useful to guide local practice, and specific approaches to using the numbers demonstrate marked local variability (Class IIa, Level B-NR). (3) For patients without comorbidities undergoing brain aneurysm treatment, there are no additional considerations for medication choice beyond the thrombotic risks of the catheterization procedure and aneurysm treatment devices (Class IIa, Level B-NR). (4) For patients undergoing neurointerventional brain aneurysm treatment who have had cardiac stents placed within the last 6-12 months, dual antiplatelet therapy (DAPT) is recommended (Class I, Level B-NR). (5) For patients being evaluated for neurointeventional brain aneurysm treatment who had venous thrombosis more than 3 months prior, discontinuation of oral anticoagulation (OAC) or vitamin K antagonists should be considered as weighed against the risk of delaying aneurysm treatment. For venous thrombosis less than 3 months in the past, delay of the neurointerventional procedure should be considered. If this is not possible, see atrial fibrillation recommendations (Class IIb, Level C-LD). (6) For patients with atrial fibrillation receiving OAC and in need of a neurointerventional procedure, the duration of TAT (triple antiplatelet/anticoagulation therapy=OAC plus DAPT) should be kept as short as possible or avoided in favor of OAC plus single antiplatelet therapy (SAPT) based on the individual's ischemic and bleeding risk profile (Class IIa, Level B-NR). (7) For patients with unruptured brain arteriovenous malformations there is no indication to change antiplatelet or anticoagulant management instituted for management of another disease (Class IIb, Level C-LD). (8) Patients with symptomatic intracranial atherosclerotic disease (ICAD) should continue DAPT following neurointerventional treatment for secondary stroke prevention (Class IIa, Level B-NR). (9) Following neurointerventional treatment for ICAD, DAPT should be continued for at least 3 months. In the absence of new stroke or transient ischemic attack symptoms, reversion to SAPT can be considered based on an individual patient's risk of hemorrhage versus ischemia (Class IIb, Level C-LD). (10) Patients undergoing carotid artery stenting (CAS) should receive DAPT before and for at least 3 months following their procedure (Class IIa, Level B-R). (11) In patients undergoing CAS during emergent large vessel occlusion ischemic stroke treatment, it may be reasonable to administer a loading dose of intravenous or oral glycoprotein IIb/IIIa or P2Y12 inhibitor followed by maintenance intravenous infusion or oral dosing to prevent stent thrombosis whether or not the patient has received thrombolytic therapy (Class IIb, C-LD). (12) For patients with cerebral venous sinus thrombosis, anticoagulation with heparin is front-line therapy; endovascular therapy may be considered particularly in cases of clinical deterioration despite medical therapy (Class IIa, Level B-R). CONCLUSIONS Although the quality of evidence is lower than for coronary interventions due to a lower number of patients and procedures, neurointerventional antiplatelet and antithrombotic management shares several themes. Prospective and randomized studies are needed to strengthen the data supporting these recommendations.
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Affiliation(s)
| | - Ketan R Bulsara
- Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA
| | - Fawaz Al-Mufti
- Neurology, Neurosurgery, and Radiology, Westchester Medical Center, Valhalla, New York, USA
| | - Neil Haranhalli
- Neurosurgery and Radiology, Montefiore Hospital and Medical Center, Bronx, New York, USA
| | - Lucie Thibault
- Scientific Committee, World Federation of Interventional and Therapeutic Neuroradiology, Paris, France
| | - Steven W Hetts
- Radiology, Biomedical Imaging, and Neurological Surgery, UCSF, San Francisco, California, USA
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49
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Malferrari G, Merli N, Inchingolo V, Siniscalchi A, Laterza D, Monaco D, Arnone G, Zini A, Prada F, Azzini C, Pugliatti M. Role of Advanced Hemodynamic Ultrasound Evaluation in the Differential Diagnosis of Middle Cerebral Artery Stenosis: Introducing Morphological Criteria. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:2428-2435. [PMID: 37550172 DOI: 10.1016/j.ultrasmedbio.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 06/28/2023] [Accepted: 07/09/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE The aim of the work described here was to determine the possible impact of the new technique advanced hemodynamic ultrasound evaluation (AHUSE) in identification of severe intracranial stenosis. Transcranial Doppler (TCD) and transcranial color-coded Doppler (TCCD) provide reliable velocimetric data, the indirect analysis of which allows us to obtain information on the patency of vessels and assumed stenosis range. However, very tight stenoses (>95%) cannot be detected with velocimetric criteria because of spectrum drops and the absence of high velocities, so that the right curve of the Spencer equation cannot be solved. Likewise, high velocities are not detected when analyzing morphologically long stenosis. Furthermore, the current classifications based on velocimetric criteria do not provide any categorization on stenoses with multiple acceleration points (MAPs). METHODS With this Technical Note we aim to introduce, in addition to velocimetric criteria, more morphological criteria based on TCCD with the algorithm of AHUSE to optimize the characterization of intracranial stenosis (IS). TCCD-AHUSE relies on intensity-based next-generation techniques and can be used to identify IS with MAPs and simultaneously perform a morphological assessment of the stenosis length. RESULTS We introduce a new technical ultrasound (U) approach that we tested in a sample of four different types of stenoses combining velocimetric data and AHUSE using Esaote Microvascularization (MicroV) technique to the M1 tract of the middle cerebral artery (MCA). CONCLUSION The authors believe that a multiparametric evaluation is more sensitive and supports the clinician by introducing the morphological concept, not just the velocimetric concept, to differentiate the IS pattern of MCA. The potential for developing a diagnostic/prognostic algorithm is discussed.
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Affiliation(s)
- Giovanni Malferrari
- Stroke Unit and Neurology Unit, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy.
| | - Nicola Merli
- Department of Neuroscience and Rehabilitation, University of Ferrara, Italy
| | - Vincenzo Inchingolo
- Neurology Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Antonio Siniscalchi
- Department of Neurology and Stroke Unit, Annunziata Hospital, Cosenza, Italy
| | - Domenico Laterza
- Neurology and Stroke Unit, Nuovo Ospedale degli Infermi, Biella (BI), Italy
| | - Daniela Monaco
- Department of Emergency Neurology and Stroke Unit, "S. Spirito" Hospital, Pescara, Italy
| | - Giorgia Arnone
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, Bologna, Italy
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, Bologna, Italy
| | - Francesco Prada
- Acoustic Neuroimaging and Therapy Lab, Fondazione IRCCS Istituto Neurologico C. Besta, Milano, Italy; Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA; Focused Ultrasound Foundation, Charlottesville, VA, USA
| | - Cristiano Azzini
- Stroke Unit and Neurology Unit, S. Anna University Hospital, Ferrara Italy
| | - Maura Pugliatti
- Department of Neuroscience and Rehabilitation, University of Ferrara, Italy; S. Anna University Hospital, Ferrara Italy
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50
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Yang W, Sam K, Qiao Y, Huang Z, Steinman DA, Wasserman BA. A Novel Window Into Human Vascular Remodeling and Diagnosing Carotid Flow Impairment: The Petro-Occipital Venous Plexus. J Am Heart Assoc 2023; 12:e031832. [PMID: 37830353 PMCID: PMC10757507 DOI: 10.1161/jaha.123.031832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/13/2023] [Indexed: 10/14/2023]
Abstract
Background Adaptive arterial remodeling caused by flow reduction from downstream stenosis has been demonstrated in animal studies. The authors sought to determine whether inward remodeling from downstream stenosis also occurs in humans and is detectable by ex vacuo expansion of the Rektorzik venous plexus (RVP) surrounding the petrous internal carotid artery. Methods and Results The authors analyzed 214 intracranial magnetic resonance imaging examinations that included contrast-enhanced vessel wall imaging. RVP symmetry was qualitatively assessed on vessel wall imaging. RVP thickness (RVPT) was measured on the thicker side if asymmetric or randomly assigned side if symmetric. Maximum stenosis (M1 or intracranial internal carotid artery) was measured. Posterior communicating artery and A1 diameters (>1.0 mm and 1.5 mm, respectively) defined adequate collateral outflow when proximal to the stenosis. Seventy-two patients had stenosis downstream from RVPT measurements. For those without adequate outflow (38 of 72), 95.0% with RVPT ≥1.0 mm had ≥50% stenosis compared with only 5.6% with RVPT <1.0 mm. For these 72 patients, higher RVPT (RVPT ≥1.0 mm versus <1.0 mm) and absent adequate outflow were associated with greater downstream stenosis (P<0.001) using multivariate regression. For patients with downstream stenosis without adequate outflow, asymmetric RVP thickening was associated with greater ipsilateral stenosis (P<0.001, all had ≥46% stenosis) when stenosis was unilateral and greater differences in stenosis between sides (P=0.005) when stenosis was bilateral. Conclusions Inward internal carotid artery remodeling measured by RVPT or RVP asymmetry occurs as downstream stenosis approaches 50%, unless flow is preserved through a sufficiently sized posterior communicating artery or A1, and may serve as a functional measure of substantial flow reduction from downstream stenosis.
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Affiliation(s)
- Wenjie Yang
- Department of Diagnostic Radiology & Nuclear MedicineUniversity of Maryland School of MedicineBaltimoreMD
| | - Kevin Sam
- Department of Diagnostic Radiology & Nuclear MedicineUniversity of Maryland School of MedicineBaltimoreMD
| | - Ye Qiao
- Russell H. Morgan Department of Radiology and Radiological SciencesJohns Hopkins School of MedicineBaltimoreMD
| | - Zhongqing Huang
- Department of Diagnostic Radiology & Nuclear MedicineUniversity of Maryland School of MedicineBaltimoreMD
| | - David A. Steinman
- Department of Mechanical & Industrial EngineeringUniversity of TorontoCanada
| | - Bruce A. Wasserman
- Department of Diagnostic Radiology & Nuclear MedicineUniversity of Maryland School of MedicineBaltimoreMD
- Russell H. Morgan Department of Radiology and Radiological SciencesJohns Hopkins School of MedicineBaltimoreMD
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