The relationship between neurological function trajectory, assessed by repeated NIHSS measurement, and long-term cardiovascular events, recurrent stroke, and mortality after ischemic stroke

Development and Validation of a Fusion Model Based on Carotid Plaques and White Matter Lesion Burden Imaging Characteristics to Evaluate Ischemic Stroke Severity in Symptomatic Patients

BACKGROUND

The diagnostic value of carotid plaque characteristics based on higher-resolution vessel wall MRI (HRVW-MRI) combined with white matter lesion (WML) burden for the risk of ischemic stroke is unclear.

PURPOSE

To combine carotid plaque features and WML burden to construct a hybrid model for evaluating ischemic stroke severity and prognosis in patients with symptomatic carotid artery stenosis.

STUDY TYPE

Retrospective.

SUBJECTS

One hundred and ninty-three patients with least one confirmed carotid atherosclerotic stenosis ≥30% and cerebrovascular symptoms within the last 2 weeks (136 in the training cohort and 57 in the test cohort).

FIELD STRENGTH/SEQUENCE

3.0T, T2-weighted fluid attenuated inversion recovery (T2-FLAIR) and diffusion-weighted imaging (DWI); HRVW-MRI: 3D T1-weighted variable flip angle fast spin-echo sequences (VISTA), T2-weighted VISTA, simultaneous noncontrast angiography and intraplaque hemorrhage (SNAP), and contrast-enhanced T1-VISTA.

ASSESSMENT

The following features of the plaques or vessel wall were assessed by three MRI readers independently: calcification (CA), intraplaque hemorrhage (IPH), lipid-rich necrotic core (LRNC), ulceration, plaque enhancement (PE), maximum vessel diameter (Max VD), maximum wall thickness (Max WT), total vessel area (TVA), lumen area (LA), plaque volume, and lumen stenosis. WMLs were graded visually and categorized as absent-to-mild WMLs (Fazekas score 0-2) or moderate-severe WMLs (Fazekas score 3-6). WML volumes were quantified using a semiautomated volumetric analysis program. Modified Rankin scores (mRS) were assessed at 90 days, following an outpatient interview, or by telephone.

STATISTICAL TESTS

LASSO-logistic regression analysis was performed to construct a model. The performance of the model was evaluated using receiver operating characteristic (ROC) curve analyses, calibration curves, decision curve analyses, and clinical imaging curves. Conditional logistic regression analysis was used to explore the associations between the hybrid model-derived score and the modified Rankin Scale (mRS) score at 90 days.

RESULTS

The model was constructed using five selected features, including IPH, plaque enhancement, ulceration, NWI, and total Fazekas score in deep WMLs (DWMLs). The hybrid model yielded an area under the curve of 0.92 (95% confidence interval [CI] 0.87-0.97) in the training cohort and 0.88 (0.80-0.96) in the test cohort. Furthermore, the hybrid model-derived score (odds ratio = 1.28; 95% CI 1.06-1.53) was independently associated with the mRS score 90 days after stroke.

DATA CONCLUSIONS

The hybrid model constructed using MRI plaque characteristics and WML burden has potential to be an effective noninvasive method of assessing ischemic stroke severity. The model-derived score has promising utility in judging neurological function recovery.

LEVEL OF EVIDENCE: 4

TECHNICAL EFFICACY

Stage 2.

Argatroban plus alteplase in posterior versus anterior circulation stroke

OBJECTIVE

ARAIS trial failed to demonstrate benefit of argatroban as an adjunct to alteplase for stroke. Given differences between anterior circulation stroke (ACS) and posterior circulation stroke (PCS), we performed prespecified secondary analysis to investigate whether benefit of argatroban was different between ACS and PCS.

METHODS

In secondary analysis of ARAIS, patients with definite stroke territories based on responsible vessel examination were classified into ACS and PCS. The primary outcome was a 90-day excellent functional outcome (modified Rankin Scale score of 0 to 1). The efficacy was compared between argatroban plus alteplase and alteplase alone.

RESULTS

This study included 356 patients from the full analysis set of ARAIS trial: 283 in the ACS group and 73 in the PCS group. Compared with alteplase alone, a higher likelihood of 90-day excellent functional outcome was associated with argatroban plus alteplase in PCS group (78.1% versus 61.0%; adjusted RD, 14.4%; 95% CI, 1.6% to 27.2%; p = 0.03), but similar in ACS group (61.7% versus 62.7%; adjusted RD, -2.4%; 95% CI, -10.1% to 5.2%; p = 0.54). After controlling unbalanced sample size bias by propensity score matching, significant interaction between efficacy and stroke territories was found (p = 0.01). The risk of symptomatic intracranial hemorrhage was higher following argatroban plus alteplase than alteplase alone in ACS group (p = 0.02).

INTERPRETATION

Argatroban plus alteplase, compared with alteplase alone, was associated with improved functional outcomes in PCS. This study first demonstrated better benefits of argatroban plus alteplase in PCS, which deserves to be confirmed.

Mobile stroke units based on rural emergency medical stations for pre-hospital intravenous thrombolysis of stroke in remote areas

OBJECTIVES

To explore a novel model of mobile stroke units (MSUs) integrated with rural emergency medical stations for pre-hospital care of stroke patients in remote areas.

METHODS

We used MSUs + Ambulance mode, where both the MSUs and conventional ambulances are sent to the patient's location. The conventional ambulance coordinates with the MSUs to choose the fastest route to meet and transfer the patient at the point along the way. We collected data from 149 patients from March 2022 to April 2023, including National Institutes of Health Stroke Scale (NIHSS) scores (on admission, 24 hours, day 7), 90-day modified Rankin Scale (mRS) scores, and other clinical variables. We performed propensity score matching (PSM) to balance the potential confounding variables between groups.

RESULTS

We found that the MSUs + Ambulance mode (OR = 12.507, 95% confidence interval [CI] [3.633, 43.061], p < 0.001) and admission NIHSS score (OR = 0.583, 95% CI [0.493, 0.690], p < 0.001) were independent prognostic risk factors for stroke patients. The MSUs + Ambulance mode reduced NIHSS scores 7 days prior to admission (OR = 0.679, 95% CI [0.563, 0.819], p < 0.001). After PSM, patients who received MSUs + Ambulance mode had a better prognosis (χ2 = 9.573, p = 0.004), as well as a lower mRS score at 90 days (Z = -3.371, p = 0.001).

CONCLUSIONS

MSUs integrated with rural emergency medical stations show the feasibility and potential benefits of pre-hospital intravenous thrombolysis for stroke patients in geographically distant regions.

Isoliquiritigenin alleviates cerebral ischemia-reperfusion injury by reducing oxidative stress and ameliorating mitochondrial dysfunction via activating the Nrf2 pathway

Cerebral ischemia-reperfusion injury (CIRI) refers to a secondary brain injury that occurs when blood supply is restored to ischemic brain tissue and is one of the leading causes of adult disability and mortality. Multiple pathological mechanisms are involved in the progression of CIRI, including neuronal oxidative stress and mitochondrial dysfunction. Isoliquiritigenin (ISL) has been preliminarily reported to have potential neuroprotective effects on rats subjected to cerebral ischemic insult. However, the protective mechanisms of ISL have not been elucidated. This study aims to further investigate the effects of ISL-mediated neuroprotection and elucidate the underlying molecular mechanism. The findings indicate that ISL treatment significantly alleviated middle cerebral artery occlusion (MCAO)-induced cerebral infarction, neurological deficits, histopathological damage, and neuronal apoptosis in mice. In vitro, ISL effectively mitigated the reduction of cell viability, Na+-K+-ATPase, and MnSOD activities, as well as the degree of DNA damage induced by oxygen-glucose deprivation (OGD) injury in PC12 cells. Mechanistic studies revealed that administration of ISL evidently improved redox homeostasis and restored mitochondrial function via inhibiting oxidative stress injury and ameliorating mitochondrial biogenesis, mitochondrial fusion-fission balance, and mitophagy. Moreover, ISL facilitated the dissociation of Keap1/Nrf2, enhanced the nuclear transfer of Nrf2, and promoted the binding activity of Nrf2 with ARE. Finally, ISL obviously inhibited neuronal apoptosis by activating the Nrf2 pathway and ameliorating mitochondrial dysfunction in mice. Nevertheless, Nrf2 inhibitor brusatol reversed the mitochondrial protective properties and anti-apoptotic effects of ISL both in vivo and in vitro. Overall, our findings revealed that ISL exhibited a profound neuroprotective effect on mice following CIRI insult by reducing oxidative stress and ameliorating mitochondrial dysfunction, which was closely related to the activation of the Nrf2 pathway.

The Role of Platelet Distribution Width in the Association Between Blood Glucose and Neurological Impairment Severity in Acute Ischemic Stroke: A Moderated Mediation Model

Objective

Fasting blood glucose (FBG) is a recognized risk factor for Ischemic Stroke, but little research has examined the interaction among FBG, Platelet Distribution Width (PDW) and the severity of neuronal damage. Thus, the present study constructs a moderated mediation model aimed to elucidate the relationships among FBG, PDW, and NIHSS scores in patients with acute ischemic stroke (AIS).

Methods

We conducted a cross-sectional study on 431 AIS patients. Upon hospital admission, we assessed the patients' NIHSS scores and collected blood samples to measure FBG and PDW levels. The relationship between FBG and NIHSS scores moderated by PDW was analyzed by linear curve fitting analysis, multiple linear regression analysis, and moderated mediation analysis respectively.

Results

In the tertile grouping based on FBG, both PDW and NIHSS scores of AIS patients demonstrated an increase corresponding with rising levels of FBG (p<0.001 for both). Multiple linear regression analysis revealed that, the β coefficients (95% CI) for the relationship between FBG and NIHSS scores were 1.49 (1.27-1.71, p<0.01) post-adjustment for potential confounders. The β coefficients (95% CI) for the relationship between FBG and PDW were 0.02 (0.01-0.04, p<0.01) post-adjustment. Likewise, for the relationship between PDW and NIHSS scores, the β coefficients (95% CI) were 4.33 (3.07-5.59, p<0.01) after adjustment. These positive association remained consistent in sensitivity analysis and hierarchical analysis. Smoothed plots suggested that there are linear relationships between FBG and PDW and NIHSS scores respectively. Further mediation analysis indicated that increased PDW significantly (p<0.01) mediated 5.91% of FBG-associated increased NIHSS scores.

Conclusion

This study suggested that FBG levels were associated with NIHSS scores, and the FBG-associated neurological impairment may be partially mediated by PDW. These findings underscore the importance of monitoring FBG and PDW levels in AIS patients, potentially guiding risk intervention strategies.

One-Year Disability Trajectories and Long-Term Cardiovascular Events, Recurrent Stroke, and Mortality After Ischemic Stroke

BACKGROUND

Patients with stroke are often affected by varying degrees of functional disability and have different evolution patterns in functional disability. However, little is known about the predictive usefulness of disability changes after stroke. We aimed to describe 1-year disability trajectories and to assess the associations of longitudinal disability trajectories with 24-month clinical outcomes after ischemic stroke.

METHODS AND RESULTS

A total of 3533 patients with ischemic stroke from CATIS (China Antihypertensive Trial in Acute Ischemic Stroke) were studied. Distinct trajectories of disability were identified by the group-based trajectory model, as measured by modified Rankin Scale score within 12 months. Cox proportional hazards regression models were used to examine the associations of disability trajectories with 24-month cardiovascular events and all-cause mortality. We identified 4 distinct disability trajectories: no significant disability (562 participants [15.9%]), slight disability to recovery (1575 participants [44.6%]), severe to moderate disability (1087 participants [30.8%]), and persistent severe disability (309 participants [8.7%]). Compared with no significant disability trajectory, the multivariable adjusted hazard ratios (95% CIs) of patients within the persistent heavy-severe trajectory were 2.63 (1.20-5.76) for cardiovascular events, 2.55 (1.12-5.79) for recurrent stroke, and 6.10 (2.22-16.72) for all-cause mortality; notably, the hazard ratios (95% CIs) for patients within the severe to moderate disability trajectory were 1.99 (1.01-3.94) for cardiovascular events and 1.85 (1.03-3.33) for the composite outcome of cardiovascular events and all-cause mortality.

CONCLUSIONS

Functional disability trajectories within 12 months after stroke onset were associated with the risk of 24-month adverse outcomes. Patients with persistent severe disability or severe to moderate disability had higher risk of cardiovascular events and all-cause mortality.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01840072.

Short-Term and Long-Term Risk of Recurrent Vascular Event by Cause After Ischemic Stroke in Young Adults

Importance

Cause of ischemic stroke in young people is highly variable; however, the risk of recurrence is often presented with all subtypes of stroke grouped together in classification systems such as the Trial of ORG (danaparoid sodium [Orgaran]) 10172 in Acute Stroke Treatment (TOAST) criteria, which limits the ability to individually inform young patients with stroke about their risk of recurrence.

Objective

To determine the short-term and long-term risk of recurrent vascular events after ischemic stroke at a young age by stroke cause and to identify factors associated with recurrence.

Design, Setting, and Participants

This cohort study used data from the Observational Dutch Young Symptomatic Stroke Study, a prospective, multicenter, hospital-based cohort study, conducted at 17 hospitals in the Netherlands between 2013 and 2021. Eligible participants included 30-day survivors of an initial, neuroimaging-proven ischemic stroke (aged 18-49 years). Data analysis was conducted from June to July 2023.

Exposure

Diagnosis of a first-ever, ischemic stroke via neuroimaging.

Main Outcome and Measures

The primary outcome was short-term (within 6 months) and long-term (within 5 years) recurrence risk of any vascular event, defined as fatal or nonfatal recurrent ischemic stroke, transient ischemic attack, myocardial infarction, and revascularization procedure. Predefined characteristics were chosen to identify factors associated with risk of recurrence (cause of stroke, age, sex, stroke severity, and cardiovascular health factors).

Results

A total of 1216 patients (median [IQR] age, 44.2 [38.4-47.7] years; 632 male [52.0%]; 584 female [48.0%]) were included, with a median (IQR) follow-up of 4.3 (2.6-6.0) years. The 6-month risk of any recurrent ischemic event was 6.7% (95% CI, 5.3%-8.1%), and the 5-year risk was 12.2% (95% CI, 10.2%-14.2%)The short-term risk was highest for patients with cervical artery dissections (13.2%; 95% CI, 7.6%-18.7%). Other factors associated with a recurrent short-term event were atherothrombotic stroke, rare causes of stroke, and hypertension. The long-term cumulative risk was highest for patients with atherothrombotic stroke (22.7%; 95% CI, 10.6%-34.7%) and lowest for patients with cryptogenic stroke (5.8%; 95% CI, 3.0%-8.5%). Cardioembolic stroke was associated with a recurrent long-term event, as were diabetes and alcohol abuse.

Conclusions and Relevance

The findings of this cohort study of 1216 patients with an ischemic stroke at a young age suggest that the risk of recurrent vascular events was high and varied by cause of stroke both for short-term and long-term follow-up, including causes that remained concealed when combined into 1 category in the routinely used TOAST criteria. This knowledge will allow for more personalized counseling of young patients with stroke.

[Dynamic functional assessment of internal carotid artery tortuosity in patients with multifocal atherosclerosis]

A personalized approach with attention to anamnesis and specific symptoms is necessary in patients with internal carotid artery tortuosity. Neuroimaging (especially before elective surgery) or functional stress tests following ultrasound of supra-aortic vessels may be necessary depending on medical history and complaints. In addition to standard Doppler ultrasound, these patients should undergo rotational and orthostatic transformation tests. We analyze changes in shape and hemodynamic parameters within the tortuosity area in various body positions. This is especially valuable for patients with concomitant carotid artery stenosis. The article presents a clinical case illustrating the importance of such approach.

[Functional assessment of internal carotid artery tortuosity in patients with multifocal atherosclerosis]

The review is devoted to diagnosis and treatment of internal carotid artery tortuosity. The authors consider modern classification, epidemiology and diagnostic options using neuroimaging or ultrasound-assisted functional stress tests depending on medical history and complaints. In addition to standard Doppler ultrasound, rotational and orthostatic tests are advisable due to possible changes of local shape and hemodynamic parameters following body position changes, especially in patients with concomitant atherosclerotic stenosis. Thus, a personalized approach is especially important for treatment and diagnostics of internal carotid artery tortuosity.