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Long B, Marcolini E, Gottlieb M. Emergency medicine updates: Transient ischemic attack. Am J Emerg Med 2024; 83:82-90. [PMID: 38986211 DOI: 10.1016/j.ajem.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/07/2024] [Accepted: 06/12/2024] [Indexed: 07/12/2024] Open
Abstract
INTRODUCTION Transient ischemic attack (TIA) is a condition commonly evaluated for in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning TIA for the emergency clinician. DISCUSSION TIA is a harbinger of ischemic stroke and can result from a variety of pathologic causes. While prior definitions incorporated symptoms resolving within 24 h, modern definitions recommend a tissue-based definition utilizing advanced imaging to evaluate for neurologic injury and the etiology. In the ED, emergent evaluation includes assessing for current signs and symptoms of neurologic dysfunction, appropriate imaging to investigate for minor stroke or stroke risk, and arranging appropriate disposition and follow up to mitigate risk of subsequent ischemic stroke. Imaging should include evaluation of great vessels and intracranial arteries, as well as advanced cerebral imaging to evaluate for minor or subclinical stroke. Non-contrast computed tomography (CT) has limited utility for this situation; it can rule out hemorrhage or a large mass causing symptoms but should not be relied on for any definitive diagnosis. Noninvasive imaging of the cervical vessels can also be used (CT angiography or Doppler ultrasound). Treatment includes antithrombotic medications if there are no contraindications. Dual antiplatelet therapy may reduce the risk of recurrent ischemic events in higher risk patients, while anticoagulation is recommended in patients with a cardioembolic source. A variety of scoring systems or tools are available that seek to predict stroke risk after a TIA. The Canadian TIA risk score appears to have the best diagnostic accuracy. However, these scores should not be used in isolation. Disposition may include admission, management in an ED-based observation unit with rapid diagnostic protocol, or expedited follow-up in a specialty clinic. CONCLUSIONS An understanding of literature updates concerning TIA can improve the ED care of patients with TIA.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Evie Marcolini
- Department of Emergency Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Marinheiro G, Araújo B, Monteiro GDA, Leite M, Mutarelli A, Almeida AMD, Cavalcante-Neto JF, Rivera A, Pinheiro AC, Telles JPM. Ticagrelor versus clopidogrel in dual antiplatelet therapy after minor stroke or transient ischemic attack: an updated network meta-analysis. J Neurol 2024; 271:3030-3038. [PMID: 38580815 DOI: 10.1007/s00415-024-12330-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/10/2024] [Accepted: 03/11/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) with clopidogrel plus aspirin is a well-established practice after a minor stroke or transient ischemic attack (TIA). However, ticagrelor plus aspirin may be an alternative. AIMS We systematically searched PubMed, Embase, and Cochrane Central from inception to January 2024. We included randomized controlled trials (RCTs) enrolling adults with acute minor stroke or TIA within 72 hours of the onset of the symptoms. RESULTS A total of 8 RCTs were included in our meta-analysis. Ticagrelor plus aspirin (RR, 0.70; 95% CrI 0.52, 0.91) and clopidogrel plus aspirin (RR, 0.79; 95% CrI 0.64, 0.98) were superior to aspirin in preventing stroke recurrence in overall analysis. Excluding studies with dual antiplatelet up to 90 days, ticagrelor plus aspirin was the only strategy that maintained superiority compared with aspirin regarding stroke recurrence (RR, 0.70; 95% CrI 0.51, 0.95) and ischemic stroke (RR, 0.68; 95% CrI 0.47, 0.94). There was no significant difference between treatment groups regarding hemorrhagic stroke, functional disability, and mortality. CONCLUSIONS DAPTs were superior to aspirin in preventing recurrence or ischemic stroke. Although no significant difference was observed between DAPTs, ticagrelor plus aspirin may be related to worse major bleeding results, including intracranial bleeding. Ticagrelor plus aspirin is a considerable option for patients after a minor stroke or TIA.
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Affiliation(s)
| | - Beatriz Araújo
- Department of Medicine, Nove de Julho University, São Bernardo do Campo, Brazil
| | | | - Marianna Leite
- School of Medicine, Santa Marcelina College, São Paulo, Brazil
| | - Antonio Mutarelli
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | | | - André Rivera
- Department of Medicine, Nove de Julho University, São Bernardo do Campo, Brazil
| | - Agostinho C Pinheiro
- Department of Neurology, Brigham and Women's Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, New York, USA
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Feng X, Fang H, Ip BYM, Chan KL, Li S, Tian X, Zheng L, Liu Y, Lan L, Liu H, Abrigo J, Ma SH, Fan FSY, Ip VHL, Soo YOY, Mok VCT, Song B, Leung TW, Xu Y, Leng X. Cerebral Hemodynamics Underlying Artery-to-Artery Embolism in Symptomatic Intracranial Atherosclerotic Disease. Transl Stroke Res 2024; 15:572-579. [PMID: 36897543 DOI: 10.1007/s12975-023-01146-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 02/13/2023] [Accepted: 02/27/2023] [Indexed: 03/11/2023]
Abstract
Artery-to-artery embolism (AAE) is a common stroke mechanism in intracranial atherosclerotic disease (ICAD), associated with a considerable risk of recurrent stroke. We aimed to investigate cerebral hemodynamic features associated with AAE in symptomatic ICAD. Patients with anterior-circulation, symptomatic ICAD confirmed in CT angiography (CTA) were recruited. We classified probable stroke mechanisms as isolated parent artery atherosclerosis occluding penetrating artery, AAE, hypoperfusion, and mixed mechanisms, largely based on infarct topography. CTA-based computational fluid dynamics (CFD) models were built to simulate blood flow across culprit ICAD lesions. Translesional pressure ratio (PR = Pressurepost-stenotic/Pressurepre-stenotic) and wall shear stress ratio (WSSR = WSSstenotic-throat/WSSpre-stenotic) were calculated, to reflect the relative, translesional changes of the two hemodynamic metrics. Low PR (PR ≤ median) and high WSSR (WSSR ≥ 4th quartile) respectively indicated large translesional pressure and elevated WSS upon the lesion. Among 99 symptomatic ICAD patients, 44 had AAE as a probable stroke mechanism, 13 with AAE alone and 31 with coexisting hypoperfusion. High WSSR was independently associated with AAE (adjusted OR = 3.90; P = 0.022) in multivariate logistic regression. There was significant WSSR-PR interaction on the presence of AAE (P for interaction = 0.013): high WSSR was more likely to associate with AAE in those with low PR (P = 0.075), but not in those with normal PR (P = 0.959). Excessively elevated WSS in ICAD might increase the risk of AAE. Such association was more prominent in those with large translesional pressure gradient. Hypoperfusion, commonly coexisting with AAE, might be a therapeutic indicator for secondary stroke prevention in symptomatic ICAD with AAE.
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Affiliation(s)
- Xueyan Feng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Hui Fang
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- NHC Key Laboratory of Prevention and Treatment of Cerebrovascular Diseases, Zhengzhou, China
| | - Bonaventure Y M Ip
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Ka Lung Chan
- Department of Neurology, the First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shuang Li
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Xuan Tian
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Lina Zheng
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yuying Liu
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Linfang Lan
- Department of Neurology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Haipeng Liu
- Research Centre for Intelligent Healthcare, Faculty of Health and Life Sciences, Coventry University, Coventry, UK
| | - Jill Abrigo
- Department of Imaging and Interventional Radiology, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Sze Ho Ma
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Florence S Y Fan
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Vincent H L Ip
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yannie O Y Soo
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Vincent C T Mok
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Bo Song
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- NHC Key Laboratory of Prevention and Treatment of Cerebrovascular Diseases, Zhengzhou, China
| | - Thomas W Leung
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yuming Xu
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
- NHC Key Laboratory of Prevention and Treatment of Cerebrovascular Diseases, Zhengzhou, China.
| | - Xinyi Leng
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China.
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Dmytriw AA, Ku J, Azzam AY, Elamin O, Cancelliere N, Kapadia A, Rabinov JD, Stapleton CJ, Regenhardt RW, Pereira VM, Patel AB, Yang VX. Intracranial stenting compared to medical treatment alone for intracranial atherosclerosis patients: An updated meta-analysis. J Cerebrovasc Endovasc Neurosurg 2024; 26:152-162. [PMID: 38018077 PMCID: PMC11220295 DOI: 10.7461/jcen.2023.e2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 09/05/2023] [Accepted: 09/08/2023] [Indexed: 11/30/2023] Open
Abstract
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.
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Affiliation(s)
- Adam A. Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women’s Hospital, Harvard Medical School, Boston MA, USA
- Neurovascular Centre, Departments of Medical Imaging & Surgery, Sunnybrook Health Sciences Centre and St. Michael’s Hospital, University of Toronto, Toronto ON, Canada
| | - Jerry Ku
- Neurovascular Centre, Departments of Medical Imaging & Surgery, Sunnybrook Health Sciences Centre and St. Michael’s Hospital, University of Toronto, Toronto ON, Canada
| | - Ahmed Y. Azzam
- Nested Knowledge, Department of Neuroradiology, Mayo Clinic, Rochester MN, USA
| | - Osman Elamin
- Nested Knowledge, Department of Neuroradiology, Mayo Clinic, Rochester MN, USA
| | - Nicole Cancelliere
- Neurovascular Centre, Departments of Medical Imaging & Surgery, Sunnybrook Health Sciences Centre and St. Michael’s Hospital, University of Toronto, Toronto ON, Canada
| | - Anish Kapadia
- Neurovascular Centre, Departments of Medical Imaging & Surgery, Sunnybrook Health Sciences Centre and St. Michael’s Hospital, University of Toronto, Toronto ON, Canada
| | - James D. Rabinov
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women’s Hospital, Harvard Medical School, Boston MA, USA
| | - Christopher J. Stapleton
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women’s Hospital, Harvard Medical School, Boston MA, USA
| | - Robert W. Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women’s Hospital, Harvard Medical School, Boston MA, USA
| | - Vitor Mendes Pereira
- Neurovascular Centre, Departments of Medical Imaging & Surgery, Sunnybrook Health Sciences Centre and St. Michael’s Hospital, University of Toronto, Toronto ON, Canada
| | - Aman B. Patel
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women’s Hospital, Harvard Medical School, Boston MA, USA
| | - Victor X.D. Yang
- Neurovascular Centre, Departments of Medical Imaging & Surgery, Sunnybrook Health Sciences Centre and St. Michael’s Hospital, University of Toronto, Toronto ON, Canada
- Neurointerventional Program, Departments of Medical Imaging & Clinical Neurological Sciences, London Health Sciences Centre, Western University, London ON, Canada
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Pannell JS, Corey AS, Shih RY, Austin MJ, Chu S, Davis MA, Ducruet AF, Hunt CH, Ivanidze J, Kalnins A, Lacy ME, Lo BM, Setzen G, Shaines MD, Soares BP, Soderlund KA, Thaker AA, Wang LL, Burns J. ACR Appropriateness Criteria® Cerebrovascular Diseases-Stroke and Stroke-Related Conditions. J Am Coll Radiol 2024; 21:S21-S64. [PMID: 38823945 DOI: 10.1016/j.jacr.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
Cerebrovascular disease encompasses a vast array of conditions. The imaging recommendations for stroke-related conditions involving noninflammatory steno-occlusive arterial and venous cerebrovascular disease including carotid stenosis, carotid dissection, intracranial large vessel occlusion, and cerebral venous sinus thrombosis are encompassed by this document. Additional imaging recommendations regarding complications of these conditions including intraparenchymal hemorrhage and completed ischemic strokes are also discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Amanda S Corey
- Panel Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia
| | - Robert Y Shih
- Panel Vice Chair, Uniformed Services University, Bethesda, Maryland
| | | | - Sammy Chu
- University of Washington, Seattle, Washington; University of British Columbia, Vancouver, British Columbia, Canada
| | - Melissa A Davis
- Yale University School of Medicine, New Haven, Connecticut; Committee on Emergency Radiology-GSER
| | - Andrew F Ducruet
- Barrow Neurological Institute, Phoenix, Arizona, Neurosurgery expert
| | - Christopher H Hunt
- Mayo Clinic, Rochester, Minnesota; Commission on Nuclear Medicine and Molecular Imaging
| | | | | | - Mary E Lacy
- Washington State University, Spokane, Washington; American College of Physicians
| | - Bruce M Lo
- Sentara Norfolk General Hospital/Eastern Virginia Medical School, Norfolk, Virginia; American College of Emergency Physicians
| | - Gavin Setzen
- Albany ENT & Allergy Services, Albany, New York; American Academy of Otolaryngology-Head and Neck Surgery
| | - Matthew D Shaines
- Albert Einstein College of Medicine Montefiore Medical Center, Bronx, New York, Primary care physician
| | - Bruno P Soares
- Stanford University School of Medicine, Stanford, California
| | - Karl A Soderlund
- Uniformed Services University of the Health Sciences, Bethesda, Maryland; Naval Medical Center Portsmouth, Portsmouth, Virginia
| | | | - Lily L Wang
- University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Judah Burns
- Specialty Chair, Montefiore Medical Center, Bronx, New York
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Qureshi AI, Lodhi A, Ma X, Ahmed R, Kwok CS, Maqsood H, Liaqat J, Hassan AE, Siddiq F, Gomez CR, Suri MFK. Self-expanding versus balloon expandable stent for intracranial arterial stenosis: A systematic review and meta-analysis. J Neuroimaging 2024; 34:295-307. [PMID: 38225680 DOI: 10.1111/jon.13188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/12/2023] [Accepted: 12/22/2023] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND AND PURPOSE There are limited data regarding the comparison of balloon expandable stents (BES) and self-expanding stents (SES) for the treatment of intracranial arterial stenosis. METHODS We conducted a systematic review to identify studies that compared SES and BES in patients with symptomatic intracranial arterial stenosis. Data were extracted from relevant studies found through a search of PubMed, Scopus, and Web of Science until from January 1, 2010 to September 28, 2023. Statistical pooling with random-effects meta-analysis was undertaken to compare the rates/severity of postprocedure stenosis, technical success, 30-day stroke and/or death, cumulative clinical endpoints, and restenosis rates. RESULTS A total of 20 studies were included. The standardized mean difference (SMD) for postprocedure stenosis (%) was significantly lower (SMD: -0.52, 95% confidence interval [CI]: -0.79 to -0.24, p < .001, 10 studies involving 1515 patients) with BES. The odds for 30-day stroke and/or death were significantly lower (odds ratio [OR] 0.68, 95% CI: 0.50-0.94, p = .019, 15 studies involving 2431 patients), and cumulative clinical endpoints on follow-up were nonsignificantly lower (OR 0.64, 95% CI: 0.30-1.37, p = .250, 10 studies involving 947 patients) with BES. The odds for restenosis during follow-up were significantly lower (OR 0.50, 95% CI: 0.31-0.80, p = .004, 13 studies involving 1115 patients) with BES. CONCLUSIONS Compared with SES, BES were associated with lower rates of postprocedure 30-day stroke and/or death with lower rates of restenosis during follow up and the treatment of symptomatic intracranial arterial stenosis.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Abdullah Lodhi
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Xiaoyu Ma
- Department of Biostatistics, University of Missouri, Columbia, Missouri, USA
| | - Rehan Ahmed
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Chun Shing Kwok
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham NHS Trust, Birmingham, UK
| | - Hamza Maqsood
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Jahanzeb Liaqat
- Department of Neurology, Pak Emirates Military Hospital Rawalpindi, Rawalpindi, Pakistan
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley School of Medicine, Harlingen, Texas, USA
| | - Farhan Siddiq
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Camilo R Gomez
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - M Fareed K Suri
- Stroke Program, St. Cloud Hospital, Minneapolis, Minnesota, USA
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Liu C, Liu M, Yang X, Luo T, Wang J, Li G. The efficacy and safety of aspirin-ticagrelor vs. aspirin-clopidogrel in ischemic stroke patients with cerebral artery stenting. Clin Neurol Neurosurg 2024; 239:108229. [PMID: 38479036 DOI: 10.1016/j.clineuro.2024.108229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/04/2024] [Accepted: 03/02/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE First, the efficacy and safety of aspirin-ticagrelor after cerebral artery stenting in ischemic stroke patients is controversial. Second, there is a gap in the research on guiding two antiplatelet therapy (DAPT) after stenting based on the CYP2C19 genotype. METHODS This retrospective study included patients who underwent cerebral artery stenting at the First Affiliated Hospital of Chongqing Medical University from January 2019 to February 2023. We divided them into the aspirin-clopidogrel group and aspirin-ticagrelor group and carefully collected baseline information laboratory data and imaging results from the patients. The efficacy outcomes were 30 days recurrent stroke, 90 days recurrent stroke, and 180 days recurrent stroke, and the safety outcome was intracranial hemorrhage. T-tests or Fisher's tests were performed for study outcomes in both groups of patients. OUTCOME A total of 372 patients were included. For efficacy outcomes, aspirin-ticagrelor was associated with a reduced risk of 180 days recurrent stroke, in patients with CYP2C19 LOF allele (OR = 0.426, CI = 0.184-0.986, P = 0.042) and CYP2C19 intermediate metabolic genotype (OR = 0.237, CI = 0.026-1.034, P = 0.044), compared with aspirin-clopidogrel. There was no significant difference in the rate of intracranial hemorrhage (ICH) between patients with aspirin-clopidogrel and aspirin-ticagrelor, regardless of overall (OR = 1.221, CI = 0.115-7.245, P = 0.683), CYP2C19 LOF allele carriers (OR = 1.226, CI = 0.411-3.658, P = 0.715), or CYP2C19 intermediate metabolizer (OR = 1.221, CI = 0.115-7.245, P = 0.683). No significant differences were found between the two DAPTs on other efficacy and safety outcomes. CONCLUSION A cohort study found that aspirin-ticagrelor was significantly superior to aspirin-clopidogrel in reducing 180 days recurrent stroke in CYP2C19 LOF allele carriers and CYP2C19 intermediate metabolizers. There was no significant difference between aspirin-ticagrelor and aspirin-clopidogrel in the risk of intracranial hemorrhage in terms of ICH rates.
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Affiliation(s)
- Chenxi Liu
- Department of Neurology, The Frist Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Mingsu Liu
- Department of Neurology, Zhongshan Hospital Affiliated to Fudan University, Shanghai 200032, China.
| | - Xun Yang
- Department of Neurology, Hechuan District People's Hospital, Chongqing 401500, China.
| | - Tingting Luo
- Department of Neurology, The Frist Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Jinping Wang
- Department of Neurology, Chongqing University Central Hospital, Chongqing 400050, China.
| | - Guangqin Li
- Department of Neurology, The Frist Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
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Berghout BP, Camarasa RY, Van Dam-Nolen DH, van der Lugt A, de Bruijne M, Koudstaal PJ, Ikram MK, Bos D. Burden of intracranial artery calcification in white patients with ischemic stroke. Eur Stroke J 2024:23969873241239787. [PMID: 38506452 DOI: 10.1177/23969873241239787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024] Open
Abstract
INTRODUCTION The diagnostic workup of stroke doesn't identify an underlying cause in two-fifths of ischemic strokes. Intracranial arteriosclerosis is acknowledged as a cause of stroke in Asian and Black populations, but is underappreciated as such in whites. We explored the burden of Intracranial Artery Calcification (IAC), a marker of intracranial arteriosclerosis, as a potential cause of stroke among white patients with recent ischemic stroke or TIA. PATIENTS AND METHODS Between December 2005 and October 2010, 943 patients (mean age 63.8 (SD ± 14.0) years, 47.9% female) were recruited, of whom 561 had ischemic stroke and 382 a TIA. CT-angiography was conducted according to stroke analysis protocols. The burden of IAC was quantified on these images, whereafter we assessed the presence of IAC per TOAST etiology underlying the stroke and assessed associations between IAC burden, symptom severity, and short-term functional outcome. RESULTS IAC was present in 62.4% of patients. Furthermore, IAC was seen in 84.8% of atherosclerotic strokes, and also in the majority of strokes with an undetermined etiology (58.5%). Additionally, patients with larger IAC burden presented with heavier symptoms (adjusted OR 1.56 (95% CI [1.06-2.29]), but there was no difference in short-term functional outcome (1.14 [0.80-1.61]). CONCLUSION IAC is seen in the majority of white ischemic stroke patients, aligning with findings from patient studies in other ethnicities. Furthermore, over half of patients with a stroke of undetermined etiology presented with IAC. Assessing IAC burden may help identify the cause in ischemic stroke of undetermined etiology, and could offer important prognostic information.
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Affiliation(s)
- Bernhard P Berghout
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Robin Yr Camarasa
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Dianne Hk Van Dam-Nolen
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marleen de Bruijne
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | - Peter J Koudstaal
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - M Kamran Ikram
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Daniel Bos
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
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Dharia AA, Byer SH, Le K, Chen X, Abraham N, Hunt S, Abraham MG. A Systematic Review and Meta-Analysis of Drug Eluting Stents for Safety and Efficacy in Intracranial Atherosclerotic Disease. Int J Neurosci 2024:1-11. [PMID: 38372660 DOI: 10.1080/00207454.2024.2313013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 01/27/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Advancements in arterial stenting technology have challenged prior notions favoring medical management for intracranial atherosclerotic disease (ICAD). Where previous conclusions were drawn from bare metal stent (BMS) technology, recent studies suggest drug-eluting stents (DES) are favorable due to their anti-proliferative effect, which reduces vascular remodeling. METHODS We conducted a systematic review and meta-analysis of the literature prior to August 2023 reviewing all reports of ICAD treated with DES. Our target outcomes were incidence of any stroke, transient ischemic attack (TIA), or death within 30 days (postprocedural complications), ischemic stroke in the territory of the qualifying artery beyond 30 days (long-term complications), radiographically detected in-stent restenosis rate (ISR), and symptomatic ISR during follow-up. A subgroup analysis further stratified preprocedural mean stenosis above and below 70% into severe and moderate cohorts, respectively. RESULTS PubMed, Web of Science, Cochrane and EMBASE query identified 527 candidate articles, from which 14 studies met inclusion criteria for a total of 607 patients and 640 ICAD lesions. Incidence of postprocedural complications was 7.3% (95% CI 3.9-11.7%) with subgroup analysis demonstrating significantly higher incidence in the severely stenotic group [9.0% (95% CI 4.7-14.5%)] than the moderately stenotic group [3.0% (95% CI 0.7-6.8%)]. Long-term complications were 1.2% (95% CI 0.4-2.3%). Radiographic ISR was 3.5% (95% CI 1.4-6.3%) and symptomatic ISR was 0.3% (95% CI 0.0-1.5%). CONCLUSIONS Our systematic review and meta-analysis suggest that DES can effectively reduce the risk of ISR and may be a viable treatment modality to reduce long-term complications in refractory ICAD patients.
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Affiliation(s)
- Anand A Dharia
- Department of Neurosurgery, The University of KS Medical Center, Kansas City, Kansas, USA
| | - Stefano H Byer
- Department of Neurology, The University of Kansas Medical Center, Kansas City, Kansas, USA
- School of Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Kevin Le
- Department of Neurology, The University of Kansas Medical Center, Kansas City, Kansas, USA
- School of Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Xi Chen
- Department of Biostatistics, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Nihil Abraham
- Department of Neurology, The University of Kansas Medical Center, Kansas City, Kansas, USA
- School of Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Suzanne Hunt
- Department of Biostatistics, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Michael G Abraham
- Department of Neurology, The University of Kansas Medical Center, Kansas City, Kansas, USA
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10
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Wabnitz AM, Turan TN. Optimal Medical Management of Atherosclerotic Intracranial Stenosis. Stroke 2024; 55:335-343. [PMID: 38252762 DOI: 10.1161/strokeaha.123.043633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Reducing the high risk of recurrent stroke in patients with symptomatic intracranial atherosclerotic stenosis (sICAS) has proven to be challenging, but aggressive medical management, with intensive risk factor control and antithrombotic therapy, has been shown to be beneficial. High-intensity statins are recommended for patients with atherosclerotic stroke, including sICAS. Ezetimibe and PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors are beneficial for those who fail to reach low-density lipoprotein targets or those with statin intolerance. The treatment target for sICAS is low-density lipoprotein <70 mg/dL. In neurologically stable patients, blood pressure should be treated to goal <140/90 mm Hg with the use of thiazide diuretics, angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers preferentially. For those with diabetes, treat to goal hemoglobin A1C ≤7% for most patients through combination of diet, insulin, and hypoglycemic drugs. Some degree of physical activity (eg, walking, stationary biking with arms or legs, etc) should be encouraged in all patients with sICAS who are not severely disabled. A minimum of 10 minutes of moderate-intensity aerobic activity 4 times a week is recommended for patients who are capable of exercise. For all patients with severe sICAS (70%-99% stenosis), dual antiplatelet therapy for up to 90 days followed by single antiplatelet agent is recommended.
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Affiliation(s)
- Ashley M Wabnitz
- Department of Neurology, Medical University of South Carolina, Charleston
| | - Tanya N Turan
- Department of Neurology, Medical University of South Carolina, Charleston
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11
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de Havenon A, Turan TN. Past, Present, and Future of Intracranial Atherosclerosis Treatment. Stroke 2024; 55:471-473. [PMID: 38152957 PMCID: PMC10842205 DOI: 10.1161/strokeaha.123.044270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Affiliation(s)
- Adam de Havenon
- Department of Neurology, Yale University School of Medicine, New Haven, CT (A.d.H.)
| | - Tanya N Turan
- Department of Neurology, Medical University of South Carolina, Charleston (T.N.T.)
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12
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Li A, Ye Z, Zhou W, Qin C. Short-term outcome of stenting with Enterprise stents for symptomatic intracranial atherosclerotic disease at a single center. Interv Neuroradiol 2023; 29:731-737. [PMID: 36259331 PMCID: PMC10680965 DOI: 10.1177/15910199221133166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/29/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate the safety and efficacy of stenting for symptomatic intracranial atherosclerotic severe stenosis or occlusion with Enterprise stents. METHODS Fifty-three consecutive patients with symptomatic intracranial atherosclerotic severe (70%-99%) stenosis or occlusion who underwent endovascular treatment with Enterprise stents between September 2019 and March 2022 were retrospectively analyzed. Primary outcomes included technical stenting success rates, the incidence of complications within 30 days of the procedure, and the in-stent restenosis rates during the follow-up period. These outcomes were further categorized based on lesion location and operation time. RESULTS Fifty-seven lesions in 53 patients aged 61.0 ± 10.0 years were treated with Enterprise stents with a technical success rate of 100%. Seven patients (12.3%) had severe complications within 30 days of the procedure: five had a symptomatic ischemic stroke, one had a symptomatic intracerebral hemorrhage, and one had a subarachnoid hemorrhage related to the procedure. No deaths were observed. The rate of in-stent restenosis was 18.2%, with a mean vascular imaging follow-up period of 6.7 months. The 30-day complication and in-stent restenosis rates did not differ significantly between patients with different lesion locations and operation times (P > 0.05). CONCLUSION This retrospective study suggests that percutaneous transluminal angioplasty and stenting with Enterprise stents is an effective treatment for symptomatic intracranial arterial stenosis or occlusion with a high technical success rate. It also indicates that stenting during the early nonacute stage after stroke may not increase the incidence of perioperative complications for symptomatic intracranial atherosclerotic stenosis when following strict inclusion criteria.
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Affiliation(s)
- Aiping Li
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
- Department of Neurology, Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, Hunan, China
| | - Ziming Ye
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Wensheng Zhou
- Department of Neurology, Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, Hunan, China
| | - Chao Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
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13
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Mongold S, Long B. What Is the Efficacy of Endovascular Therapy With Medical Management Compared With That of Medical Management Alone for Patients With Basilar Occlusion Stroke? Ann Emerg Med 2023; 82:752-755. [PMID: 37389493 DOI: 10.1016/j.annemergmed.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/19/2023] [Accepted: 05/24/2023] [Indexed: 07/01/2023]
Affiliation(s)
- Sarah Mongold
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX
| | - Brit Long
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX
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14
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Malferrari G, Merli N, Inchingolo V, Siniscalchi A, Laterza D, Monaco D, Arnone G, Zini A, Prada F, Azzini C, Pugliatti M. Role of Advanced Hemodynamic Ultrasound Evaluation in the Differential Diagnosis of Middle Cerebral Artery Stenosis: Introducing Morphological Criteria. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:2428-2435. [PMID: 37550172 DOI: 10.1016/j.ultrasmedbio.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 06/28/2023] [Accepted: 07/09/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE The aim of the work described here was to determine the possible impact of the new technique advanced hemodynamic ultrasound evaluation (AHUSE) in identification of severe intracranial stenosis. Transcranial Doppler (TCD) and transcranial color-coded Doppler (TCCD) provide reliable velocimetric data, the indirect analysis of which allows us to obtain information on the patency of vessels and assumed stenosis range. However, very tight stenoses (>95%) cannot be detected with velocimetric criteria because of spectrum drops and the absence of high velocities, so that the right curve of the Spencer equation cannot be solved. Likewise, high velocities are not detected when analyzing morphologically long stenosis. Furthermore, the current classifications based on velocimetric criteria do not provide any categorization on stenoses with multiple acceleration points (MAPs). METHODS With this Technical Note we aim to introduce, in addition to velocimetric criteria, more morphological criteria based on TCCD with the algorithm of AHUSE to optimize the characterization of intracranial stenosis (IS). TCCD-AHUSE relies on intensity-based next-generation techniques and can be used to identify IS with MAPs and simultaneously perform a morphological assessment of the stenosis length. RESULTS We introduce a new technical ultrasound (U) approach that we tested in a sample of four different types of stenoses combining velocimetric data and AHUSE using Esaote Microvascularization (MicroV) technique to the M1 tract of the middle cerebral artery (MCA). CONCLUSION The authors believe that a multiparametric evaluation is more sensitive and supports the clinician by introducing the morphological concept, not just the velocimetric concept, to differentiate the IS pattern of MCA. The potential for developing a diagnostic/prognostic algorithm is discussed.
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Affiliation(s)
- Giovanni Malferrari
- Stroke Unit and Neurology Unit, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy.
| | - Nicola Merli
- Department of Neuroscience and Rehabilitation, University of Ferrara, Italy
| | - Vincenzo Inchingolo
- Neurology Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Antonio Siniscalchi
- Department of Neurology and Stroke Unit, Annunziata Hospital, Cosenza, Italy
| | - Domenico Laterza
- Neurology and Stroke Unit, Nuovo Ospedale degli Infermi, Biella (BI), Italy
| | - Daniela Monaco
- Department of Emergency Neurology and Stroke Unit, "S. Spirito" Hospital, Pescara, Italy
| | - Giorgia Arnone
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, Bologna, Italy
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, Bologna, Italy
| | - Francesco Prada
- Acoustic Neuroimaging and Therapy Lab, Fondazione IRCCS Istituto Neurologico C. Besta, Milano, Italy; Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA; Focused Ultrasound Foundation, Charlottesville, VA, USA
| | - Cristiano Azzini
- Stroke Unit and Neurology Unit, S. Anna University Hospital, Ferrara Italy
| | - Maura Pugliatti
- Department of Neuroscience and Rehabilitation, University of Ferrara, Italy; S. Anna University Hospital, Ferrara Italy
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15
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Liu Z, Zhang WW, Dai P, Long X, Shen L, Luo YB. Clinical Reasoning: A 74-Year-Old Woman Presenting With Monocular Ptosis and Binocular Diplopia. Neurology 2023; 101:e1753-e1758. [PMID: 37580165 PMCID: PMC10624488 DOI: 10.1212/wnl.0000000000207751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/28/2023] [Indexed: 08/16/2023] Open
Abstract
A 74-year-old woman presented with acute-onset right ptosis and binocular diplopia. CT scan showed low-density lesions in the bilateral basal ganglia and adjacent to lateral ventricles. Intracranial aneurysm was not detected. This case highlights the importance of neurologic localization of ophthalmoplegia based on physical examination and the microanatomy of the oculomotor nerve.
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Affiliation(s)
- Zhenghui Liu
- From the Departments of Neurology (Z.L., X.L., L.S., Y.-B.L.), Radiology (W.W.Z.), and Nephrology (P.D.), Xiangya Hospital, National Clinical Research Center for Geriatric Disorders (L.S.), and Engineering Research Center of Hunan Province in Cognitive Impairment Disorders (L.S.), Central South University, Changsha; Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic Diseases (L.S.), Changsha; Key Laboratory of Hunan Province in Neurodegenerative Disorders (L.S.), Central South University, Changsha; and Key Laboratory of Organ Injury (L.S.), Aging and Regenerative Medicine of Hunan Province, Changsha, China
| | - Wei Wei Zhang
- From the Departments of Neurology (Z.L., X.L., L.S., Y.-B.L.), Radiology (W.W.Z.), and Nephrology (P.D.), Xiangya Hospital, National Clinical Research Center for Geriatric Disorders (L.S.), and Engineering Research Center of Hunan Province in Cognitive Impairment Disorders (L.S.), Central South University, Changsha; Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic Diseases (L.S.), Changsha; Key Laboratory of Hunan Province in Neurodegenerative Disorders (L.S.), Central South University, Changsha; and Key Laboratory of Organ Injury (L.S.), Aging and Regenerative Medicine of Hunan Province, Changsha, China
| | - Piaoyu Dai
- From the Departments of Neurology (Z.L., X.L., L.S., Y.-B.L.), Radiology (W.W.Z.), and Nephrology (P.D.), Xiangya Hospital, National Clinical Research Center for Geriatric Disorders (L.S.), and Engineering Research Center of Hunan Province in Cognitive Impairment Disorders (L.S.), Central South University, Changsha; Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic Diseases (L.S.), Changsha; Key Laboratory of Hunan Province in Neurodegenerative Disorders (L.S.), Central South University, Changsha; and Key Laboratory of Organ Injury (L.S.), Aging and Regenerative Medicine of Hunan Province, Changsha, China
| | - Xiaoyan Long
- From the Departments of Neurology (Z.L., X.L., L.S., Y.-B.L.), Radiology (W.W.Z.), and Nephrology (P.D.), Xiangya Hospital, National Clinical Research Center for Geriatric Disorders (L.S.), and Engineering Research Center of Hunan Province in Cognitive Impairment Disorders (L.S.), Central South University, Changsha; Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic Diseases (L.S.), Changsha; Key Laboratory of Hunan Province in Neurodegenerative Disorders (L.S.), Central South University, Changsha; and Key Laboratory of Organ Injury (L.S.), Aging and Regenerative Medicine of Hunan Province, Changsha, China
| | - Lu Shen
- From the Departments of Neurology (Z.L., X.L., L.S., Y.-B.L.), Radiology (W.W.Z.), and Nephrology (P.D.), Xiangya Hospital, National Clinical Research Center for Geriatric Disorders (L.S.), and Engineering Research Center of Hunan Province in Cognitive Impairment Disorders (L.S.), Central South University, Changsha; Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic Diseases (L.S.), Changsha; Key Laboratory of Hunan Province in Neurodegenerative Disorders (L.S.), Central South University, Changsha; and Key Laboratory of Organ Injury (L.S.), Aging and Regenerative Medicine of Hunan Province, Changsha, China
| | - Yue-Bei Luo
- From the Departments of Neurology (Z.L., X.L., L.S., Y.-B.L.), Radiology (W.W.Z.), and Nephrology (P.D.), Xiangya Hospital, National Clinical Research Center for Geriatric Disorders (L.S.), and Engineering Research Center of Hunan Province in Cognitive Impairment Disorders (L.S.), Central South University, Changsha; Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic Diseases (L.S.), Changsha; Key Laboratory of Hunan Province in Neurodegenerative Disorders (L.S.), Central South University, Changsha; and Key Laboratory of Organ Injury (L.S.), Aging and Regenerative Medicine of Hunan Province, Changsha, China.
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16
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Lozano Gonzalez R, Singh RB, Virador GM, Barrett KM, Farres H, Miller DA, Meschia JF, Sandhu SJS, Erben Y. Systematic Review on Magnetic Resonance Angiography with Vessel Wall Imaging for the Characterization of Symptomatic Carotid Artery Plaque. Ann Vasc Surg 2023; 95:224-232. [PMID: 37164170 DOI: 10.1016/j.avsg.2023.04.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/26/2023] [Accepted: 04/23/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND To perform a systematic literature review to assess the usefulness of performing magnetic resonance angiography (MRA) with vessel wall imaging (VWI) sequences for the assessment of symptomatic carotid artery plaques and the identification of risky plaque features predisposing for stroke. METHODS We performed a systematic review of the literature pertaining to MRA with VWI techniques in patients with carotid artery disease, focusing on symptomatic patients' plaque features and morphology. Independent reviewers screened and analyzed data extracted from eligible studies, and a modified Newcastle-Ottawa Scale was used to appraise the quality of the design and content of the selected manuscripts to achieve an accurate interpretation. RESULTS This review included nineteen peer-reviewed manuscripts, all of them including MRA and VWI assessments of the symptomatic carotid artery plaque. We focused on patients' comorbidities and reviewed plaque features, including intraplaque hemorrhage, a lipid-rich necrotic core, a ruptured fibrous cap, and plaque ulceration. CONCLUSIONS MRA with VWI is a useful tool in the evaluation of carotid artery plaques. This imaging technique allows clinicians to identify plaques at risk of causing a neurovascular event. The presence of intraplaque hemorrhage, plaque ulceration, a ruptured fibrous cap, and a lipid-rich necrotic core are associated with neurovascular symptoms. The timely identification of these features could have a positive impact on neurovascular event prevention.
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Affiliation(s)
| | - Rahul B Singh
- Department of Radiology, Mayo Clinic, Jacksonville, FL
| | | | | | - Houssam Farres
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL
| | | | | | | | - Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL.
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17
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Li F, Wang Y, Du Y, Hu T, Wu Y. Correlation of the middle cerebral artery atherosclerotic plaque characteristics with ischemic stroke recurrence: a vessel wall magnetic resonance imaging study. Aging (Albany NY) 2023; 15:7844-7852. [PMID: 37566778 PMCID: PMC10457062 DOI: 10.18632/aging.204950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/20/2023] [Indexed: 08/13/2023]
Abstract
This study aims to analyze the imaging features of atherosclerotic plaques in the middle cerebral artery (MCA) of patients with recurrent ischemic stroke using vessel wall magnetic resonance imaging (VWMRI) and investigate the correlation between these imaging features and the recurrence of ischemic stroke. Consecutive patients with ischemic stroke caused by atherosclerotic stenosis of the MCA were collected. The patients were divided into recurrent and non-recurrent ischemic stroke groups. We obtained VWMRI images of MCA plaques using 3.0T MRI by black-blood sequences, and the differences in VWMRI characteristics and clinical information between the two groups were compared. A binary Logistic regression model was used to analyze the VWMRI characteristics and clinical information related to ischemic stroke recurrence. 179 patients were collected from August 2018 to May 2020, and 81 patients were included in the study. The recurrent ischemic stroke group patients had a higher stenosis rate (0.69 vs 0.64). Meanwhile, the rate of centripetal wall thickening was significantly higher in patients with recurrent ischemic stroke (33.3% vs 11.7%). Binary Logistic regression analysis showed that sex (P=0.036, OR:2.983, CI:1.075-8.279), stenosis rate (P=0.038, OR:148.565, CI:1.331-16583.631), and vessel wall thickening pattern (P=0.012, OR:0.171, CI:0.043-0.678) were related to ischemic stroke recurrence. The patients with ischemic stroke caused by atherosclerotic stenosis of MCA, female patients, and those with concentric wall thickening and a high degree of stenosis have a higher risk of recurrence. Our results suggest that VWMRI is a valuable tool for predicting the risk of ischemic stroke recurrence in patients with MCA plaques.
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Affiliation(s)
- Fangbing Li
- Department of Radiology, Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Yilin Wang
- Department of Radiology, Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Ying Du
- Department of Radiology, Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Tianxiang Hu
- Department of Radiology, Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Yejun Wu
- Department of Radiology, Fourth Affiliated Hospital of China Medical University, Shenyang, China
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18
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Johnston JC, Sartwelle TP. Medical Malpractice and the Neurologist: Specific Neurological Claims. Neurol Clin 2023; 41:493-512. [PMID: 37407102 DOI: 10.1016/j.ncl.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
This chapter highlights the most frequently encountered neurological malpractice claims. The format is designed to provide a rudimentary understanding of how lawsuits arise and thereby focus discussion on adapting practice patterns to improve patient care and minimize liability risk.
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Affiliation(s)
- James C Johnston
- GlobalNeurology, 17B Farnham Street, Auckland 1052, New Zealand; GlobalNeurology®, 5290 Medical Drive, San Antonio, TX 78229, USA.
| | - Thomas P Sartwelle
- Hicks Davis Wynn, PC, 3555 Timmons Lane, Suite 1000, Houston, TX 77027, USA
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19
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Ton MD, Phuong DV, Thom VT, Dung NT, Tho PQ, Thuan LD, Nguyen TN. Factors related to unfavorable outcome in minor ischemic stroke. J Stroke Cerebrovasc Dis 2023; 32:107203. [PMID: 37441912 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Stroke recurrence and disability are important challenges to overcome in patients with minor ischemic stroke. The aim of our study was to determine the factors associated with unfavorable outcomes in patients with minor ischemic stroke. METHODS This was a prospective cohort study including patients with minor ischemic stroke with a National Institutes of Health Stroke Scale (NIHSS) score ≤ 4 who were treated at the Bach Mai Hospital stroke center from June 15, 2021, to September 15, 2022. Unfavorable outcome was defined as mRS 2-6 at 90 days. Multivariable logistic regression analysis was conducted to assess risk factors related to clinical outcomes. RESULTS Of 678 patients presenting with minor ischemic stroke, there were 90 (13.3%, 90/678) patients with no intracranial artery imaging. Hence, 588 were patients analyzed, of whom 6.0% received thrombolytic therapy, 8.5% developed NIHSS > 4 in 24 hours, and 30.4% had intracranial stenosis > 50%. Compared with the group of unfavorable outcomes, the favorable outcome group had more NIHSS 0-1 (29.9% vs.8.7%, P<0.001), lower cardioembolic (3.2% vs.7.9%, P=0.021), low IV-tPA ratio (4.8% vs.10.3%, P=0.019), lower NIHSS progression > 4 in the first 24 hours (3.9% vs.25.4%, P<0.001), and lower ICAS rate (28.1% vs.38.9%, P=0.02). Multivariable regression analysis of factors affecting unfavorable outcomes included baseline NIHSS 2-4 (OR, 3.85; 95% CI, 1.97-7.52), NIHSS progression > 4 (OR, 7.57; 95% CI, 3.80-15.10), and ICAS (OR 1.68; 95%CI, 1.07-2.64). CONCLUSIONS In patients with minor ischemic stroke, unfavorable outcomes were associated with baseline NIHSS 2-4, NIHSS progression > 4 points in 24 hours, and ICAS. These factors may identify a patient population in need of close monitoring and at higher risk of adverse outcomes.
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Affiliation(s)
- Mai Duy Ton
- Department of Stroke and Cerebrovascular disease, VNU-University of Medicine and Pharmacy, 144 Xuan Thuy, Cau Giay, Hanoi 10000, Vietnam; Stroke Center, Bach Mai hospital, 78 Giai phong road, Phương Mai ward, Dong Da district, Hanoi 10000, Vietnam; Hanoi Medical University, Vietnam
| | - Dao Viet Phuong
- Department of Stroke and Cerebrovascular disease, VNU-University of Medicine and Pharmacy, 144 Xuan Thuy, Cau Giay, Hanoi 10000, Vietnam; Stroke Center, Bach Mai hospital, 78 Giai phong road, Phương Mai ward, Dong Da district, Hanoi 10000, Vietnam; Hanoi Medical University, Vietnam
| | - Vu Thi Thom
- Department of Basic Science in Medicine and Pharmacy, VNU-University of Medicine and Pharmacy, 144 Xuan Thuy, Cau Giay, Hanoi, 100000, Vietnam
| | - Nguyen Tien Dung
- Department of Stroke and Cerebrovascular disease, VNU-University of Medicine and Pharmacy, 144 Xuan Thuy, Cau Giay, Hanoi 10000, Vietnam; Stroke Center, Bach Mai hospital, 78 Giai phong road, Phương Mai ward, Dong Da district, Hanoi 10000, Vietnam
| | - Pham Quang Tho
- Stroke Center, Bach Mai hospital, 78 Giai phong road, Phương Mai ward, Dong Da district, Hanoi 10000, Vietnam
| | | | - Thanh N Nguyen
- Boston Medical Center, 1 Boston Medical Center, Boston, MA 02118, United States.
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20
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Lin CJ, Chung CP, Liao NC, Chen PL, Chi NF, Lai YJ, Tang CW, Wu CH, Chang FC, Luo CB, Fay LY, Lin CF, Chou CH, Lee TH, Lee JT, Jeng JS, Lee IH. The 2023 Taiwan Stroke Society Guidelines for the management of patients with intracranial atherosclerotic disease. J Chin Med Assoc 2023; 86:697-714. [PMID: 37341526 DOI: 10.1097/jcma.0000000000000952] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
Abstract
Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke, especially in Asian populations, which has a high risk of recurrent stroke and cardiovascular comorbidities. The present guidelines aim to provide updated evidence-based recommendations for diagnosis and management of patients with ICAD. Taiwan Stroke Society guideline consensus group developed recommendations for management of patients with ICAD via consensus meetings based on updated evidences. Each proposed class of recommendation and level of evidence was approved by all members of the group. The guidelines cover six topics, including (1) epidemiology and diagnostic evaluation of ICAD, (2) nonpharmacological management of ICAD, (3) medical therapy for symptomatic ICAD, (4) endovascular thrombectomy and rescue therapy for acute ischemic stroke with underlying ICAD, (5) endovascular interventional therapy for postacute symptomatic intracranial arterial stenosis, and (6) surgical treatment of chronic symptomatic intracranial arterial stenosis. Intensive medical treatment including antiplatelet therapy, risk factor control, and life style modification are essential for patients with ICAD.
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Affiliation(s)
- Chun-Jen Lin
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chih-Ping Chung
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Nien-Chen Liao
- Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Po-Lin Chen
- Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Nai-Fang Chi
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yen-Jun Lai
- Radiology Department, Far-Eastern Memorial Hospital, New Taipei City, Taiwan, ROC
| | - Chih-Wei Tang
- Neurology Department and Stroke Center, Far-Eastern Memorial Hospital, New Taipei City, Taiwan, ROC
| | - Chia-Hung Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Li-Yu Fay
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chun-Fu Lin
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chung-Hsing Chou
- Neurology Department, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Tsong-Hai Lee
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Jiunn-Tay Lee
- Neurology Department, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Jiann-Shing Jeng
- Department of Neurology and Stroke Center, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - I-Hui Lee
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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21
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Li X, Qin X, Liu C, Zhu L, Wang M, Jiang T, Liu Y, Li S, Shi H, Sun H, Deng Q, Zhou J. Percutaneous angioplasty and/or stenting versus aggressive medical therapy in patients with symptomatic intracranial atherosclerotic stenosis: a 1-year follow-up study. Front Aging Neurosci 2023; 15:1192681. [PMID: 37396661 PMCID: PMC10313453 DOI: 10.3389/fnagi.2023.1192681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Background Symptomatic intracranial atherosclerotic stenosis (sICAS) is one of the common causes of ischemic stroke. However, the treatment of sICAS remains a challenge in the past with unfavorable findings. The purpose of this study was to explore the effect of stenting versus aggressive medical management on preventing recurrent stroke in patients with sICAS. Methods We prospectively collected the clinical information of patients with sICAS who underwent percutaneous angioplasty and/or stenting (PTAS) or aggressive medical therapy from March 2020 to February 2022. Propensity score matching (PSM) was employed to ensure well-balanced characteristics of two groups. The primary outcome endpoint was defined as recurrent stroke or transient ischemic attack (TIA) within 1 year. Results We enrolled 207 patients (51 in the PTAS and 156 in the aggressive medical groups) with sICAS. No significant difference was found between PTAS group and aggressive medical group for the risk of stroke or TIA in the same territory beyond 30 days through 6 months (P = 0.570) and beyond 30 days through 1 year (P = 0.739) except for within 30 days (P = 0.003). Furthermore, none showed a significant difference for disabling stroke, death and intracranial hemorrhage within 1 year. These results remain stable after adjustment. After PSM, all the outcomes have no significant difference between these two groups. Conclusion The PTAS has similar treatment outcomes compared with aggressive medical therapy in patients with sICAS across 1-year follow-up.
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Affiliation(s)
- Xiaohui Li
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiaodan Qin
- General Clinical Research Center, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chengfang Liu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Lin Zhu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Meng Wang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Teng Jiang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yukai Liu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Shuo Li
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Hongchao Shi
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Huiling Sun
- General Clinical Research Center, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Qiwen Deng
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Junshan Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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22
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Siddiq F, Nunna RS, Beall JM, Khan I, Khan M, Tekle WG, Ezzeldin M, Tanweer O, Burkhardt JK, Jabbour PM, Tjoumakaris SI, Herial NA, Siddiqui AH, Grandhi R, Martin RL, Qureshi AI, Hassan AE. Thirty-Day Outcomes of Resolute Onyx Stent for Symptomatic Intracranial Stenosis: A Multicenter Propensity Score-Matched Comparison With Stenting Versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis Trial. Neurosurgery 2023; 92:1155-1162. [PMID: 36700730 PMCID: PMC10553131 DOI: 10.1227/neu.0000000000002338] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/02/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Symptomatic intracranial atherosclerotic disease (sICAD) is estimated to cause 10% of strokes annually in the United States. However, treatment remains a challenge with several different stenting options studied in the past with unfavorable results. OBJECTIVE To report the 30-day stroke and/or death rate associated with intracranial stent placement for sICAD using Resolute Onyx Zotarolimus-Eluting Stent (RO-ZES) and provide a comparison with the results of Stenting Versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial. METHODS Prospectively maintained databases across 8 stroke centers were used to identify adult patients treated with RO-ZES for sICAD between January 2019 and December 2021. Primary end point was composite of 30-day stroke, intracerebral hemorrhage, and/or death. Propensity score matching was performed using age, hypertension, lipid disorder, cigarette smoking, and symptomatic target vessel to create a matched group for comparison between RO-ZES and the SAMMPRIS medical management and treatment groups (SAMMPRIS percutaneous angioplasty and stenting [S-PTAS]). RESULTS A total of 132 patients met the inclusion criteria for analysis (mean age: 64.2 years). Mean severity of stenosis was 81.4% (±11.4%). A total of 4 (3.03%) stroke and/or deaths were reported within 30 days of treatment in the RO-ZES group compared with 6.6% in the SAMMPRIS medical management group (OR [odds ratio] 2.26, 95% CI 0.7-9.56, P = .22) and 15.6% in the S-PTAS group (OR 5.9, 95% CI 2.04-23.4, P < .001). Propensity score match analysis of 115 patients in each group demonstrated 30-day stroke and/or death rate of 2.6% in the RO-ZES group and 15.6% in the S-PTAS group (OR 6.88, 95% CI 1.92-37.54, P < .001). CONCLUSION Patients treated with RO-ZES had a relatively low 30-day stroke and/or death rate compared with the S-PTAS group. Further large-scale prospective studies are warranted to evaluate the safety and efficacy of RO-ZES for the treatment of sICAD.
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Affiliation(s)
- Farhan Siddiq
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Ravi S. Nunna
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Jonathan M. Beall
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Inamullah Khan
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Musharaf Khan
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Wondwossen G. Tekle
- Department of Neurology, Valley Baptist—University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Mohamad Ezzeldin
- Department of Clinical Science, University of Houston, HCA Houston, Houston, Texas, USA
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Pascal M. Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Nabeel A. Herial
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Adnan H. Siddiqui
- Department of Neurosurgery, University of Buffalo, Buffalo, New York, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Renee L. Martin
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Adnan I. Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Ameer E. Hassan
- Department of Neurology, Valley Baptist—University of Texas Rio Grande Valley, Harlingen, Texas, USA
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23
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de Havenon A, Zaidat OO, Amin-Hanjani S, Nguyen TN, Bangad A, Abassi M, Anadani M, Almallouhi E, Chatterjee R, Mazighi M, Mistry E, Yaghi S, Derdeyn C, Hong KS, Kvernland A, Leslie-Mazwi T, Al Kasab S. Large Vessel Occlusion Stroke due to Intracranial Atherosclerotic Disease: Identification, Medical and Interventional Treatment, and Outcomes. Stroke 2023; 54:1695-1705. [PMID: 36938708 PMCID: PMC10202848 DOI: 10.1161/strokeaha.122.040008] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Large vessel occlusion stroke due to underlying intracranial atherosclerotic disease (ICAD-LVO) is prevalent in 10 to 30% of LVOs depending on patient factors such as vascular risk factors, race and ethnicity, and age. Patients with ICAD-LVO derive similar functional outcome benefit from endovascular thrombectomy as other mechanisms of LVO, but up to half of ICAD-LVO patients reocclude after revascularization. Therefore, early identification and treatment planning for ICAD-LVO are important given the unique considerations before, during, and after endovascular thrombectomy. In this review of ICAD-LVO, we propose a multistep approach to ICAD-LVO identification, pretreatment and endovascular thrombectomy considerations, adjunctive medications, and medical management. There have been no large-scale randomized controlled trials dedicated to studying ICAD-LVO, therefore this review focuses on observational studies.
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Affiliation(s)
| | | | | | | | | | | | | | - Eyad Almallouhi
- Neurology, Medical University of South Carolina, Charleston, SC
| | | | - Mikael Mazighi
- Neurology, Lariboisière hospital-APHP NORD, FHU Neurovasc, Paris Cité University, INSERM 1144, France
| | - Eva Mistry
- Neurology and Rehabilitation Medicine, University of Cincinnati, OH
| | - Shadi Yaghi
- Neurology, Warren Alpert Medical School of Brown University, Providence, RI
| | - Colin Derdeyn
- Neurosurgery, Carver College of Medicine, Iowa City, Iowa
| | - Keun-Sik Hong
- Neurology, Ilsan Paik Hospital, Inje University, Goyang, South Korea
| | | | | | - Sami Al Kasab
- Neurology, Medical University of South Carolina, Charleston, SC
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24
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Lee YC, Liao YC, Lin CJ, Chung CP. Baseline P2Y12 reactivity, kidney function, and CYP2C19 genotype determine clopidogrel responsiveness in acute stroke. Sci Rep 2023; 13:8085. [PMID: 37208337 DOI: 10.1038/s41598-023-34481-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 05/02/2023] [Indexed: 05/21/2023] Open
Abstract
Clopidogrel is the most-widely used platelet P2Y12-inhibitor for secondary-prevention of ischemic stroke. Platelet P2Y12 reactivity before and after inhibitors can be measured with blood sampling by commercialized system. We aimed to evaluate (1) whether high-on-clopidogrel platelet P2Y12 reactivity (HCPR) is associated with short-term vascular events and (2) the predictors of HCPR in acute stroke. The inclusion criterion was patients with acute stroke who received clopidogrel within 12-48 h after the onset. Platelet reactivity was assayed at baseline and after clopidogrel treatment using the VerifyNow system. The primary endpoint was recurrent ischemic events within 21 days after stroke. Among 190 patients, 32(16.9%) had recurrent ischemic stroke. Multivariate analyses showed that HCPR was significantly associated with the short-term events with an odds-ratio of 2.5 (95% CI 1.1-5.7, p = 0.027). Patients with HCPR had significantly higher frequencies of high baseline platelet P2Y12 reactivity, impaired kidney function, and carrying one or two CYP2C19 loss-of-function alleles. A poor clopidogrel response score combining these factors was developed. Ten percent of patients with score 0, 20.3% of those with score 1, 38.3% of those with score 2, and 66.7% of those with score 3 had HCPR (χ2-test, p < 0.001). Multivariate analyses showed that, compared with the score-0 group, the score-2 and -3 groups had higher risks of HCPR with hazard-ratios of 5.4 (95% CI 1.5-20.3, p = 0.012) and 17.4 (95% CI 3.4-88.9, p = 0.001) for developing recurrent ischemic strokes. The study emphasized the role of HCPR in ischemic stroke. We also developed an HCPR risk score, which could be used in clinical practice or trials, potentially with more precision, to weigh the clinical benefit of a tailored antiplatelet-strategy for patients with stroke.
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Affiliation(s)
- Yi-Chung Lee
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Taipei, 112, Taiwan
- Department of Neurology, School of Medicine, National Yang Ming Chao Tung University, Taipei, Taiwan
| | - Yi-Chu Liao
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Taipei, 112, Taiwan
- Department of Neurology, School of Medicine, National Yang Ming Chao Tung University, Taipei, Taiwan
| | - Chun-Jen Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Taipei, 112, Taiwan
- Department of Neurology, School of Medicine, National Yang Ming Chao Tung University, Taipei, Taiwan
| | - Chih-Ping Chung
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Taipei, 112, Taiwan.
- Department of Neurology, School of Medicine, National Yang Ming Chao Tung University, Taipei, Taiwan.
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25
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Lai Z, Peng M, He H, Li Y, Bai X, Cai J. Percutaneous transluminal angioplasty and stenting vs aggressive medical management on stroke or intracranial atherosclerotic stenosis: a systematic review and meta-analysis. Sci Rep 2023; 13:7567. [PMID: 37161029 PMCID: PMC10169842 DOI: 10.1038/s41598-023-34663-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/05/2023] [Indexed: 05/11/2023] Open
Abstract
There are currently two main treatment strategies mainly for high-risk patients: percutaneous transluminal angioplasty and stenting (PTAS) and aggressive medical management (AMM). However, the choice between PTAS or AMM remains controversial for patients with stroke or intracranial atherosclerotic stenosis (ICAS). The investigators searched the PubMed, Web of Science, Embase, Scopus, and Cochrane library databases. Randomized controlled trial (RCT) comparing PTAS and AMM for patients with stroke or ICAS were selected. RevMan 5.3 was used to analyze the results and assess risk of bias. The primary endpoints are stroke and death within 30 days after enrollment, or ischemic stroke in the territory of the qualifying artery beyond 30 days, and entire follow-up endpoints. The secondary outcomes were the disabling or fatal stroke, and incidence of death within 3 years. Four studies, 989 patients were included in this article. The AMM group was superior in the entire follow-up endpoint (OR 0.56; 95% CI 0.40, 0.79). The AMM also better in primary endpoint within 30 days (OR 0.32; 95% CI 0.17, 0.61). There was no significant difference beyond 30 days (OR 1.08; 95% CI 0.63, 1.86). The remaining outcomes, such as stroke and death, were not significantly different (P > 0.05). This meta-analysis shows AMM is significantly more effective than PTAS in subjects with ICAS due to the high rate of periprocedural stroke (OR 0.32; 95% CI 0.17, 0.61) and stroke during the entire follow-up (OR 0.56; 95% CI 0.40, 0.79) associated with PTAS. Furthermore, PTAS offers no additional benefits over AMM beyond 30 days (OR 1.08; 95% CI 0.63, 1.86).
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Affiliation(s)
- Zhiyu Lai
- Diagnosis and Treatment Center of Encephalopathy, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
- Department of Cerebrovascular Surgery, Hospital of Guangzhou University Mega Center, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510006, China
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
| | - Mingqiang Peng
- Diagnosis and Treatment Center of Encephalopathy, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
- Department of Cerebrovascular Surgery, Hospital of Guangzhou University Mega Center, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510006, China
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
| | - Haoming He
- Diagnosis and Treatment Center of Encephalopathy, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
- Department of Cerebrovascular Surgery, Hospital of Guangzhou University Mega Center, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510006, China
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
| | - Yingbin Li
- Diagnosis and Treatment Center of Encephalopathy, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
- Department of Cerebrovascular Surgery, Hospital of Guangzhou University Mega Center, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510006, China
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
| | - Xiaoxin Bai
- Diagnosis and Treatment Center of Encephalopathy, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
- Department of Cerebrovascular Surgery, Hospital of Guangzhou University Mega Center, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510006, China
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
| | - Jun Cai
- Diagnosis and Treatment Center of Encephalopathy, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China.
- Department of Cerebrovascular Surgery, Hospital of Guangzhou University Mega Center, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510006, China.
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China.
- Department of Neurosurgery, Hospital of Guangzhou Higher Education Mega Center, Guangdong Provincial Hospital of Chinese Medicine, No. 55 Neihuan Xi Road, Guangzhou, 510006, Guangdong, China.
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26
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Bhatia K, Ladd LM, Carr KH, Di Napoli M, Saver JL, McCullough LD, Hosseini Farahabadi M, Alsbrook DL, Hinduja A, Ortiz Garcia JG, Sabbagh SY, Jafarli A, Divani AA. Contemporary Antiplatelet and Anticoagulant Therapies for Secondary Stroke Prevention: A Narrative Review of Current Literature and Guidelines. Curr Neurol Neurosci Rep 2023; 23:235-262. [PMID: 37037980 DOI: 10.1007/s11910-023-01266-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE OF REVIEW Stroke is a leading cause of death and disability worldwide. The annual incidence of new or recurrent stroke is approximately 795,000 cases per year in the United States, of which 87% are ischemic in nature. In addition to the management of modifiable high-risk factors to reduce the risk of recurrent stroke, antithrombotic agents (antiplatelets and anticoagulants) play an important role in secondary stroke prevention. This review will discuss the published literature on the use of antiplatelets and anticoagulants in secondary prevention of acute ischemic stroke and transient ischemic attack (TIA), including their pharmacology, efficacy, and adverse effects. We will also highlight the role of dual antiplatelet therapy (DAPT) in secondary stroke prevention, along with supporting literature. RECENT FINDINGS Single antiplatelet therapy (SAPT) with aspirin or clopidogrel reduces the risk of recurrent ischemic stroke in patients with non-cardioembolic ischemic stroke or TIA. However, as shown in recent trials, short-term DAPT with aspirin and clopidogrel or ticagrelor for 21-30 days is more effective than SAPT in patients with minor acute non-cardioembolic stroke or high-risk TIA. Although short-term DAPT is highly effective in preventing recurrent stroke, a more prolonged course can increase bleeding risks without additional benefit. DAPT for 90 days, followed by aspirin monotherapy for patients with large vessel intracranial atherosclerotic disease, is suitable for secondary stroke prevention. However, patients need to be monitored for both minor (e.g., bruising) and major (e.g., intracranial) bleeding complications. Conversely, oral warfarin and newer direct oral anticoagulant (DOACs) such as dabigatran, rivaroxaban, apixaban, and edoxaban are the agents of choice for secondary stroke prevention in patients with non-valvular cardioembolic strokes. DOACs may be preferred over warfarin due to decreased bleeding risks, including ICH, lack of need for international normalized ratio monitoring, no dietary restrictions, and limited drug-drug interactions. The choice between different antiplatelets and anticoagulants for prevention of ischemic stroke depends on the underlying stroke mechanism, cytochrome P450 2C19 polymorphisms, bleeding risk profile, compliance, drug tolerance, and drug resistance. Physicians must carefully weigh each patient's relative benefits and bleeding risks before initiating an antiplatelet/anticoagulant treatment regimen. Further studies are warranted to study the optimal duration of DAPT in symptomatic intracranial atherosclerosis since the benefit is most pronounced in the short term while the bleeding risk remains high during the extended duration of therapy.
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Affiliation(s)
- Kunal Bhatia
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Lindsey M Ladd
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Kelsey H Carr
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Sulmona, L'Aquila, Italy
| | - Jeffrey L Saver
- Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Louise D McCullough
- Department of Neurology, McGovern Medical School, University of Texas Health Sciences Center, Houston, TX, USA
| | | | - Diana L Alsbrook
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Archana Hinduja
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jorge G Ortiz Garcia
- Department of Neurology, the University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Sara Y Sabbagh
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Alibay Jafarli
- Department of Neurology, Tufts Medical Center, Boston, MA, USA
| | - Afshin A Divani
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA.
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27
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Alemseged F, Nguyen TN, Coutts SB, Cordonnier C, Schonewille WJ, Campbell BCV. Endovascular thrombectomy for basilar artery occlusion: translating research findings into clinical practice. Lancet Neurol 2023; 22:330-337. [PMID: 36780915 DOI: 10.1016/s1474-4422(22)00483-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/09/2022] [Accepted: 11/21/2022] [Indexed: 02/12/2023]
Abstract
BACKGROUND Basilar artery occlusion is a rare and severe condition. The effectiveness of endovascular thrombectomy in patients with basilar artery occlusion was unclear until recently, because these patients were excluded from most trials of endovascular thrombectomy for large-vessel occlusion ischaemic stroke. RECENT DEVELOPMENTS The Basilar Artery International Cooperation Study (BASICS) and the Basilar Artery Occlusion Endovascular Intervention versus Standard Medical Treatment (BEST) trials, specifically designed to investigate the benefit of thrombectomy in patients with basilar artery occlusion, did not find significant evidence of a benefit of endovascular thrombectomy in terms of disability outcomes at 3 months after stroke. However, these trials suggested a potential benefit of endovascular thrombectomy in patients presenting with moderate-to-severe symptoms. Subsequently, the Endovascular Treatment for Acute Basilar Artery Occlusion (ATTENTION) and the Basilar Artery Occlusion Chinese Endovascular (BAOCHE) trials, which compared endovascular thrombectomy versus medical therapy within 24 h of onset, showed clear benefit of endovascular thrombectomy in reducing disability and mortality, particularly in patients with moderate-to-severe symptoms. The risk of intracranial haemorrhage with endovascular thrombectomy was similar to the risk in anterior circulation stroke. Thrombectomy was beneficial regardless of age, baseline characteristics, the presence of intracranial atherosclerotic disease, and time from symptom onset to randomisation. Therefore, the question of whether endovascular thrombectomy is beneficial in basilar artery occlusion now appears to be settled in patients with moderate-to-severe symptoms, and endovascular thrombectomy should be offered to eligible patients. WHERE NEXT?: Key outstanding issues are the potential benefits of endovascular thrombectomy in patients with mild symptoms, the use of intravenous thrombolysis in an extended time window (ie, after 4·5 h of symptom onset), and the optimal endovascular technique for thrombectomy. Dedicated training programmes and automated software to assist with the assessment of imaging prognostic markers could be useful in the selection of patients who might benefit from endovascular thrombectomy. Large international research networks should be built to address knowledge gaps in this field and allow the conduct of clinical trials with fast and consecutive enrolment and a diverse ethnic representation.
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Affiliation(s)
- Fana Alemseged
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Thanh N Nguyen
- Department of Neurology and Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Shelagh B Coutts
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Charlotte Cordonnier
- Université Lille, INSERM UMR-S1172, Centre Hospitalier Universitaire de Lille, Lille Neuroscience et Cognition, Lille, France
| | | | - Bruce C V Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia.
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28
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Singhal AB, Silverman SB, Romero JM, Lang-Orsini M. Case 6-2023: A 68-Year-Old Man with Recurrent Strokes. N Engl J Med 2023; 388:747-757. [PMID: 36812438 DOI: 10.1056/nejmcpc2211368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Affiliation(s)
- Aneesh B Singhal
- From the Departments of Neurology (A.B.S., S.B.S.), Radiology (J.M.R.), and Pathology (M.L.-O.), Massachusetts General Hospital, and the Departments of Neurology (A.B.S., S.B.S.), Radiology (J.M.R.), and Pathology (M.L.-O.), Harvard Medical School - both in Boston
| | - Scott B Silverman
- From the Departments of Neurology (A.B.S., S.B.S.), Radiology (J.M.R.), and Pathology (M.L.-O.), Massachusetts General Hospital, and the Departments of Neurology (A.B.S., S.B.S.), Radiology (J.M.R.), and Pathology (M.L.-O.), Harvard Medical School - both in Boston
| | - Javier M Romero
- From the Departments of Neurology (A.B.S., S.B.S.), Radiology (J.M.R.), and Pathology (M.L.-O.), Massachusetts General Hospital, and the Departments of Neurology (A.B.S., S.B.S.), Radiology (J.M.R.), and Pathology (M.L.-O.), Harvard Medical School - both in Boston
| | - Melanie Lang-Orsini
- From the Departments of Neurology (A.B.S., S.B.S.), Radiology (J.M.R.), and Pathology (M.L.-O.), Massachusetts General Hospital, and the Departments of Neurology (A.B.S., S.B.S.), Radiology (J.M.R.), and Pathology (M.L.-O.), Harvard Medical School - both in Boston
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Liu H, Liu K, Zhang K, Zong C, Yang H, Li Y, Li S, Wang X, Zhao J, Xia Z, Song B, Xu X, Gao Y. Early neurological deterioration in patients with acute ischemic stroke: a prospective multicenter cohort study. Ther Adv Neurol Disord 2023; 16:17562864221147743. [PMID: 36710721 PMCID: PMC9880581 DOI: 10.1177/17562864221147743] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 12/08/2022] [Indexed: 01/26/2023] Open
Abstract
Background There is still no precise knowledge of the causes of progression in patients with acute ischemic stroke (AIS), and we are unable to predict patients at risk. Objective To explore the frequency, predictive factors, and the prognosis of early neurological deterioration (END) in patients with AIS. Methods In this prospective multicenter observational study, we assessed patients with AIS admitted to 18 hospitals in Henan, China. We defined END as an increase of ⩾2 points in total National Institutes of Health Stroke Scale (NIHSS) score or ⩾1 point in the motor items of the NIHSS within 7 days after admission. Risk factors were analyzed using multivariate logistic regression models. Prognosis was evaluated using the modified Rankin Scale (mRS), with poor prognosis defined as mRS 3-6. Results A total of 9114 patients with AIS within 24 h of symptom onset were enrolled in the study. END occurred in 1286 (14.1%) patients. The highest incidence (62.5%) of END occurred within 24 h after admission. After adjusting potential confounders, age, body mass index, waist-hip ratio, systolic blood pressure, baseline NIHSS, disabled at baseline, history of atrial fibrillation, diabetes mellitus, intracranial arterial stenosis, infarct location in the lenticulostriate artery area and cerebral watershed, neutrophils, lymphocytes, uric acid, and triglycerides were identified as independent predictors for END. END was significantly associated with poor prognosis at 90 days, and the adjusted OR was 1.74 (95% CI: 1.53-1.97). Conclusion One in seven hospitalized patients with AIS may experience END within 24 h of onset. The highest incidence of END occurred within 24 h of admission and decreased steeply with time. Easily identifiable risk factors predict END and could help understand the causal mechanisms and thereby prevent END.
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Affiliation(s)
- Hongbing Liu
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Kai Liu
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Ke Zhang
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Ce Zong
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongxun Yang
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Yapeng Li
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Shen Li
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Xin Wang
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiawei Zhao
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
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Song HX, Zhang B, Liu S, Shi ZC, Wang ZY, Lu HL, Yao J, Chen J. Efficacy and safety of low dose aspirin plus clopidogrel in the treatment of elderly patients with symptomatic intracranial artery stenosis. Front Neurol 2023; 14:1060733. [PMID: 36937518 PMCID: PMC10017526 DOI: 10.3389/fneur.2023.1060733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 02/06/2023] [Indexed: 03/06/2023] Open
Abstract
Background As one of the most common causes of stroke, symptomatic intracranial artery stenosis (sICAS) is a great threat to public health, and its financial burden is substantial, with annual direct high medical costs particularly in China. Currently, the long-term use of conventional dual antiplatelet therapy (DAPT) as the primary modality of treatment for sICAS decreases the risk of stroke recurrence but increases the risk of bleeding. We aimed to evaluate the efficacy and safety of low dose aspirin plus clopidogrel for the treatment of sICAS in the elderly population. Methods This randomized, controlled study included 181 older patients with transient ischemic attack (TIA) or ischemic stroke (IS) attributed to sICAS, who were recruited between April 2015 and November 2020. The 90 patients assigned to the low dose therapy group included aspirin, 75 mg, plus clopidogrel, 50 mg, daily for 90 and 91 patients assigned to the conventional group included aspirin, 100 mg, plus clopidogrel, 75 mg, daily for 90 days (aspirin or clopidogrel alone daily thereafter) were included in this intention-to-treat analysis. Efficacy and safety analyses were done in this trial. Results One hundred eighty-one eligible elderly patients with sICAS were enrolled in this trial. The median age was 70 years ranged 60-83 years. Seventy-five participants were with TIA and 106 with IS. The median time of follow-up was 30 months ranged 1-36 months. Ninety patients were assigned randomly to the low dose group and 91 patients to the conventional group. The rate of primary, secondary and composite efficacy were not significantly different between the low dose and conventional group (P > 0.05). The rate of composite safety outcome was 7.8% (7/90) in the low dose group, which was lower than 17.6% (16/91) in the conventional group (χ2 = 3.921, P = 0.048). At the time of last follow-up, 17 (9.4%) of 181 patients developed GI injuries, which occurred in four (4.4%) of 90 patients in the low dose group and in 13 (14.3%) of 91 patients in the conventional group (χ2 = 4.058, P = 0.044). The primary efficacy outcome occurred in six (18.2%) of 33 patients with severe sICAS and in 22 (38.6%) of 57 patients with moderate sICAS (χ2 = 4.064, P = 0.044) in the low dose group. Conclusion In this study, the safety of low dose aspirin combined with clopidogrel proved to be equally efficient and significantly safer than those of conventional dose within 24 months in elderly patients with sICAS. However, the small size of this study limits the validity of the results. Further larger longitudinal and randomized controlled trials are necessary to evaluate the role of low dose DAPT in the patients with sICAS.
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Abdalkader M, Finitsis S, Li C, Hu W, Liu X, Ji X, Huo X, Alemseged F, Qiu Z, Strbian D, Puetz V, Siegler JE, Yaghi S, Asif K, Klein P, Zhu Y, Campbell BC, Chen HS, Nagel S, Tsivgoulis G, Miao Z, Nogueira RG, Jovin TG, Schonewille WJ, Nguyen TN. Endovascular versus Medical Management of Acute Basilar Artery Occlusion: A Systematic Review and Meta-Analysis of the Randomized Controlled Trials. J Stroke 2023; 25:81-91. [PMID: 36746382 PMCID: PMC9911851 DOI: 10.5853/jos.2022.03755] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/06/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND AND PURPOSE The optimal management of patients with acute basilar artery occlusion (BAO) is uncertain. We aimed to evaluate the safety and efficacy of endovascular thrombectomy (EVT) compared to medical management (MM) for acute BAO through a meta-analysis of randomized controlled trials (RCTs). METHODS We performed a systematic review and meta-analysis of RCTs of patients with acute BAO. We analyzed the pooled effect of EVT compared to MM on the primary outcome (modified Rankin Scale [mRS] of 0-3 at 3 months), secondary outcome (mRS 0-2 at 3 months), symptomatic intracranial hemorrhage (sICH), and 3-month mortality rates. For each study, effect sizes were computed as odds ratios (ORs) with random effects and Mantel-Haenszel weighting. RESULTS Four RCTs met inclusion criteria including 988 patients. There were higher odds of mRS of 0-3 at 90 days in the EVT versus MM group (45.1% vs. 29.1%, OR 1.99, 95% confidence interval [CI] 1.04-3.80; P=0.04). Patients receiving EVT had a higher sICH compared to MM (5.4% vs. 0.8%, OR 7.89, 95% CI 4.10-15.19; P<0.01). Mortality was lower in the EVT group (35.5% vs. 45.1%, OR 0.64, 95% CI 0.42-0.99; P=0.05). In an analysis of two trials with BAO patients and National Institutes of Health Stroke Scale (NIHSS) <10, there was no difference in 90-day outcomes between EVT versus MM. CONCLUSION In this systematic review and meta-analysis, EVT was associated with favorable outcome and decreased mortality in patients with BAO up to 24 hours from stroke symptoms compared to MM. The treatment effect in BAO patients with NIHSS <10 was less certain. Further studies are of interest to evaluate the efficacy of EVT in basilar occlusion patients with milder symptoms.
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Affiliation(s)
- Mohamad Abdalkader
- Departments of Radiology and Neurology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Stephanos Finitsis
- Department of Radiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Chuanhui Li
- Stroke Center and Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Wei Hu
- Department of Neurology and Stroke Center, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Xinfeng Liu
- Department of Neurology and Stroke Center, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Fana Alemseged
- Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VC, Australia
| | - Zhongming Qiu
- Department of Neurology, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
| | - Daniel Strbian
- Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Volker Puetz
- Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany,Dresden Neurovascular Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Shadi Yaghi
- Rhode Island Hospital, Brown University, Providence, RI, USA
| | - Kaiz Asif
- Amita Health and University of Illinois-Chicago, Chicago, IL, USA
| | - Piers Klein
- Departments of Radiology and Neurology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Yuyou Zhu
- Department of Neurology and Stroke Center, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Bruce C.V. Campbell
- Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VC, Australia
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Simon Nagel
- Neurology, Heidelberg University Hospital, Heidelberg, Germany,Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Georgios Tsivgoulis
- Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Zhongrong Miao
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Raul G. Nogueira
- Department of Neurology, Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Tudor G. Jovin
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Wouter J. Schonewille
- Department of Neurology, St. Antonius Hospital, Nieuwegein, the Netherlands,Corresponding Author:
| | - Thanh N. Nguyen
- Departments of Radiology and Neurology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA,Corresponding Author:
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Abstract
The CASSISS trial (China Angioplasty & Stenting for Symptomatic Intracranial Severe Stenosis), recently published in JAMA, is the most recent of several randomized controlled trials that have failed to show a benefit of percutaneous angioplasty and stenting over medical therapy for the prevention of stroke due to intracranial atherosclerotic stenosis. Current practice guidelines recommended that percutaneous angioplasty and stenting should not be performed routinely as a treatment for stroke prevention in patients with intracranial atherosclerotic stenosis. The CASSISS trial reinforces those recommendations and will not change practice, but it may provide some important lessons for future trial design.
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Affiliation(s)
- Tanya N Turan
- Department of Neurology, Medical University of South Carolina, Charleston (T.N.T.)
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Mistry EA, Nguyen TN. Blood pressure goals after mechanical thrombectomy: a moving target. Lancet 2022; 400:1558-1559. [PMID: 36341751 DOI: 10.1016/s0140-6736(22)01987-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Eva A Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45267, USA.
| | - Thanh N Nguyen
- Department of Neurology, Neurosurgery and Radiology, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
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34
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Perceptions on basilar artery occlusion management in China versus other countries: Analysis of the after the BEST of BASICS (ABBA) survey. J Stroke Cerebrovasc Dis 2022; 31:106804. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/21/2022] [Accepted: 09/21/2022] [Indexed: 11/23/2022] Open
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35
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Gao P, Wang T, Wang D, Liebeskind DS, Shi H, Li T, Zhao Z, Cai Y, Wu W, He W, Yu J, Zheng B, Wang H, Wu Y, Dmytriw AA, Krings T, Derdeyn CP, Jiao L. Effect of Stenting Plus Medical Therapy vs Medical Therapy Alone on Risk of Stroke and Death in Patients With Symptomatic Intracranial Stenosis: The CASSISS Randomized Clinical Trial. JAMA 2022; 328:534-542. [PMID: 35943472 PMCID: PMC9364128 DOI: 10.1001/jama.2022.12000] [Citation(s) in RCA: 96] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/27/2022] [Indexed: 12/31/2022]
Abstract
Importance Prior randomized trials have generally shown harm or no benefit of stenting added to medical therapy for patients with symptomatic severe intracranial atherosclerotic stenosis, but it remains uncertain as to whether refined patient selection and more experienced surgeons might result in improved outcomes. Objective To compare stenting plus medical therapy vs medical therapy alone in patients with symptomatic severe intracranial atherosclerotic stenosis. Design, Setting, and Participants Multicenter, open-label, randomized, outcome assessor-blinded trial conducted at 8 centers in China. A total of 380 patients with transient ischemic attack or nondisabling, nonperforator (defined as nonbrainstem or non-basal ganglia end artery) territory ischemic stroke attributed to severe intracranial stenosis (70%-99%) and beyond a duration of 3 weeks from the latest ischemic symptom onset were recruited between March 5, 2014, and November 10, 2016, and followed up for 3 years (final follow-up: November 10, 2019). Interventions Medical therapy plus stenting (n = 176) or medical therapy alone (n = 182). Medical therapy included dual-antiplatelet therapy for 90 days (single antiplatelet therapy thereafter) and stroke risk factor control. Main Outcomes and Measures The primary outcome was a composite of stroke or death within 30 days or stroke in the qualifying artery territory beyond 30 days through 1 year. There were 5 secondary outcomes, including stroke in the qualifying artery territory at 2 years and 3 years as well as mortality at 3 years. Results Among 380 patients who were randomized, 358 were confirmed eligible (mean age, 56.3 years; 263 male [73.5%]) and 343 (95.8%) completed the trial. For the stenting plus medical therapy group vs medical therapy alone, no significant difference was found for the primary outcome of risk of stroke or death (8.0% [14/176] vs 7.2% [13/181]; difference, 0.4% [95% CI, -5.0% to 5.9%]; hazard ratio, 1.10 [95% CI, 0.52-2.35]; P = .82). Of the 5 prespecified secondary end points, none showed a significant difference including stroke in the qualifying artery territory at 2 years (9.9% [17/171] vs 9.0% [16/178]; difference, 0.7% [95% CI, -5.4% to 6.7%]; hazard ratio, 1.10 [95% CI, 0.56-2.16]; P = .80) and 3 years (11.3% [19/168] vs 11.2% [19/170]; difference, -0.2% [95% CI, -7.0% to 6.5%]; hazard ratio, 1.00 [95% CI, 0.53-1.90]; P > .99). Mortality at 3 years was 4.4% (7/160) in the stenting plus medical therapy group vs 1.3% (2/159) in the medical therapy alone group (difference, 3.2% [95% CI, -0.5% to 6.9%]; hazard ratio, 3.75 [95% CI, 0.77-18.13]; P = .08). Conclusions and Relevance Among patients with transient ischemic attack or ischemic stroke due to symptomatic severe intracranial atherosclerotic stenosis, the addition of percutaneous transluminal angioplasty and stenting to medical therapy, compared with medical therapy alone, resulted in no significant difference in the risk of stroke or death within 30 days or stroke in the qualifying artery territory beyond 30 days through 1 year. The findings do not support the addition of percutaneous transluminal angioplasty and stenting to medical therapy for the treatment of patients with symptomatic severe intracranial atherosclerotic stenosis. Trial Registration ClinicalTrials.gov Identifier: NCT01763320.
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Affiliation(s)
- Peng Gao
- Departments of Neurosurgery and Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tao Wang
- Departments of Neurosurgery and Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Daming Wang
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - David S. Liebeskind
- David Geffen School of Medicine, Department of Neurology and Comprehensive Stroke Center, University of California, Los Angeles
| | - Huaizhang Shi
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Tianxiao Li
- Department of Cerebrovascular and Neurosurgery, Henan Provincial People’s Hospital, Zhengzhou University, Zhengzhou, China
| | - Zhenwei Zhao
- Department of Neurosurgery, Tangdu Hospital of Air Force Medical University, Xi’an, China
| | - Yiling Cai
- Department of Neurology, Strategic Support Force Medical Center, Beijing, China
| | - Wei Wu
- Department of Neurology, Qilu Hospital of Shandong University, Ji’nan, China
| | - Weiwen He
- Department of Neurosurgery, Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jia Yu
- Department of Neurosurgery, Tangdu Hospital of Air Force Medical University, Xi’an, China
| | - Bingjie Zheng
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Haibo Wang
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Yangfeng Wu
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Adam A. Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Timo Krings
- Department of Medical Imaging, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Colin P. Derdeyn
- Departments of Radiology and Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Liqun Jiao
- Departments of Neurosurgery and Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Wu CH, Chung CP, Chen TY, Yu KW, Lin TM, Tai WA, Luo CB, Chang FC. Influence of angioplasty and stenting on intracranial artery stenosis: preliminary results of high-resolution vessel wall imaging evaluation. Eur Radiol 2022; 32:6788-6799. [DOI: 10.1007/s00330-022-09010-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/13/2022] [Accepted: 06/30/2022] [Indexed: 12/15/2022]
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Kamarova M, Majid A, Bell SM. Reply: Antiplatelet Use in Ischemic Stroke. Ann Pharmacother 2022; 56:1386-1387. [PMID: 35503804 DOI: 10.1177/10600280221096865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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38
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Caton MT, Mark IT, Narsinh KH, Baker A, Cooke DL, Hetts SW, Dowd CF, Halbach VV, Higashida RT, Ko NU, Chung SA, Amans MR. Endovascular Therapy for Intracranial Giant Cell Arteritis : Systematic Review, Technical Considerations and the Effect of Intra-arterial Calcium Channel Blockers. Clin Neuroradiol 2022; 32:1045-1056. [PMID: 35503467 PMCID: PMC9744710 DOI: 10.1007/s00062-022-01171-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/06/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Giant cell arteritis (GCA) is a systemic vasculitis that may cause ischemic stroke. Rarely, GCA can present with aggressive intracranial stenoses, which are refractory to medical therapy. Endovascular treatment (EVT) is a possible rescue strategy to prevent ischemic complications in intracranial GCA but the safety and efficacy of EVT in this setting are not well-described. METHODS A systematic literature review was performed to identify case reports and series with individual patient-level data describing EVT for intracranial GCA. The clinical course, therapeutic considerations, and technique of seven endovascular treatments in a single patient from the authors' experience are presented. RESULTS The literature review identified 9 reports of 19 treatments, including percutaneous transluminal angioplasty (PTA) with or without stenting, in 14 patients (mean age 69.6 ± 6.3 years). Out of 12 patients 8 (66.7%) with sufficient data had > 1 pre-existing cardiovascular risk factor. All patients had infarction on MRI while on glucocorticoids and 7/14 (50%) progressed despite adjuvant immunosuppressive agents. Treatment was PTA alone in 15/19 (78.9%) cases and PTA + stent in 4/19 (21.1%). Repeat treatments were performed in 4/14 (28.6%) of patients (PTA-only). Non-flow limiting dissection was reported in 2/19 (10.5%) of treatments. The indications, technical details, and results of PTA are discussed in a single illustrative case. We report the novel use of intra-arterial calcium channel blocker infusion (verapamil) as adjuvant to PTA and as monotherapy, resulting in immediate improvement in cerebral blood flow. CONCLUSION Endovascular treatment, including PTA with or without stenting or calcium channel blocker infusion, may be effective therapies in medically refractory GCA with intracranial stenosis.
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Affiliation(s)
- M. Travis Caton
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Ian T. Mark
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Kazim H. Narsinh
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Amanda Baker
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Daniel L. Cooke
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Steven W. Hetts
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Christopher F. Dowd
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Van V. Halbach
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Randall T. Higashida
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Nerissa U. Ko
- Department of Neurology, University of California, San Francisco, USA
| | - Sharon A. Chung
- Department of Medicine, Division of Rheumatology, University of California, San Francisco, USA
| | - Matthew R. Amans
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
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