Ischemic stroke subtype incidence among whites, blacks, and Hispanics: the Northern Manhattan Study

Determinants of post-stroke cognitive impairment in patients with periodontal disease

INTRODUCTION

Periodontal disease (PD) is a risk factor for stroke and cardiovascular disease. The effect of PD on post-stroke cognitive impairment (PSCI) remains underexplored.

METHODS

A cross-sectional analysis of the Periodontal tReatment to Eliminate Minority InEquality and Rural disparities in Stroke (PREMIERS) study participants was conducted. Baseline cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) within 90 days of the index event. MoCA score ≤21 indicated severe PSCI. White matter hyperintensity, indicating cerebral small vessel disease (cSVD), was evaluated using the Fazekas scale on MRI. Due to non-normal MoCA distribution, two analytical approaches were employed: 1) logistic regression using dichotomized MoCA scores based on clinically relevant cutoffs and 2) generalized linear mixed modeling after bootstrap normalization that examined MoCA scores continuously.

RESULTS

Among 280 participants with PD, 48% exhibited severe PSCI. Both analytical approaches demonstrated that severe PD, African American (AA) race, and greater stroke severity significantly and independently predicted severe PSCI, while advanced education was protective. Fazekas' scale showed no significant associations with PSCI.

CONCLUSIONS

This study identifies PD severity as a novel and independent contributor to early PSCI. Traditional predictors like AA race, educational attainment, and stroke severity remained significant.

CLINICAL TRIAL REGISTRATION INFORMATION

https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02541032.

Stroke risk prediction in symptomatic anterior circulation ICAD: Analysis of regional QMRA flow from the MYRIAD study

BACKGROUND

Intracranial atherosclerotic disease (ICAD) remains a major source of stroke world-wide, with high recurrence risk. Prior evaluation of posterior circulation ICAD patients enrolled in the prospective VERiTAS and MYRIAD studies revealed regional hypoperfusion assessed by large vessel flow measurements using quantitative MRA (QMRA) predicts subsequent stroke risk. We examined whether a similar approach to regional flow assessment predicted stroke risk in anterior circulation ICAD patients in MYRIAD.

METHODS

MYRIAD enrolled patients with symptomatic 50-99 % stenosis of proximal intracranial artery. The primary outcome was recurrent ischemic stroke in the stenotic artery territory within one year. Flow was measured in the major intracranial arteries at baseline using QMRA. We designated patients as low or normal flow based on an algorithm assessing distal flow and collateral capacity using age-normalized middle cerebral artery (MCA) and hemispheric flows. Thresholds for flow status categorization were tested to determine the optimal algorithm for stroke risk prediction.

RESULTS

Of 73 enrolled subjects with symptomatic anterior circulation ICAD, 7 (9.6 %) had recurrent stroke. Z-score thresholds for age-normalized flow were examined, from which we identified an optimal threshold of -1 for the MCA and -0.75 for hemispheric flow. Based on these thresholds, 24 (33 %) patients were categorized as low flow; recurrent stroke occurred in 21 % of low flow vs 4 % of normal flow patients (age adjusted OR 7.2, 95 % CI 1.2-43.2). In the full cohort of 99 subjects with anterior and posterior circulation ICAD, 11 (11.1 %) had recurrent stroke, with a higher recurrent stroke risk in low flow patients (21.4 % vs 7 %, age adjusted OR 3.8, 95 % CI 1.02-14.2).

CONCLUSIONS

Distal flow status assessed through QMRA regional flow measurement appears to be similarly predictive for recurrent clinical stroke in both the anterior and posterior ciruclation. Identification of high-risk patients has implications for future investigation of therapeutic interventions.

Acute arterial mesenteric ischaemia: comparison of partial and complete occlusion of the superior mesenteric artery

OBJECTIVES

To describe the characteristics and outcomes of patients with an incomplete occlusion of the superior mesenteric artery (SMA) (persistence of contrast-enhanced vessel lumen) and compare them to those with a complete occlusion of the SMA (complete interruption of the contrast-enhanced vessel lumen) in arterial acute mesenteric ischaemia (AMI).

MATERIAL AND METHODS

Retrospective study of arterial AMI patients (2006-2022). Demographics, laboratory tests, clinical characteristics, CT, treatments and outcomes were compared between patients with complete or incomplete SMA obstruction after adjusting for aetiology (embolic or atherosclerotic). The primary outcome was 30-day mortality, and the secondary outcome was 6-month gastrointestinal disability-free survival (no short bowel syndrome or parenteral nutritional support or permanent stoma).

RESULTS

151 patients (65 women, mean age 69) were included, 62 (41%) with incomplete and 89 (59%) with occlusive SMA occlusion. After adjusting for aetiology, chronic kidney failure (p = 0.03) and normal bowel enhancement on CT (p < 0.01) were associated with incomplete SMA occlusion. Patients with incomplete SMA occlusion were more frequently treated by endovascular revascularisation (p < 0.01) and stenting (p < 0.01), while patients with complete SMA occlusion were treated by open revascularisation. The 30-day mortality rate was 13% with no difference between incomplete (11%) and complete SMA occlusion (15%; p = 0.89). Nevertheless, complete SMA occlusion patients had a lower 6-month gastrointestinal disability-free survival rate (p = 0.01), more transmural necrosis (p < 0.01) and a higher risk of gastrointestinal disability (p = 0.02).

CONCLUSION

Incomplete SMA occlusion can cause AMI with a similar 30-day mortality rate to completely occlusive forms. However, it is associated with poorer gastrointestinal outcomes, regardless of aetiology.

CRITICAL RELEVANCE STATEMENT

Acute arterial mesenteric ischaemia caused by incomplete occlusion of the superior mesenteric artery demonstrates similar 30-day mortality to complete occlusion but distinctively better gastrointestinal outcomes, emphasising nuanced imaging evaluation for targeted management strategies in these patients.

KEY POINTS

Occlusive acute mesenteric ischaemia can be caused by incomplete superior mesenteric artery (SMA) occlusion. Acute mesenteric ischaemia caused by incomplete SMA occlusion has a similar 30-day mortality rate to complete SMA occlusion. A complete occlusion of the SMA is associated with poorer gastrointestinal outcomes.

Mortality risk among older adults of indigenous ancestry with asymptomatic intracranial atherosclerotic stenosis. A population-based, longitudinal prospective study in rural Ecuador

BACKGROUND

Intracranial atherosclerotic stenosis (ICAS)-related mortality may vary according to race/ethnicity, but information about this association in diverse populations is limited. We aimed to assess mortality according to ICAS severity in stroke-free older adults of indigenous ancestry living in Ecuador.

METHODS

We invited stroke-free individuals ≥60 years old enrolled in the population-based Atahualpa Project cohort to undergo time-of-flight brain MRA. Participants were followed to ascertain mortality (as the primary outcome) during the observation period. Luminal stenosis in 11 large intracranial arteries was calculated to reflect the stenosis score. We categorized prevalent ICAS as a stenosis score ≥3 points or as the presence of moderate-to-severe stenosis (≥50 %). Cox proportional hazards models were fitted to estimate mortality risk according to ICAS severity.

RESULTS

Analysis included 358 participants (mean age: 67.5 ± 6.9 years; 57 % women) followed on average for 10.1 ± 2.9 years. Seventy-four (21 %) participants had a stenosis score ≥3 points, and 37 (10 %) had moderate-to-severe stenosis. In adjusted analysis, mortality risk was higher in participants with a ICAS score ≥3 points (HR: 2.38; 95 % C.I.: 1.49-3.80; p < 0.001) and among those with moderate-to-severe stenosis (HR: 1.96; 95 % C.I.: 1.12-3.43; p = 0.018). Thirty-five (10 %) participants had incident strokes. Overall, 97 (27 %) participants died during the follow-up, including 11/35 who developed an incident stroke and 86/323 who did not (31 % versus 27 %; p = 0.544).

DISCUSSION

The burden of asymptomatic ICAS is high in older adults of indigenous Ecuadorian ancestry and is significantly associated with mortality. Incident strokes do not influence mortality in this population.

The role of per- and polyfluoroalkyl substances in cognitive impairment and dementia

Per- and polyfluoroalkyl substances (PFAS) are ubiquitous persistent organic pollutants. The neurotoxic and cardiometabolic effects of PFAS are well documented, leading to the hypothesis that exposure increases dementia risk. However, empirical data on PFAS in relation to cognitive impairment and dementia are weak, limited, and inconsistent. This report reviews the literature on PFAS and cognitive impairment and provides a rationale and overview of the PFAS VascCog Longitudinal Study, a new study using the population-based Northern Manhattan Study cohort, to prospectively examine serum concentrations of 13 PFAS in relation to lipids, carotid atherosclerosis, cognitive impairment, and dementia. We hypothesize that PFAS deleteriously impact cognition through a pathway involving hyperlipidemia and atherosclerosis. Rigorous examination of PFAS exposure in relation to dementia is needed to inform public health policies on PFAS-containing products, support regulations to reduce community exposure, and provide new avenues to protect cognitive health and impact dementia at the individual and community levels. HIGHLIGHTS: PFAS exposure increases cardiometabolic risk factors and neurotoxicity. Data on PFAS in relation to cognitive health is limited, weak, and controversial. We hypothesize that PFAS exposure increases dementia risk. We hypothesize a mechanistic pathway involving hyperlipidemia and atherosclerosis. Rigorous study of PFAS exposure and dementia risk can inform public health policy.

Impact of Carotid Artery Geometry and Clinical Risk Factors on Carotid Atherosclerotic Plaque Prevalence

Objectives: Carotid geometry and cardiovascular risk factors play a significant role in the development of carotid atherosclerotic plaques. This study aimed to investigate the correlation between carotid plaque formation and carotid artery geometry characteristics. Methods: A retrospective cross-sectional analysis was performed on 1227 patients, categorized into a normal group (n = 685) and carotid plaque groups causing either mild stenosis (<50% stenosis based on NASCET criteria, n = 385) or moderate-to-severe stenosis (>50%, n = 232). The left and right carotid were evaluated individually for each group. Patient data, including cardiovascular risk factors and laboratory test results, were collected. Carotid geometric measurements were obtained from 3D models reconstructed from cranio-cervical computed tomography angiography (CTA) using semi-automated software (MIMICS). The geometric variables analyzed included the vascular diameter and sectional area of the common carotid artery (CCA), internal carotid artery (ICA), external carotid artery (ECA), and carotid artery bifurcation (CAB), as well as the carotid bifurcation angles and carotid tortuosity. Results: Compared to the normal group, in both the right and left carotid arteries, patients with carotid plaques exhibited a significantly higher age (p < 0.001) and a greater prevalence of hypertension (p < 0.001) and diabetes mellitus (p < 0.001). Additionally, they demonstrated a larger CCA and a smaller carotid bifurcation dimension (p < 0.05). In the analysis of the left carotid artery, patients with carotid plaques also had a significantly smaller ICA dimension (p < 0.05) than the normal group. Conclusions: This study found that patients with carotid plaques were older and had a higher prevalence of hypertension and diabetes, larger CCAs, and smaller carotid bifurcations. The plaque-positive left ICA was significantly smaller than that of the plaque-negative group, suggesting a side-specific vulnerability. These findings highlight the role of carotid geometry in plaque formation and its potential clinical implications for personalized risk assessment and targeted interventions.

Real-World Dual Antiplatelet Therapy Use Exceeds Randomized Trials Boundaries With Possible Safety Issues in Patients With Large Artery Atherosclerosis-Insights From the READAPT Study

BACKGROUND AND AIM

According to randomized controlled trials (RCTs), dual antiplatelet therapy (DAPT) is more effective for secondary prevention of ischemic events attributable to large artery atherosclerosis (LAA) than other mechanisms. We investigated whether real-world application may impact DAPT effectiveness and safety in the REAl-life study on short-term Dual Antiplatelet treatment in Patients with ischemic stroke or Transient ischemic attack (READAPT, NCT05476081).

METHODS

READAPT was an observational multicenter study including patients with minor ischemic stroke or TIA treated with short-term DAPT. At 90 days, we assessed primary effectiveness (ischemic recurrence, severe bleeding, or vascular death) and safety (severe to moderate bleeding) outcomes. We explored associations between LAA and outcomes using Cox regression. Within patients with and without LAA, outcomes were compared between subgroups based on age, NIHSS score (for ischemic stroke patients), ABCD2 score (for TIA patients), presence and number of MRI acute lesions, and DAPT regimen characteristics.

RESULTS

Among 1920 analyzed patients (of 2278 enrolled), 452 had LAA. Unlike RCTs, 21.2% of patients with LAA had NIHSS > 5, and 48.2% received DAPT > 30 days. Patients with LAA had higher bleeding rates (3.5% vs. 2.1%, p = 0.004), primarily hemorrhagic infarctions and moderate bleeding, than those without LAA. However, primary effectiveness outcomes were similar (4.9% vs. 3.5%, p = 0.201) between the groups. In patients with LAA, prolonged DAPT (> 21 days), multiple MRI lesions, age ≥ 65, and loading doses increased bleeding risk.

CONCLUSIONS

The real-world DAPT use in patients with LAA exceeds RCTs boundaries with possible drawbacks on treatment safety.

Outcomes of Carotid Artery Stenting and Endarterectomy in Patients with Prior Contralateral Carotid Revascularization

BACKGROUND

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are available treatment options for stroke prevention in individuals with severe carotid stenosis. This study aims to compare the early postoperative outcomes in patients who underwent CEA or CAS after prior contralateral carotid revascularization.

METHODS

We conducted a retrospective review of the Society of Vascular Surgery Vascular Quality Initiative database, identifying patients who had prior carotid artery revascularization followed by a contralateral CEA or CAS between 2017 and 2023. Based on the sequence of the procedures performed, patients were categorized into 4 groups: 1) patients who had a prior unilateral CEA followed by a contralateral CEA; 2) patients who had a prior unilateral CAS followed by a contralateral CEA; 3) patients had a prior unilateral CAS followed by a contralateral CAS; and 4) patients had a prior unilateral CEA followed by a contralateral CAS. Univariate analysis (Pearson χ2, Wilcoxon rank sum test) and multivariate logistic regression were employed to assess length of stay, rates of in-hospital stroke, myocardial infarction, new-onset arrhythmia, and 30-day mortality.

RESULTS

A total of 20,761 patients with a history of prior unilateral carotid revascularization procedures were identified, of which 12,788 underwent contralateral CEA and another 7,973 underwent contralateral CAS. Compared to the prior unilateral CAS followed by a contralateral CAS group, patients who underwent CEA followed by contralateral CAS (prior unilateral CEA followed by a contralateral CAS group) were associated with higher rates of postoperative in-hospital stroke (1.8% vs. 1%, P = 0.003), new-onset arrhythmia (2% vs. 1.2%, P = 0.006), and 30-day mortality (1.3% vs. 0.8%, P = 0.04). On multivariate analysis, preoperative use of statins and beta-blockers was associated with lower odds of in-hospital stroke (odds ratio [OR] 0.42; 95% confidence interval 0.29-0.69; P = 0.0002) and new-onset arrhythmia (OR 0.62; 95% confidence interval 0.49-0.9; P = 0.01), respectively, after CAS. There were no significant differences in outcomes for prior unilateral CEA followed by a contralateral CEA and prior unilateral CEA followed by a contralateral CAS groups.

CONCLUSIONS

Patients with prior CEA undergoing contralateral CAS had higher rates of in-hospital stroke, new-onset arrhythmia, and 30-day mortality. Beta-blockers may reduce postoperative arrhythmia rates in these patients, and established regimens should not be discontinued in the perioperative period; however, further prospective studies are needed to confirm this finding. Optimized medical treatment and appropriate imaging follow-up remain crucial for improvement outcomes.

Thrombosis at Unusual Sites: Focus on Myeloproliferative Neoplasms and Paroxysmal Nocturnal Hemoglobinuria

Patients with thrombosis at an unusual site will need to be explored for rare causes of thrombosis. Two of these rare causes include myeloproliferative neoplasms (MPNs) and paroxysmal nocturnal hemoglobinuria (PNH). It is important not to overlook these causes, since they require specific management, in addition to antithrombotic treatment (anticoagulants, antiplatelet agents). Unusual sites of venous thrombosis include upper extremity veins, splanchnic veins, cerebral veins, and retinal veins, and unusual sites of arterial thrombosis include renal, adrenal, splenic and mesenteric arteries, and intracardiac and aortal locations. Suspicion for MPN and PNH should be raised if there are concomitant abnormalities, such as elevated or decreased blood cell counts or splenomegaly. Diagnosis of MPN and PNH should include JAK2V617F mutational screening as well as flow cytometric assessment of GPI-anchored proteins in the peripheral blood, respectively. Specific treatments for MPN may include phlebotomy or cytoreductive drugs such as hydroxyurea, anagrelide, pegylated interferon-alpha, or Janus kinase inhibitors. Drugs used for PNH treatment include terminal complement inhibitors, such as eculizumab and ravulizumab, as well as proximally acting inhibitors such as pegcetacoplan or iptacopan. Patients with MPN and PNH are at high risk for thrombosis during their entire lifetime and should thus be followed by specialists experienced in the care of these diseases.

Association between C-reactive protein-triglyceride glucose index and stroke risk in different glycemic status: insights from the China Health and Retirement Longitudinal Study (CHARLS)

OBJECTIVE

C-reactive protein-triglyceride-glucose index (CTI) has been proposed as a novel biomarker for insulin resistance and inflammation. However, the association between CTI and the risk of stroke, particularly in individuals with different glycemic status, remains unclear.

METHODS

A total of 10,443 middle-aged and elderly participants were enrolled from the China Health and Retirement Longitudinal Study (CHARLS). The primary endpoint was the occurrence of stroke events. The CTI was calculated using the formula 0.412* Ln (CRP [mg/L]) + Ln (TG [mg/dl] × FPG [mg/dl])/2. The Kaplan-Meier curves, Cox proportional hazard models, and restricted cubic spline analysis were applied to explore the association between CTI and the risk of stroke according to gender, age and glycemic status.

RESULTS

During a median follow-up of 9 years, 960 (9.2%) participants experienced a stroke. Our findings revealed a significant positive linear relationship between CTI and the occurrence of stroke. The association was similar between male and female, despite the HR tended to be higher in females (HR 1.22, 95% CI 1.09, 1.36) than males (HR 1.15, 95% CI 1.02, 1.29), and similar in middle-aged (HR 1.25, 95% CI 1.11, 1.41) and elderly participants (HR 1.12, 95% CI 1.00, 1.26). In different glycemic status, high levels of CTI were found to be linked to an increased risk of stroke in individuals with normal glucose regulation (NGR) (HR 1.33, 95% CI 1.11, 1.59) and prediabetes mellitus (Pre-DM) (HR 1.20, 95% CI 1.04, 1.39). However, this association was not observed in individuals with diabetes mellitus (DM).

CONCLUSIONS

Our findings revealed a significant positive linear relationship between CTI and the occurrence of stroke. The association between CTI and stroke was similar between male and female, and similar in middle-aged and elderly participants. In different glycemic status, the association was significant in individuals with NGR and Pre-DM.

MetS in the prediction of asymptomatic intracranial arterial stenosis: the potential mediating role of hsCRP

BACKGROUND

We aimed to investigate the relationships between metabolic syndrome (MetS) and its severity score (Metsss) with asymptomatic intracranial arterial stenosis (aICAS) while also assessing the additional effect of high-sensitivity C reactive protein (hsCRP).

METHODS

This cross-sectional study included 2390 individuals who underwent health examinations at our centre from June 2019 to August 2023. Participants received physical examinations, laboratory tests and magnetic resonance angiography evaluations. MetS was defined by the modified acknowledged criteria and quantified by Metsss. Logistic regression, interaction analysis and mediation analysis were employed.

RESULTS

Among the 2390 participants, 135 (5.65%) had aICAS, and 726 (30.40%) had MetS. After adjusting for confounders, MetS was significantly associated with aICAS (OR: 1.68, 95% CI: 1.16 to 2.43, p=0.006). The prevalence of aICAS increased significantly from 3.6% to 8.6% as the number of MetS components increased. Higher quartiles of Metsss also significantly increased aICAS risk (P for trend <0.001). After multivariable adjustment, MetS (p=0.001) and elevated Metsss (p<0.001) were only associated with posterior circulation aICAS (vs anterior). Furthermore, participants with both MetS and elevated hsCRP levels had a greater risk for aICAS (OR: 2.32, 95% CI: 1.36 to 3.96, p=0.002). hsCRP mediated the association between MetS and alCAS in participants ≤65 years old.

CONCLUSIONS

MetS and Metsss were independently associated with the risk of aICAS. The mediating effect of hsCRP on the relationship between MetS and aICAS appears to be age-dependent. These findings offer valuable insights into clinical decision making of aICAS and further improve the primary stroke prevention.

Ethnicity as a Risk Factor for Early Neurological Deterioration: A Post Hoc Analysis of the Secondary Prevention of Small Subcortical Strokes Trial

OBJECTIVES

Nearly 25% of those with a small vessel stroke will develop early neurological deterioration (END). The objectives of this study were to identify clinical risk factors for small vessel stroke-related END and its associated impact on functional outcomes in an ethnically diverse data set.

METHODS

We performed a post hoc analysis of the "Secondary Prevention of Small Subcortical Strokes" trial. The primary outcome was END defined as progressive or stuttering stroke-related neurological symptoms. Standard descriptive and inferential statistical methods were used for analysis. Functional outcomes are reported by modified Rankin Scale score and analyzed by the Wilcoxon signed-rank test.

RESULTS

In all, 69 participants met the inclusion criteria; 21 (30%) had END. Of the cohort, Spanish, Hispanic, or Latino ethnicity (grouping per trial definition) most frequently developed END [11 (52.4%) vs 4 (8.3%), P < 0.001] with a higher adjusted likelihood of END (odds ratio: 14.1, 95% CI: 2.57-76.7, P = 0.002). Black or African-American race less commonly had END [3 (14.3%) vs 21 (43.8%), P = 0.03] but lost significance after adjustment (odds ratio: 1.46, 95% CI: 0.26-8.17, P = 0.67) due to powering. END was associated with a higher mean modified Rankin Scale (2.06 ± 0.94 vs 1.17 ± 0.79, P = 0.006) but did not differ in the shift analysis.

CONCLUSIONS

We found that Spanish, Hispanic, or Latino ethnicity was the most consistent risk factor for END though it was without meaningful functional outcome differences.

Association Between Triglyceride-Glucose Index and Carotid Plaque Stability in Different Glycemic Status: A Single-Center Retrospective Study

BACKGROUND

The triglyceride-glucose (TyG) index has been proposed as a reliable marker of insulin resistance. However, its value in patients with carotid plaque stability remains unclear. This study investigated the association between the TyG index and unstable carotid plaque.

METHODS

A total of 12 068 participants were enrolled. Carotid ultrasound was used to determine the stability of carotid plaque. Logistic regression was used to analyze the relationship between the TyG index and unstable carotid plaque. The relationship between the TyG index and unstable carotid plaque was evaluated according to sex, age, and glucose metabolism states. Further, the dose-response relationship between the TyG index and unstable carotid plaque was also determined by restrictive cubic splines.

RESULTS

Of the 12 068 participants, 11 601 had stable carotid plaque and 467 had unstable carotid plaque. In several different adjustment models, the TyG index is significantly related to the risk of unstable carotid plaque. The association between the TyG index and an unstable carotid plaque was similar between men and women, despite the fact that the odds ratio (OR) tended to be higher in men (OR, 2.80 [95% CI, 2.04-3.83]) than women (OR, 2.07 [95% CI, 1.51-2.82]), and higher in older patients (aged >60 years; (OR, 3.59 [95% CI, 2.74-4.70]) than middle-aged patients (aged ≤60 years) (OR, 2.00 [95% CI, 1.36-2.95]). The TyG index of patients with different glycemic status was significantly correlated with the risk of unstable carotid plaque, among which the OR value of diabetes (OR, 2.51 [95% CI, 1.87-3.36]) was the highest. The restrictive cubic spline analysis indicated a nonlinear relationship between the TyG index and unstable carotid plaque, with TyG index >8.63 identified as an independent risk factor for unstable carotid plaque.

CONCLUSIONS

The TyG index has a significant association with unstable carotid plaque. The association between the TyG index and unstable carotid plaque is similar between men and women, and the association in older patients is higher than that in middle-aged patients. In different glycemic status, the association between the TyG index and unstable carotid plaque is highest in patients with diabetes.

Development and validation of a nomogram for cerebral hemorrhage in patients with carotid stenosis undergoing stenting: a multicenter retrospective study

BACKGROUND

Hyperperfusion-induced cerebral hemorrhage (HICH) is a rare but severe complication in patients with carotid stenosis undergoing stent placement for which predictive models are lacking. Our objective was to develop a nomogram to predict such risk.

METHODS

We included a total of 1226 patients with carotid stenosis who underwent stenting between June 2015 and December 2022 from three medical centers, divided into a development cohort of 883 patients and a validation cohort of 343 patients. The model used LASSO regression for feature optimization and multivariable logistic regression to develop the predictive model. Model accuracy was assessed via the receiver operating characteristic curve, with further evaluation of calibration and clinical utility through calibration curves and decision curve analysis (DCA). The model underwent internal validation using bootstrapping and external validation with the validation cohort.

RESULTS

Older age (OR 1.07, p=0.005), higher degrees of carotid stenosis (OR 1.07, p=0.006), poor collateral circulation (OR 6.26, p<0.001), elevated preoperative triglyceride levels (OR 1.27, p=0.041) and neutrophil counts (OR 1.36, p<0.001) were identified as independent risk factors for HICH during hospitalization. The nomogram constructed based on these predictive factors demonstrated an area under the curve (AUC) of 0.817. The AUCs for internal and external validation were 0.809 and 0.783, respectively. Calibration curves indicated good model fit, and DCA confirmed substantial clinical net benefit in both cohorts.

CONCLUSION

We developed and validated a nomogram to predict HICH in patients with carotid stenosis post-stenting, facilitating early identification and preventive intervention in high-risk individuals.

Clinical Outcomes of Carotid Artery Stenting for Carotid Artery Stenosis in Maintenance Hemodialysis Patients

Most previous large studies of carotid artery stenting (CAS) in maintenance hemodialysis patients are old-era, do not describe the types of stents and method of protection, and their effectiveness is unknown. CAS has progressed remarkably, and tailor-made CAS is now possible in hemodialysis patients according to the lesion. We aimed to analyze the outcomes of CAS in maintenance hemodialysis patients treated in our institution.We retrospectively investigated the data of patients who underwent elective CAS in our institution between January 2012 and April 2023. Firstly, we verified the outcomes of CAS in maintenance hemodialysis patients. Secondly, the outcomes of CAS in maintenance hemodialysis patients were compared with CAS in nondialysis patients during the same period.During the study period, 212 patients with carotid stenosis underwent CAS. Among these, 18 patients undergoing maintenance hemodialysis were identified for analysis. All 18 patients underwent lesion-specific tailor-made CAS. All 18 patients were technically successfully stented with good vasodilation and improvement in stenosis. No symptomatic cerebral infarction occurred within 30 days after CAS. There was no difference between dialysis and nondialysis patients in the risk of symptomatic complications and death occurring within 30 days after surgery. There was a higher risk of hemorrhagic complications not associated with prognosis in the dialysis group (23.1% vs 1.0%, P = 0.0047). No in-stent restenosis (>50% stenosis) and ipsilateral cerebral infarction at 1 year occurred during follow-up.CAS in hemodialysis patients may be safe and effective.

Patch-Wise Deep Learning Method for Intracranial Stenosis and Aneurysm Detection-the Tromsø Study

Intracranial atherosclerotic stenosis (ICAS) and intracranial aneurysms are prevalent conditions in the cerebrovascular system. ICAS causes a narrowing of the arterial lumen, thereby restricting blood flow, while aneurysms involve the ballooning of blood vessels. Both conditions can lead to severe outcomes, such as stroke or vessel rupture, which can be fatal. Early detection is crucial for effective intervention. In this study, we introduced a method that combines classical computer vision techniques with deep learning to detect intracranial aneurysms and ICAS in time-of-flight magnetic resonance angiography images. The process began with skull-stripping, followed by an affine transformation to align the images to a common atlas space. We then focused on the region of interest, including the circle of Willis, by cropping the relevant area. A segmentation algorithm was used to isolate the arteries, after which a patch-wise residual neural network was applied across the image. A voting mechanism was then employed to identify the presence of atrophies. Our method achieved accuracies of 76.5% for aneurysms and 82.4% for ICAS. Notably, when occlusions were not considered, the accuracy for ICAS detection improved to 85.7%. While the algorithm performed well for localized pathological findings, it was less effective at detecting occlusions, which involved long-range dependencies in the MRIs. This limitation was due to the architectural design of the patch-wise deep learning approach. Regardless, this can, in the future, be mitigated in a multi-scale patch-wise algorithm.

Outcomes of Symptomatic Intracranial Large Artery Stenoses: A Prospective Cohort Study from the Asian Registry of Intracranial Atherosclerosis

INTRODUCTION

Intracranial large artery atherosclerosis (ICAS) is a common cause of stroke in Asia. Prior epidemiological publications on ICAS have largely been single-country reports. This collaborative study involving several Asian countries aims to investigate the characteristics and outcomes of patients with stroke attributable to ICAS.

METHODS

This is an international, multicenter, observational, prospective cohort study of patients admitted with acute ischemic stroke secondary to ICAS to stroke centers in six Asian countries. Stroke due to ICAS was diagnosed when there was a ≥50% intracranial large artery stenosis ipslateral to a non-lacunar infarct, without significant ipsilateral extracranial stenosis, cardiac cause or other mechanism found for the stroke. Data were collected on patient demographics, vascular risk factors, stroke location, and severity. Outcomes of interest were stroke recurrence and mortality at 12-month follow-up.

RESULTS

A total of 356 patients were recruited. Mean age was 62.7 ± 13.8 years, and 39.9% were females. Mean NIHSS on admission was 9 ± 8, with majority of patients having mild (39.3%) or moderate (37.9%) strokes. Stroke recurrence was 6.7% (95% CI: 4.4-9.9%) while mortality rate was 13.2% (95% CI: 9.9-17.2%) within 1 year. The risk of stroke recurrence was associated with increasing age (odds ratio [OR]: 1.04, 95% CI: 1-1.06, p = 0.05) and hypertension (OR: 3.23, 95% CI: 1.09-9.61, p = 0.035). Mortality was associated with age (OR: 1.05, 95% CI: 1.01-1.08, p = 0.006) and NIHSS (OR: 1.12, 95% CI: 1.07-1.17, p < 0.001).

CONCLUSIONS

This multicenter Asian study demonstrates a high risk of stroke recurrence and mortality among patients with acute stroke due to ICAS. They are associated with age (both), as well as hypertension (for recurrence) and NIHSS (for mortality). Better treatment modalities are needed to reduce the frequency of adverse outcomes in symptomatic ICAS.

Insulin resistance, vulnerable plaque and stroke risk in patients with carotid artery stenosis

Insulin resistance (IR) is linked to both the vulnerable plaque and the stroke risk. However, the precise extent of this correlation and its impact on stroke risk in carotid artery stenosis patients remain unclear. Therefore, this study aims to investigate the relationship between vulnerable plaque and IR and stroke risk and the mediating role of vulnerable plaque in patients with carotid artery stenosis. This study included 505 patients with carotid artery stenosis. IR was assessed using the triglyceride-glucose (TyG) index. The association of the TyG index and vulnerable plaque with stroke risk was investigated using the restricted cubic splines (RCS)and adjusted Logistic regression. Additionally, the mediation analysis was used to explore the mediating impact of the vulnerable plaque on the association between the TyG index and stroke risk. A total of 184 (36.4%) stroke events were recorded. The RCS curves revealed a positive linear association between TyG index and risk events among patients with carotid artery stenosis (P-value < 0.001 and P for nonlinear = 0.860). After fully adjusting for covariates, both the TyG index and vulnerable plaque emerged as significant predictors of stroke events. Mediation analysis indicated that the vulnerable plaque mediated 18.3%, 15.8%, 13.9%, and 11.6% of the correlation between the TyG index and stroke risk in different adjusted models, respectively. TyG index and vulnerable plaque are associated with a higher risk of stroke in patients with carotid artery stenosis. In addition, vulnerable plaques partially mediated the relationship between TyG index and stroke risk.

Clinical and perfusion imaging characteristics of acute large vessel occlusion in intracranial atherosclerosis

OBJECTIVES

This study aimed to compare clinical and perfusion imaging profiles in acute ischemic stroke with large vessel occlusion (AIS-LVO) between patients with intracranial atherosclerotic disease (ICAD) and non-ICAD who underwent endovascular treatment (EVT).

METHODS

Data from AIS-LVO patients over the anterior circulation undergoing EVT across two stroke centers were retrospectively analyzed. Clinical profiles and perfusion parameters from automated processing of perfusion imaging were compared between ICAD and non-ICAD groups. Ischemic core was defined as relative cerebral blood flow < 30 % on CT perfusion or apparent diffusion coefficient ≤ 620 × 10-6 mm2/s on MR diffusion weighted imaging.

RESULTS

A total of 111 patients were included (46 ICAD, 65 non-ICAD). The ICAD group exhibited a higher male proportion (60.9 % vs. 35.4 %), more M1 segment occlusions (78.3 % vs. 56.9 %), lower atrial fibrillation rates (17.4 % vs. 63.1 %), and lower baseline NIH Stroke Scale (NIHSS) scores (median [IQR]: 13 [8.75-18] vs. 15 [10-21]) at presentation compared to non-ICAD (all p < 0.05). However, there was no difference in NIHSS scores at discharge or in good functional outcomes (modified Rankin Scale 0-2) at 3 months between the two groups. ICAD patients also had smaller median ischemic core volumes (0 [IQR 0-9.7] vs. 4.4 [0-21.6] ml, p = 0.038), smaller median Tmax >6s tissue volulmes (89.3 [IQR 51.1-147.1] vs. 124.4 [80.5-178.6] ml, p = 0.017) and lower median HIR (hypoperfusion intensity ratio defined as Tmax >10s divided by Tmax >6s; 0.28 [IQR 0.09-0.42] vs. 0.44 [0.24-0.60], p = 0.003). Higher baseline NIHSS scores correlated with larger Tmax >6s lesion volumes as well as higher HIR value in non-ICAD patients, but not in ICAD patients.

CONCLUSIONS

In anterior circulation of AIS-LVO, ICAD patients exhibited distinct clinical presentations and perfusion imaging characteristics when compared to non-ICAD patients. Perfusion imaging profiles may serve as indicators for identifying ICAD patients before EVT.

Racial/ethnic differences in the association of incident stroke with late onset epilepsy: The Northern Manhattan Study

OBJECTIVE

Little is known about the incidence of late onset epilepsy (LOE) across different racial/ethnic groups in the USA, particularly in the Hispanic population. Stroke, a strong predictor of LOE, is more common in non-Hispanic Blacks (NHBs) and Hispanics than in non-Hispanic Whites (NHWs). We assessed the incidence of LOE across racial/ethnic groups and examined whether the associations of stroke with LOE risk differ by race/ethnicity.

METHODS

The Northern Manhattan Study is a population-based longitudinal study of older adults enrolled between 1993 and 2001. Participants free of history of stroke or epilepsy at baseline (n = 3419) were followed prospectively for incidence of LOE. We estimated LOE incidence per 1000 person-years in each racial/ethnic group. We used Cox proportional hazards regression to assess the association of race/ethnicity with LOE and multiplicative interactions of race/ethnicity with incident stroke in relation to LOE, adjusting for demographics and comorbid diagnoses.

RESULTS

During 51 176 person-years of follow-up, 183 individuals developed LOE. Incidence of LOE was significantly higher in NHBs (6.2 per 1000 person-years) than in NHWs (3.3 per 1000 person-years, p = .004). There was no significant difference in LOE incidence between NHWs (3.3 per 1000 person-years) and Hispanics (2.6 per 1000 person-years, p = .875). However, following incident stroke, the risk of LOE differed across racial/ethnic groups. Incident stroke was associated with 2.55 times the risk of LOE among NHWs (95% confidence interval [CI] = .88-7.35), 8.53 times the risk of LOE among Hispanics (95% CI = 5.36-13.57, p = .04 for stronger association than that in NHWs), and 6.46 times the risk of LOE among NHBs (95% CI = 3.79-11.01, p = .12 for stronger association than that in NHWs).

SIGNIFICANCE

We found a stronger association of incident stroke with LOE risk in Hispanics and NHBs than in NHWs, offering some insight into the racial/ethnic disparities of LOE incidence.

Electrical Heterogeneity in Hispanic Background Subpopulations: The HCHS/SOL

Background

The Hispanic/Latino population is not uniform. Prevalence and clinical outcomes of cardiac arrhythmias in ethnic background subgroups are variable, but the reasons for differences are unclear. Vectorcardiographic Global Electrical Heterogeneity (GEH) has been shown to be associated with adverse cardiovascular outcomes.

Objectives

The purpose of this study was to compare GEH in Hispanic/Latino background subpopulations. We hypothesized that ethnicity category moderates an association of prevalent cardiovascular disease (CVD) with GEH.

Methods

Cross-sectional analysis of the HCHS/SOL (Hispanic Community Health Study/Study of Latinos) included 15,684 participants (mean age 41 years; 38% Mexican, 20% Cuban, 16% Puerto Rican, 10% Dominican, 7% Central American, 5% South American, 4% mixed Hispanic/Latino background). Acculturation and socioeconomic data were collected. GEH was measured as spatial QRS-T angle, spatial ventricular gradient (SVG) azimuth, SVG elevation, SVG magnitude, and sum absolute QRST integral. Linear regression models included interaction terms of ethnic background category by CVD and were adjusted for age, sex, education attainment, hypertension, diabetes, smoking, dyslipidemia, obesity, chronic kidney disease, physical activity, diet quality, heart rate, and rhythm.

Results

The adjusted spatial QRS-T angle was significantly (P < 0.0001) narrower in Dominican background (-3.4°[95% CI -5.0° to -1.7°]) as compared to a total mean. SVG azimuth pointed farther posteriorly in Dominican (+2.9 [95% CI: 1.6-4.2]) and Puerto Rican (+3.8 [2.4-5.2]), but farther anteriorly in South American (-2.9 [95% CI: -4.4 to -1.4]) and Mexican (-3.5 [95% CI: -4.3 to -2.6]) vs total mean. An association of coronary heart disease with GEH was especially strong in Cuban background subpopulation.

Conclusions

In CVD-free Hispanic/Latino subpopulations, cardiovascular risk factors do not fully explain GEH differences across ethnic background categories, which likely reflect unmeasured health disparities.

Procedural and Short-Term Outcomes of Carotid Artery Stenting: A Single-Center Experience

Background Carotid artery stenting is a well-established alternative treatment to carotid endarterectomy for carotid artery stenosis for preventing stroke. This study assessed the procedural and clinical outcomes in patients undergoing carotid artery stenting in a tertiary care center in India. Methods A total of 39 patients underwent carotid artery stenting from January 2022 to December 2023, with different embolic protection devices and carotid stents. All the patients had symptomatic carotid artery stenosis with at least 50% stenosis as per the North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria. Procedural and technical success was assessed, and patients were followed for 20 ± 7 months for survival, new-onset stroke, and quality of life. Results The mean age was 64.8 ± 9.1 years and 25 (64.1%) of the patients were males. A total of 26 (66.7%) patients were hypertensive and 21 (53.9%) patients had a history of diabetes mellitus. Out of 39 patients, 2 (5.1%) had recurrent transient ischemic attacks while the rest (37; 94.9%) had a subacute and chronic ischemic stroke. A total of 37 (94.9%) patients had carotid artery stenosis of more than 70%. In this study, 9 (23.1%) patients had a history of sub-acute ischemic stroke of a 1 to 3-week duration. Two patients underwent bilateral staged stenting over a gap of one month. The overall procedural success rate was 39 (100%) and none of the patients had access site-related major complications. Out of the total 41 implants, 21 (51.2%) were self-expanding carotid WALLSTENT (Boston Scientific, Marlborough, Massachusetts, US) and 20 (48.8%) implants were Protégé RX tapered self-expanding carotid stent (Medtronic, Dublin, Ireland). A FilterWire EZ (Boston Scientific) embolic protection device was used in 23 (56.1%) cases and Spider FX (Medtronic) in 18 (43.9%) cases. None of our patients had an intraprocedural death. One patient had postprocedural ipsilateral third nerve palsy, which was resolved partially on the next day of carotid angioplasty. We used dual-antiplatelet drug therapy post-procedure for a month followed by a single antiplatelet drug lifelong. All patients were followed for a minimum of six months and a maximum of 30 months. A total of three (7.7%) patients have died, and 2 (5.1%) patients had a new-onset ischemic stroke with one on the same side of the carotid stenting. A total of 31 (79.5%) patients were doing well and in the recovery phase while those two patients who had a recurrent stroke were bedridden. None of the patients had clinically significant restenosis that needed revascularization of the carotid artery over a mean follow-up period. Conclusion Carotid artery stenting is an effective method to reduce the recurrence of ischemic stroke in significant symptomatic carotid stenosis patients. Experience in neuro-interventional procedures at our center leads to an acceptable rate of peri-procedural stroke, recurrence, and mortality in carotid artery stenting procedures.

European Stroke Organisation and European Society for Minimally Invasive Neurological Therapy guideline on acute management of basilar artery occlusion

The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology. Although BAO accounts for only 1%-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five ESMINT) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements. First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (albeit in small numbers) in IVT trials. Non-randomised studies of IVT-only cohorts showed high proportion of favourable outcomes. Expert Consensus suggests using IVT up to 24 h unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared to BMT alone within 6 and 6-24 h from last seen well. In both time windows, we observed a different effect of treatment depending on (a) the region where the patients were treated (Europe vs. Asia), (b) on the proportion of IVT in the BMT arm, and (c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with NIHSS below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT + BMT over BMT alone (i.e. based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT + BMT over BMT alone in proximal and middle locations of BAO compared to distal location. While recommendations for patients without extensive early ischaemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischaemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 h after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).

Evaluation of the Frequency of Migraine and CVA Patients Based on Circle of Willis Morphological Variations in MRA Images

Background

The Circle of Willis (CoW) forms a critical collateral route for the compensation pathway at the basal cistern of the brain. This study aims to determine if migraine headaches and cerebrovascular accidents (CVAs) are associated with the prevalence and patterns of CoW arterial variations seen in the three-dimensional time-of-flight magnetic resonance angiography technique in patients.

Materials and Methods

A cross-sectional study was undertaken by a systemic search of electronic databases in the Imaging Center, Abadan's Taleghani Hospital, Iran, from March 2020 to March 2022. Data on the prevalence of variations in patients who presented for screening for migraine and CVA were extracted and analyzed with Student t-test and the Chi-square method.

Results

Findings show complete CoW has been visible in 20.19% of our patients. The anterior part of the CoW was almost intact in all patients. The posterior part of CoW was mostly bilaterally hypoplastic (31.73%) or bilateral aplastic (29.81%) and in some rare cases unilaterally varied. In migraine patients, CoW was rarely in its classic form (15%) and was varied bilaterally in 72.5% of the cases. In CVA patients, CoW was in its complete vascular structure in 23.08% and bilaterally varied in 46.15% of all cases.

Conclusions

Overall, migraine and CVA are associated with anatomical variations in the posterior portions of the CoW. Further larger prospective trials are needed to determine the true prevalence of CoW variations and their pathological significance.

Vessel wall MRI characteristics associated with intraprocedural stent thrombosis during angioplasty for intracranial atherosclerotic stenosis

BACKGROUND

Few studies have so far explored plaque characteristics on high-resolution magnetic resonance vessel wall imaging (HR-VWI) associated with intraprocedural stent thrombosis (IPST) during angioplasty for intracranial atherosclerotic stenosis (ICAS). We aimed to investigate the plaque features on HR-VWI associated with IPST during stenting for ICAS.

METHODS

This study recruited 77 patients with ICAS who underwent intracranial stenting using the Gateway-Wingspan system, and were performed with enhanced pre- and post-contrast T1-weighted HR-VWI on a 3.0T MRI scanner before angioplasty. During stenting for ICAS, eight patients (male: 100%, age mean ± standard deviation (SD): 58.7±2.47) developed IPST within 30 minutes after stenting. To ensure comparability, 16 patients who had undergone intracranial stenting but did not develop IPST were matched as controls for this study. Univariable and binary logistic models were used to explore the plaque characteristics on HR-VWI associated with IPST.

RESULTS

Patients who developed IPST had less plaque diffusion (37.50% vs 81.25%, p=0.036), a more severe degree of area stenosis (median 96.30% vs 81.65%, p<0.01), and a higher plaque enhancement index (median 37.99 vs 13.12, p<0.01) compared with those who did not. After multivariate adjustment, IPST was independently associated with a more severe degree of area stenosis (adjusted odds ratio (OR) 1.20, 95% confidence interval (CI) 1.01-1.43, p=0.044) and a higher plaque enhancement index (adjusted OR 1.17, 95% CI 1.01 to 1.36, p=0.036).

CONCLUSION

Intraprocedural stent thrombosis during intracranial angioplasty for patients with ICAS may be independently associated with a higher plaque enhancement index and a more severe degree of area stenosis on HR-VWI.

Development and Validation of a Flow-Dependent Endothelialized 3D Model of Intracranial Atherosclerotic Disease

Intracranial atherosclerotic disease (ICAD) is a major cause of stroke globally, with mechanisms presumed to be shared with atherosclerosis in other vascular regions. Due to the scarcity of relevant animal models, testing biological hypotheses specific to ICAD is challenging. We developed a workflow to create patient-specific models of the middle cerebral artery (MCA) from neuroimaging studies, such as CT angiography. These models, which can be endothelialized with human endothelial cells and subjected to flow forces, provide a reproducible ICAD model. Using imaging from the SAMMPRIS clinical trial, we validated this novel model. Computational fluid dynamics flow velocities correlated strongly with particle-derived flow, regardless of stenosis degree. Post-stenotic flow disruption varied with stenosis severity. Single-cell RNA-seq identified flow-dependent endothelial gene expression and specific endothelial subclusters in diseased MCA segments, including upregulated genes linked to atherosclerosis. Confocal microscopy revealed flow-dependent changes in endothelial cell proliferation and morphology in vessel segments related to stenosis. This platform, rooted in the specific anatomy of cerebral circulation, enables detailed modeling of ICAD lesions and pathways. Given the high stroke risk associated with ICAD and the lack of effective treatments, these experimental models are crucial for developing new ICAD-related stroke therapies.

Efficacy and safety of thrombectomy with or without intravenous thrombolysis in the treatment of acute basilar artery occlusion ischemic stroke: an updated systematic review and meta-analysis

Background

Mechanical thrombectomy (MT) is a well-established treatment for acute basilar artery occlusion (BAO)-induced posterior circulation ischemic stroke.

Objective

The objective of the study was to compare the outcomes of endovascular therapy (EVT) with and without bridging intravenous thrombolysis (IVT) in patients with acute BAO, using an updated meta-analysis.

Methods

A systematic literature search was conducted to identify studies that compared the efficacy and safety of EVT with and without IVT in the treatment of acute BAO ischemic stroke. The extracted data included sample size, patient age, National Institutes of Health Stroke Scale (NIHSS) scores, 90-day modified Rankin Scale (mRS) scores of 0-2 and 0-3, mortality rates, symptomatic intracranial hemorrhage (sICH), and occurrence of subarachnoid hemorrhage (SAH).

Results

Five studies that included a total of 1,578 patients (594 IVT + EVT vs. 984 EVT), met the inclusion criteria and were analyzed. The meta-analysis demonstrated that bridging IVT was associated with a higher likelihood of achieving a 90-day mRS score of 0-2 (41% vs. 34%; OR = 1.35, 95% CI 1.09-1.68, p = 0.006). Furthermore, the mortality rate was significantly lower in the IVT + EVT group than in the direct EVT group (25% vs. 30%; OR = 0.70, 95% CI 0.55-0.89, p = 0.003), with low heterogeneity observed (I 2 = 0.0%, p = 0.78). However, there were no significant differences between the groups regarding the rates of sICH (5% vs. 6%; OR = 0.85, 95% CI: 0.52-1.39, p = 0.53), SAH (3% vs. 3%; OR = 0.93, 95% CI: 0.39-2.22, p = 0.87), perforation (2% vs. 3%; OR = 0.71, 95% CI 0.26-1.95, p = 0.51), and dissection (3% vs. 2%; OR = 0.97, 95% CI: 0.13-7.14, p = 0.98).

Conclusion

Bridging IVT in conjunction with EVT was associated with better functional outcomes and reduced mortality rates in patients with acute ischemic stroke (AIS) due to BAO compared to EVT alone, without an increased risk of sICH, SAH, perforation, and dissection. In addition, the benefit of bridging IVT to EVT appeared to be more pronounced in European patients than in Asian patients compared to EVT alone. However, the conclusions of this study are not definitive and require validation through large-scale randomized controlled trials (RCTs) to draw more robust conclusions.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42024531363.

Stenting for symptomatic intracranial arterial stenosis with different qualifying arteries: a preplanned pooled individual patient data analysis

BACKGROUND

The efficacy of percutaneous transluminal angioplasty and stenting (PTAS) relative to medical management in treating symptomatic intracranial arterial stenosis (ICAS) varies based on the qualifying artery. This study aims to evaluate PTAS compared with medical therapy alone in cases of ICAS involving the internal carotid artery (ICA), middle cerebral artery (MCA), vertebral artery (VA) and basilar artery (BA).

METHODS

This study involves a thorough pooled analysis of individual patient data from two randomised controlled trials, evaluating the efficacy of PTAS in comparison to medical management for symptomatic ICAS with different qualifying arteries. The primary outcome was stroke or death within 30 days postenrolment, or stroke in the region of the qualifying artery beyond 30 days through 1 year. A methodology based on intention-to-treat was employed, and HR accompanied by 95% CIs were used to convey risk estimates.

RESULTS

The data of 809 individuals were collected from Stenting vs Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis trial and China Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis trial. Four hundred were designated for PTAS, while 409 were assigned to medical therapy alone. For the primary outcome, patients with symptomatic BA stenosis had a significantly higher risk of receiving PTAS compared with medical therapy (17.17% vs 7.77%; 9.40; HR, 2.38 (1.03 to 5.52); p=0.04). However, PTAS had no significant difference in patients with symptomatic ICA (26.67% vs 16.67%; HR, 1.68 (0.78 to 3.62); p=0.19), MCA (8.28% vs 9.79%; HR, 0.85 (0.42 to 1.74); p=0.66) and VA stenosis (9.52% vs 10.71%; HR, 0.91 (0.32 to 2.62); p=0.86) compared with medical therapy.

CONCLUSIONS

PTAS significantly increases the risk of both short-term and long-term stroke in patients with symptomatic BA stenosis. Without significant technological advancements to mitigate these risks, PTAS offers limited benefits. For symptomatic ICA, MCA and VA stenosis, PTAS provided no significant advantage.

Long-term outcome followed for more than 5 years after revascularization surgery for the treatment of atherosclerotic steno-occlusive disease: poor outcome prediction using machine learning and analysis of the results

Cerebral revascularization for the treatment of atherosclerotic steno-occlusive disease (ASOD) was found to have no benefit compared with medical treatment. However, there is also criticism that with sufficiently long-term follow-up, a crossover might emerge demonstrating the advantages of surgery. Therefore, we examined the long-term outcome of cerebral revascularization performed on patients with carefully selected ASOD at our center. Patients undergoing bypass surgery for non-moyamoya ischemic disease were retrospectively identified. The inclusion criteria were symptomatic ASOD with hemodynamic insufficiency, follow-up of more than 5 years, and stroke or surgical complications during follow-up. The clinical course and radiological findings were investigated. Poor outcomes were predicted using machine learning (ML) models, and Shapley additive explanation (SHAP) values and feature importance of each model were analyzed. A total of 109 patients were included from 2007 to 2018. The 30-day risk of any stroke or death was 6.4% (7/109). The risk of ipsilateral ischemic stroke during median follow-up of 116 months was 7.3% (8/109). The SHAP values showed that previously and empirically known stroke risk factors exert a relatively consistent effect on the prediction of models. The number of lesions with stenosis > 50% (odds ratio [OR] 5.77), age (OR 1.13), and coronary artery disease (OR 5.73) were consistent risk factors for poor outcome. We demonstrated an acceptable long-term outcome of cerebral revascularization surgery for patients with hemodynamically insufficient and symptomatic ASOD. Multicenter studies are encouraged to predict poor outcomes and suitable patients with large numbers of quantitative and qualitative data.

Race, Ethnicity, and Gender Disparities in the Management and Outcomes of Critically Ill Adults with Acute Stroke

Racial, ethnicity and sex disparities are pervasive in the evaluation and acute care of ischemic stroke patients. Administration of intravenous thrombolysis and mechanical thrombectomy are the most critical steps in ischemic stroke treatment but compared to White patients, ischemic stroke patients from minority racial and ethnic groups are less likely to receive these potentially life-saving interventions. Sex and racial disparities in intracerebral hemorrhage or subarachnoid hemorrhage treatment have not been well studied.

Addressing racial differences in the management of atrial fibrillation: Focus on black patients

Atrial fibrillation (AF) is the most common sustained arrhythmia, affecting between 3 and 6 million people in the United States. It is associated with a reduced quality of life and increased risk of stroke, cognitive decline, heart failure and death. Black patients have a lower prevalence of AF than White patients but are more likely to suffer worse outcomes with the disease. It is important that stakeholders understand the disproportionate burden of disease and management gaps that exists among Black patients living with AF. Appropriate treatments, including aggressive risk factor control, early referral to cardiovascular specialists and improving healthcare access may bridge some of the gaps in management and improve outcomes.

Impact of Race on Outcomes in the Endovascular and Microsurgical Treatment in Patients With Intracranial Aneurysms

BACKGROUND AND OBJECTIVES

The impact of race on outcomes in the treatment of intracranial aneurysm (IA) remains unclear. We aimed to investigate the relationship between race classified into White, Black, Hispanic, and other and treatment outcomes in patients with ruptured and unruptured IAs.

METHODS

The study population consisted of 2836 patients with IA with endovascular treatment or microsurgical treatment (MST) from 16 centers in the United States and Asia, all participating in the observational "STAR" registry. The primary outcome was a 90-day modified Rankin Scale of 0 to 2. Secondary outcomes included periprocedural cerebral infarction and intracranial hemorrhage, perioperative symptomatic cerebral vasospasm in ruptured IA and mortality, and all causes of mortality within 90 days.

RESULTS

One thousand fifty-three patients were White (37.1%), 350 were Black (12.3%), 264 were Hispanic (9.3%), and 1169 were other (41.2%). Compared with White patients, Hispanic patients had a significantly lower proportion of primary outcome (adjusted odds ratio [aOR] 0.36, 95% CI, 0.23-0.56) and higher proportion of the periprocedural cerebral infarction, perioperative mortality, and all causes of mortality (aOR 2.53, 95% CI, 1.40-4.58, aOR 1.84, 95% CI, 1.00-3.38, aOR 1.83, 95% CI, 1.06-3.17, respectively). Outcomes were not significantly different in Black and other patients. The subgroup analysis showed that Hispanic patients with age ≥65 years (aOR 0.19, 95% CI, 0.10-0.38, interaction P = .048), Hunt-Hess grades 0 to 3 (aOR 0.29, 95% CI, 0.19-0.46, interaction P = .03), and MST (aOR 0.24, 95% CI, 0.13-0.44, interaction P = .04) had a significantly low proportion of primary outcome.

CONCLUSION

This study demonstrates that Hispanic patients with IA are more likely to have a poor outcome at 90 days after endovascular treatment or MST than White patients. Physicians have to pay attention to the selection of treatment modalities, especially for Hispanic patients with specific factors to reduce racial discrepancies.

Latent profiles of global electrical heterogeneity: the Hispanic Community Health Study/Study of Latinos

Aims

Despite the highest prevalence of stroke, obesity, and diabetes across races/ethnicities, paradoxically, Hispanic/Latino populations have the lowest prevalence of atrial fibrillation and major Minnesota code-defined ECG abnormalities. We aimed to use Latent Profile Analysis in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) population to obtain insight into epidemiological discrepancies.

Methods and results

We conducted a cross-sectional analysis of baseline HCHS/SOL visit. Global electrical heterogeneity (GEH) was measured as spatial QRS-T angle (QRSTa), spatial ventricular gradient azimuth (SVGaz), elevation (SVGel), magnitude (SVGmag), and sum absolute QRST integral (SAIQRST). Statistical analysis accounted for the stratified two-stage area probability sample design. We fitted a multivariate latent profile generalized structural equation model adjusted for age, sex, ethnic background, education, hypertension, diabetes, smoking, dyslipidaemia, obesity, chronic kidney disease, physical activity, diet quality, average RR' interval, median beat type, and cardiovascular disease (CVD) to gain insight into the GEH profiles. Among 15 684 participants (age 41 years; 53% females; 6% known CVD), 17% had an increased probability of likely abnormal GEH profile (QRSTa 80 ± 27°, SVGaz -4 ± 21°, SVGel 72 ± 12°, SVGmag 45 ± 12 mVms, and SAIQRST 120 ± 23 mVms). There was a 23% probability for a participant of being in Class 1 with a narrow QRSTa (40.0 ± 10.2°) and large SVG (SVGmag 108.3 ± 22.6 mVms; SAIQRST 203.4 ± 39.1 mVms) and a 60% probability of being in intermediate Class 2.

Conclusion

A substantial proportion (17%) in the Hispanic/Latino population had an increased probability of altered, likely abnormal GEH profile, whereas 83% of the population was resilient to harmful risk factors exposures.

European Stroke Organisation (ESO) and European Society for Minimally Invasive Neurological Therapy (ESMINT) guideline on acute management of basilar artery occlusion

The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology.Although BAO accounts for only 1-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five representing the European Society of Minimally Invasive Neurological Therapy (ESMINT)) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements.First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (although in small numbers) in IVT trials. Non-randomized studies of IVT-only cohorts showed a high proportion of favorable outcomes. Expert Consensus suggests using IVT up to 24 hours unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared with BMT alone within 6 and 6-24 hours from last seen well. In both time windows, we observed a different effect of treatment depending on a) the region where the patients were treated (Europe vs Asia), b) on the proportion of IVT in the BMT arm, and c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with a National Institutes of Health Stroke Scale (NIHSS) score below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT+BMT over BMT alone (this is based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS score below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT+BMT over BMT alone in proximal and middle locations of BAO compared with distal location. While recommendations for patients without extensive early ischemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 hours after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).

Causal Relationship between Chronic Hepatitis B and Stroke in East Asians: A Mendelian Randomization Study

Both chronic hepatitis B (CHB) and stroke contribute to a high burden of disease in the majority of low- and middle-income countries. Epidemiological studies yield conflicting results on the association between CHB and stroke, and the causal relationship remains inconclusive. This study aimed to assess the causal effects of CHB on stroke and its subtypes in East Asians by Mendelian randomization (MR) analysis. Variants associated with CHB were obtained from a genome-wide association study (GWAS) of Chinese samples as instrumental variables. The summary statistics for stroke in East Asians were derived from the largest published GWAS to date. Two-sample MR analyses were implemented to evaluate the causal effects of CHB on stroke and its subtypes by using the canonical inverse variance weighting method and other supplementary approaches. We observed an association between genetic predisposition to CHB and a decreased risk of large-artery atherosclerotic stroke (odds ratio = 0.872, 95% confidence interval = 0.786-0.967, p = 0.010). The causal effects of CHB on other stroke outcomes were not statistically significant. Evidence for heterogeneity and horizontal pleiotropy were not found in our analyses. This study provides genetic evidence for a negative association between CHB and stroke in East Asians, which helps improve our understanding of the etiology of stroke.

Estimated Pulse-Wave Velocity and Magnetic Resonance Imaging Markers of Cerebral Small-Vessel Disease in the NOMAS

BACKGROUND

Pulse-wave velocity is a measure of arterial stiffness and a risk factor for cardiovascular disease. Recently, an estimated pulse-wave velocity (ePWV) was introduced that was predictive of increased risk of cardiovascular disease. Our objective was to determine whether ePWV was associated with cerebral small-vessel disease on magnetic resonance imaging.

METHODS AND RESULTS

We included 1257 participants from the NOMAS (Northern Manhattan Study). The ePWV values were calculated using a nonlinear function of age and mean arterial blood pressure. The association between ePWV and white matter hyperintensity volume was assessed. Modification by race and ethnicity was evaluated. Associations between ePWV and other cerebral small-vessel disease markers, covert brain infarcts, cerebral microbleeds, and enlarged perivascular spaces, were explored as secondary outcomes. Mean±SD age of the cohort was 64±8 years; 61% were women; 18% self-identified as non-Hispanic Black, 67% as Hispanic, and 15% as non-Hispanic White individuals. Mean±SD ePWV was 11±2 m/s in the total NOMAS population and was similar across race and ethnic groups. The ePWV was significantly associated with white matter hyperintensity volume (β=0.23 [95% CI, 0.20-0.26]) after adjustment. Race and ethnicity modified the association between ePWV and white matter hyperintensity volume, with stronger associations in Hispanic and non-Hispanic Black individuals. Significant associations were found between ePWV and covert brain infarcts, cerebral microbleeds, and perivascular spaces after adjustment.

CONCLUSIONS

The ePWV function may provide a vascular mechanism for deleterious cerebrovascular outcomes in individuals with cerebral small-vessel disease and is particularly apparent in the racial and ethnic minorities represented in the NOMAS cohort.

Association between BMI-based metabolic phenotypes and prevalence of intracranial atherosclerotic stenosis: a cross-sectional study

BACKGROUND

Obesity and metabolic syndrome (MetS) have been acknowledged to commonly co-exist and lead to increased risks of stroke, whereas the association between various BMI-based metabolic phenotypes and development of intracranial atherosclerotic stenosis (ICAS) remained controversial.

METHODS

A total of 5355 participants were included from the Asymptomatic Polyvascular Abnormalities Community (APAC) study. Participants were categorized into six groups according to their body mass index (BMI) and MetS status. ICAS was assessed using transcranial Doppler (TCD) Ultrasonography. Logistic regression was employed to evaluate the association between BMI-based metabolic phenotypes and ICAS.

RESULTS

704 participants were diagnosed with ICAS. Compared to the metabolic healthy normal weight (MH-NW) group, the metabolic unhealthy normal weight (MUH-NW) group demonstrated a higher risk of ICAS (full-adjusted odds ratio [OR], 1.91; 95% confidence interval [CI], 1.42-2.57), while no significant association was observed in the metabolic unhealthy obesity (MUO) group (full-adjusted OR, 1.07; 95% CI, 0.70-1.65) and other metabolic healthy groups regardless of BMI. The results were consistent across gender, age, smoking, alcohol intake, and physical activity subgroups.

CONCLUSION

The present study suggested that MUH-NW individuals had a significant association with increased risk of ICAS compared with MH-NW individuals.

High prevalence of intracranial arterial stenosis among acute ischemic stroke patients in a Brazilian center: a transcranial color-coded duplex sonography study

BACKGROUND

 There is limited data available regarding the prevalence of intracranial arterial stenosis (ICAS) among acute ischemic stroke (AIS) patients in Brazil and Latin America.

OBJECTIVE

 The present study sought to investigate the frequency and predictors of ICAS among patients with AIS or transient ischemic attack (TIA) in a Brazilian center, with transcranial color-coded duplex sonography (TCCS) technique.

METHODS

 Consecutive AIS and TIA patients, admitted to an academic public comprehensive stroke center in Brazil from February to December 2014, evaluated by TCCS were prospectively selected. Vascular narrowings > 50% were considered as ICAS, based on ultrasound criteria previously defined in the literature.

RESULTS

 We assessed 170 consecutive patients with AIS or TIA, of whom 27 (15.9%) were excluded due to an inadequate transtemporal acoustic bone window. We confirmed ICAS in 55 patients (38.5%). The most common location was the proximal segment of the middle cerebral artery (28.2%), followed by the vertebral (15.4%), posterior cerebral (13.6%), terminal internal carotid (9.1%) and basilar (8.2%) arteries. On multivariate models adjusting for potential confounders, systolic blood pressure (OR: 1.03, 95%CI: 1.01-1.04; p = 0.008) was independently associated with ICAS.

CONCLUSION

 We found significant ICAS in approximately ⅓ of patients admitted with symptoms of AIS or TIA in a public tertiary academic stroke center in Brazil. The TCCS is an accessible and noninvasive technique that can be used to investigate the presence of moderate and severe ICAS, especially in patients who cannot be exposed to more invasive exams, such as the use of intravenous contrast agents.

The guardian of intracranial vessels: Why the pericyte?

Intracranial atherosclerotic stenosis (ICAS) is a pathological condition characterized by progressive narrowing or complete blockage of intracranial blood vessels caused by plaque formation. This condition leads to reduced blood flow to the brain, resulting in cerebral ischemia and hypoxia. Ischemic stroke (IS) resulting from ICAS poses a significant global public health challenge, especially among East Asian populations. However, the underlying causes of the notable variations in prevalence among diverse populations, as well as the most effective strategies for preventing and treating the rupture and blockage of intracranial plaques, remain incompletely comprehended. Rupture of plaques, bleeding, and thrombosis serve as precipitating factors in the pathogenesis of luminal obstruction in intracranial arteries. Pericytes play a crucial role in the structure and function of blood vessels and face significant challenges in regulating the Vasa Vasorum (VV)and preventing intraplaque hemorrhage (IPH). This review aims to explore innovative therapeutic strategies that target the pathophysiological mechanisms of vulnerable plaques by modulating pericyte biological function. It also discusses the potential applications of pericytes in central nervous system (CNS) diseases and their prospects as a therapeutic intervention in the field of biological tissue engineering regeneration.

Hypothyroidism's effect on stroke limited to specific subtypes: A Mendelian randomization study

BACKGROUND

The association between hypothyroidism and stroke remains controversial and the association between hypothyroidism and stroke subtypes has not been satisfactorily researched. This study aimed to explore the causal effect of hypothyroidism on the risk of stroke and its subtypes by Mendelian randomization (MR) analysis.

METHODS

Single nucleotide polymorphisms (SNPs) were selected from published genome-wide association studies (GWAS) meta-analysis as instrumental variables (IVs) for hypothyroidism. As outcomes, summary GWAS data for stroke and its subtypes were obtained from two other large GWAS meta-analyses, including any stroke (AS), any ischemic stroke (AIS), large vessel stroke (LAS), cardiogenic embolic stroke (CES), small vessel stroke (SVS), and intracranial hemorrhage (ICH). Univariate Mendelian randomization (UVMR) and multivariate Mendelian randomization (MVMR) were used to assess the causal effect of hypothyroidism on stroke and its subtypes.

RESULTS

In UVMR, genetically predicted hypothyroidism was significantly associated with LAS (OR = 1.14, 95CI = 1.02-1.27) and SVS (OR = 1.14, 95CI = 1.04-1.25), but not with AS, AIS, CES, and ICH. The results of the MVMR showed that after adjusting for smoking, alcohol consumption, hypertension, diabetes, low-density lipoprotein cholesterol (LDL-c), and body mass index (BMI), the causal association between hypothyroidism and SVS remained significant, while the association between hypothyroidism and LAS became nonsignificant.

CONCLUSION

Hypothyroidism is causally associated with risk for LAS and SVS, but not for other stroke subtypes. Hypothyroidism may be an independent risk factor for SVS, and vascular risk factors play an important role in hypothyroidism causing LAS.

Recent Translational Research Models of Intracranial Atherosclerotic Disease

Intracranial atherosclerotic disease (ICAD) is a leading cause of ischemic stroke worldwide. However, research on the pathophysiology of ICAD is scarce due to the relative inaccessibility of histology samples and the lack of comprehensive experimental models. As a result, much of the current understanding of ICAD relies on research on extracranial atherosclerosis. This approach is problematic as intracranial and extracranial arteries are anatomically, structurally, physiologically, and metabolically distinct, indicating that intracranial and extracranial atherosclerosis likely develop through different biologic pathways. The current standard of care for ICAD treatment relies predominantly on therapeutics developed to treat extracranial atherosclerosis and is insufficient given the alarmingly high risk of stroke. To provide a definitive treatment for the disease, a deeper understanding of the pathophysiology underlying ICAD is specifically required. True mechanistic understanding of disease pathogenesis is only possible using robust experimental models. In this review, we aim to identify the advantages and limitations of the existing in vivo and in vitro models of ICAD and basic atherosclerotic processes, which may be used to inform better models of ICAD in the future and drive new therapeutic strategies to reduce stroke risk.

Intracranial stenting compared to medical treatment alone for intracranial atherosclerosis patients: An updated meta-analysis

OBJECTIVE

Stroke is the second-leading cause of death globally. Intracranial atherosclerotic stenosis (ICAS) represents 10-15% of ischemic strokes in Western countries and up to 47% in Asian countries. Patients with ICAS have an especially high risk of stroke recurrence. The aim of this meta-analysis is to reassess recurrent stroke, transient ischemic attack (TIA), and other outcomes with stenting versus best medical management for symptomatic ICAS.

METHODS

The search protocol was developed a priori according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The OVID Medline, Embase, Web of Science, and Cochrane Library databases were searched from inception to August 14th, 2022.

RESULTS

This Meta-analysis Included Four Randomized Controlled Trials (Rcts), With A Total Number Of 991 Patients. The Mean Age Of Participants Was 57 Years. The Total Number Of Intracranial Stenting Patients Was 495, And The Number Of Medical Treatment Patients Was 496. The Included Studies Were Published Between 2011 And 2022. Two Studies Were Conducted In The Usa, And The Other Two In China. All Included Studies Compared Intracranial Stenting To Medical Treatment For Icas.

CONCLUSIONS

In patients with ischemic stroke due to symptomatic severe intracranial atherosclerosis, the rate of 30-day ischemic stroke, 30-day intracerebral hemorrhage, one-year stroke in territory or mortality favored the medical treatment alone without intracranial stenting. The risk of same-territory stroke at last follow-up, disabling stroke at last follow-up, and mortality did not significantly favor either group. Intracranial stenting for atherosclerosis did not result in significant benefit over medical treatment.

MR Vessel Wall Imaging for Atherosclerosis and Vasculitis

Conventional imaging modalities, such as computed tomography angiography, MR angiography, transcranial Doppler ultrasonography, and digital subtraction angiography, are utilized in evaluating intraluminal or intravascular pathology of the intracranial vessels. Limitations of luminal imaging techniques can lead to inaccurate diagnosis, evaluation, and risk stratification, as many cerebrovascular pathologies contain an extrinsic vessel wall component. Furthermore, vessel wall imaging can provide information regarding extent, treatment response, and biopsy targets for vasculitis cases. Overall, while vessel wall imaging can provide robust data regarding intracranial pathologies, further prospective, multicenter studies are required to improve diagnostic application and accuracy.

Cumulative Systolic Blood Pressure and Incident Stroke Type Variation by Race and Ethnicity

Importance

Stroke risk varies by systolic blood pressure (SBP), race, and ethnicity. The association between cumulative mean SBP and incident stroke type is unclear, and whether this association differs by race and ethnicity remains unknown.

Objective

To examine the association between cumulative mean SBP and first incident stroke among 3 major stroke types-ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH)-and explore how these associations vary by race and ethnicity.

Design, Setting, and Participants

Individual participant data from 6 US longitudinal cohorts (January 1, 1971, to December 31, 2019) were pooled. The analysis was performed from January 1, 2022, to January 2, 2024. The median follow-up was 21.6 (IQR, 13.6-31.8) years.

Exposure

Time-dependent cumulative mean SBP.

Main Outcomes and Measures

The primary outcome was time from baseline visit to first incident stroke. Secondary outcomes consisted of time to first incident IS, ICH, and SAH.

Results

Among 40 016 participants, 38 167 who were 18 years or older at baseline with no history of stroke and at least 1 SBP measurement before the first incident stroke were included in the analysis. Of these, 54.0% were women; 25.0% were Black, 8.9% were Hispanic of any race, and 66.2% were White. The mean (SD) age at baseline was 53.4 (17.0) years and the mean (SD) SBP at baseline was 136.9 (20.4) mm Hg. A 10-mm Hg higher cumulative mean SBP was associated with a higher risk of overall stroke (hazard ratio [HR], 1.20 [95% CI, 1.18-1.23]), IS (HR, 1.20 [95% CI, 1.17-1.22]), and ICH (HR, 1.31 [95% CI, 1.25-1.38]) but not SAH (HR, 1.13 [95% CI, 0.99-1.29]; P = .06). Compared with White participants, Black participants had a higher risk of IS (HR, 1.20 [95% CI, 1.09-1.33]) and ICH (HR, 1.67 [95% CI, 1.30-2.13]) and Hispanic participants of any race had a higher risk of SAH (HR, 3.81 [95% CI, 1.29-11.22]). There was no consistent evidence that race and ethnicity modified the association of cumulative mean SBP with first incident stroke and stroke type.

Conclusions and Relevance

The findings of this cohort study suggest that cumulative mean SBP was associated with incident stroke type, but the associations did not differ by race and ethnicity. Culturally informed stroke prevention programs should address modifiable risk factors such as SBP along with social determinants of health and structural inequities in society.

Risk of Recurrent Stroke and Mortality Among Black and White Patients With Poststroke Depression

BACKGROUND

Poststroke depression (PSD) is a treatable and common complication of stroke that is underdiagnosed and undertreated in minority populations. We compared outcomes of Black and White patients with PSD in the United States to assess whether race is independently associated with the risk of recurrent stroke and mortality.

METHODS

We used deidentified Medicare data from inpatient, outpatient, and subacute nursing facilities for Black and White US patients from January 1, 2016, to December 31, 2019, to perform this retrospective cohort analysis. International Classification of Diseases, Tenth Revision codes were used to identify patients diagnosed with depression within 6 months of index stroke with no depression diagnosis 1-year preceding index stroke. We performed an unadjusted Kaplan-Meier analysis of the cumulative risk of recurrent stroke up to 3 years after index acute ischemic stroke admission and all-cause mortality following acute ischemic stroke stratified by Black and White race. We performed adjusted and reduced Cox regression to calculate hazard ratios for the main predictor of race (Black versus White), for recurrent stroke and all-cause mortality, adjusting for sociodemographic characteristics, comorbidities, characteristics of the hospitalization, and acute stroke interventions.

RESULTS

Of 474 770 Medicare patients admitted with acute index stroke, 443 486 were categorized as either Black or White race and 35 604 fulfilled our criteria for PSD. Within the PSD cohort, 25 451 (71.5%) had no death or recurrent stroke within 6 months and 5592 (15.7%) had no death or readmission of any cause within 6 months. Black patients with PSD had a persistently elevated cumulative risk of recurrent stroke compared with White patients with PSD up to 3 years following acute ischemic stroke (log-rank P=0.0011). In our reduced multivariable model, Black patients had a 19.8% (hazard ratio, 1.198 [95% CI, 1.022-1.405]; P=0.0259) greater risk of recurrent stroke than White patients. The unadjusted cumulative risk of all-cause mortality was higher in this cohort of older White patients with PSD compared with Black patients; however, this difference disappeared with adjustment for age and other cofactors.

CONCLUSIONS

Black patients with PSD face a persistently elevated risk of recurrent stroke compared with White patients but a similar risk of all-cause mortality. Our findings support that black race is an independent predictor of recurrent stroke in patients with PSD and highlight the need to address social determinants of health and systemic racism that impact poststroke outcomes among racial minorities.

Health Care Disparities in Stroke Rehabilitation

Stroke outcomes are influenced by factors such as education, lifestyle, and access to care, which determine the extent of functional recovery. Disparities in stroke rehabilitation research have traditionally included age, race/ethnicity, and sex, but other areas make up a gap in the literature. This article conducted a literature review of original research articles published between 2008 and 2022. The article also expands on research that highlights stroke disparities in risk factors, rehabilitative stroke care, language barriers, outcomes for stroke survivors, and interventions focused on rehabilitative stroke disparities.

Outcome of Mechanical Thrombectomy for Acute Basilar Artery Occlusion in Patients with Intracranial Atherosclerotic Disease

INTRODUCTION

Intracranial atherosclerotic disease (ICAD) has been identified as a major cause of acute basilar artery occlusion (BAO).This study compared the characteristics and treatment outcomes in acute BAO patients with and without ICAD.

METHODS

A prospective cohort study was conducted at 115 People's Hospital, Ho Chi Minh city, Vietnam from August 2021 to June 2023. Patients with acute BAO who underwent endovascular treatment within 24 h from symptom onset were included (thrombectomy alone or bridging with intravenous alteplase). The baseline characteristics and outcomes were analyzed and compared between patients with and without ICAD. Good functional outcome was defined as mRS ≤3 at 90 days.

RESULTS

Among the 208 patients enrolled, 112 (53.8%) patients were categorized in the ICAD group, and 96 (46.2%) in the non-ICAD group. Occlusion in the proximal segment of the basilar artery was more common in patients with ICAD (55.4% vs. 21.9%, p < 0.001), whereas the distal segment was the most common location in the non-ICAD group (58.3% vs. 10.7%, p < 0.001). Patients in the ICAD group were more likely to undergo treatment in the late window, with a higher mean onset-to-treatment time compared to the non-ICAD group (11.6 vs. 9.5 h, p = 0.01). In multivariable logistic regression analysis, distal segment BAO was negatively associated with ICAD (aOR 0.13, 95% CI: 0.05-0.32, p < 0.001), while dyslipidemia showed a positive association (aOR 2.44, 95% CI: 1.15-5.17, p = 0.02). There was a higher rate for rescue stenting in the ICAD compared to non-ICAD group (15.2% vs. 0%, p < 0.001). However, no significant differences were found between the two groups in terms of good outcome (45.5% vs. 44.8%, p = 0.91), symptomatic hemorrhage rates (4.5% vs. 8.3%, p = 0.25), and mortality (42% vs. 50%, p = 0.25).

CONCLUSION

ICAD was a common etiology in patients with BAO. The location segment of BAO and dyslipidemia were associated with ICAD in patients with BAO. There was no difference in 90-day outcomes between BAO patients with and without ICAD undergoing endovascular therapy.

Assessing ascertainment bias in atrial fibrillation across US minority groups

The aim of this study is to define atrial fibrillation (AF) prevalence and incidence rates across minority groups in the United States (US), to aid in diversity enrollment target setting for randomized controlled trials. In AF, US minority groups have lower clinically detected prevalence compared to the non-Hispanic or Latino White (NHW) population. We assess the impact of ascertainment bias on AF prevalence estimates. We analyzed data from adults in Optum's de-identified Clinformatics® Data Mart Database from 2017-2020 in a cohort study. Presence of AF at baseline was identified from inpatient and/or outpatient encounters claims using validated ICD-10-CM diagnosis algorithms. AF incidence and prevalence rates were determined both in the overall population, as well as in a population with a recent stroke event, where monitoring for AF is assumed. Differences in prevalence across cohorts were assessed to determine if ascertainment bias contributes to the variation in AF prevalence across US minority groups. The period prevalence was respectively 4.9%, 3.2%, 2.1% and 5.9% in the Black or African American, Asian, Hispanic or Latino, and NHW population. In patients with recent ischemic stroke, the proportion with AF was 32.2%, 24.3%, 25%, and 24.5%, respectively. The prevalence of AF among the stroke population was approximately 7 to 10 times higher than the prevalence among the overall population for the Asian and Hispanic or Latino population, compared to approximately 5 times higher for NHW patients. The relative AF prevalence difference of the Asian and Hispanic or Latino population with the NHW population narrowed from respectively, -46% and -65%, to -22% and -24%. The study findings align with previous observational studies, revealing lower incidence and prevalence rates of AF in US minority groups. Prevalence estimates of the adult population, when routine clinical practice is assumed, exhibit higher prevalence differences compared to settings in which monitoring for AF is assumed, particularly among Asian and Hispanic or Latino subgroups.

Post stroke pain: Is there under-diagnosis in Black versus White patients?

Stroke incidence is higher and stroke outcomes are poorer in Black patients compared to White patients. Poststroke pain, however, is not a well understood stroke outcome. Using the National Institutes of Health All of Us Research Program database, we hypothesized that the dataset would demonstrate proportionately higher relative risk of poststroke pain in the Black poststroke patient population compared to the White poststroke patient population. However, our analysis showed that Black stroke patients were diagnosed with poststroke pain at a similar rate as White stroke patients. As our results are not consistent with other poststroke outcomes in the literature, this study identifies a potentially underdiagnosed patient population, highlighting the need for further research.

Rescue stenting after failure of endovascular thrombectomy for acute vertebrobasilar artery occlusion: data from the PERSIST registry

BACKGROUND

Among acute vertebrobasilar artery occlusion (VBAO) patients, successful reperfusion is a strong predictor of favorable outcomes. However, failed reperfusion (FR) with endovascular thrombectomy (EVT) in VBAO was observed to occur in 18-50% of cases. We aim to evaluate the safety and efficacy of rescue stenting (RS) for VBAO after failed EVT.

METHODS

Patients with VBAO who received EVT were enrolled retrospectively. Propensity score matching was performed as the primary analysis to compare the outcomes between patients with RS and FR. Furthermore, a comparison between using the self-expanding stent (SES) and balloon-mounted stent (BMS) in the RS group was also conducted. The primary and secondary outcomes were defined as a 90-day modified Rankin Scale (mRS) score 0-3, and a 90-day mRS score 0-2, respectively. Safety outcomes included all-cause mortality at 90 days and symptomatic intracranial hemorrhage (sICH).

RESULTS

The RS group showed a significantly higher rate of 90-day mRS score 0-3 (46.6% vs 20.7%; adjusted OR (aOR) 5.06, 95% CI 1.88 to 13.59, P=0.001) and a lower rate of 90-day mortality (34.5% vs 55.2%; aOR 0.42, 95% CI 0.23 to 0.90, P=0.026) than the FR group. The rates of 90-day mRS score 0-2 and sICH were not significantly different between the RS group and FR group. There were no differences in all outcomes between SES and BMS groups.

CONCLUSIONS

RS appeared to be a safe and effective rescue approach in patients with VBAO who failed EVT, and there was no difference between using SES and BMS.