Comparative investigation of transport and deposition of nebulized particles in nasal airways following various middle turbinectomy

BACKGROUND

Topical intranasal medication is required following functional endoscopic sinus surgery (FESS). The optimal particle size of transnasal nebulization aimed at the sinonasal cavities is not conclusive. The current study aims to evaluate the effect of particle size and various surgery scope of middle turbinectomy (MT) on post-full FESS drug delivery to the sinonasal cavities.

METHODS

Sinonasal reconstructions were performed from post-full FESS CT scans in 6 chronic rhinosinusitis with nasal polyps (CRSwNP) patients. Four additional models representing alternative surgery scopes of MT were established from each post-FESS reconstruction for simulation data comparison. Airflow and particle deposition of nebulized delivery were simulated via computational fluid dynamics (CFD) and validated through in vitro experiments. The optimal particle sizes reaching a deposition of at least 75% of the maximum in the targeted regions were identified.

RESULTS

The drug deposition rate onto the targeted regions increased following MT, with the greatest deposition following posterior MT (P-MT). Droplets in the range of 18-26 μm reached a deposition of larger than 75% of the maximum onto the targeted regions. Drug delivery rate in the sinonasal cavities varied significantly among individuals and across different types of MT with varying surgical scopes.

CONCLUSIONS

This study is the first to investigate the effect of various surgery scope on drug delivery by transnasal nebulization to the sinonasal cavities. The findings strongly affirm the vast potential of transnasal nebulization as an effective post-FESS treatment option. Moreover, it emphasizes that the drug delivery process via atomizers to the nasal cavity and paranasal sinuses is highly sensitive to the particle size.

Safety of early antiplatelet therapy in non-cardioembolic mild stroke patients with thrombocytopenia

OBJECTIVES

To investigate the safety of early antiplatelet therapy in non-cardioembolic mild stroke patients with thrombocytopenia.

METHODS

Data of acute ischemic stroke patients with baseline National Institutes of Health Stroke scale (NIHSS) score ≤3 and a platelet count <100×109/L were obtained from a multicenter register. Those who required anticoagulation or had other contraindications to antiplatelet therapy were excluded. Short-term safety outcomes were in-hospital bleeding events, while the long-term safety outcome was 1-year all-cause death. The short-term neurological outcomes were evaluated by modified Rankin scale (mRS) score at discharge.

RESULTS

A total of 1868 non-cardioembolic mild stroke patients with thrombocytopenia were enrolled in this study. Multivariate regression analyses showed that mono-antiplatelet therapy significantly increased the proportion of mRS of 0-1 at discharge (OR=1.657, 95%CI: 1.253-2.192, P<0.01) and did not increase the risk of hemorrhage (OR=2.359, 95%CI: 0.301-18.503, P>0.05), compared to those without antiplatelet therapy. However, dual-antiplatelet therapy did not bring more neurological benefits (OR=0.923, 95%CI: 0.690-1.234, P>0.05), but increased the risk of gastrointestinal bleeding (OR=2.837, 95%CI: 1.311-6.136, P<0.01), compared with those with mono-antiplatelet therapy. For patients with platelet counts ≤75×109/L and >90×109/L, antiplatelet therapy significantly improved neurological functional outcomes (P<0.05). In contrast, for patients with platelet counts (>75-90)×109/L, antiplatelet therapy resulted in a significant improvement of 1-year survival (P<0.05). Even with concurrent coagulation abnormalities, monotherapy did not increase the risk of various types of bleeding (all P>0.05) and improved neurological functional outcomes (all P<0.01). There was no significant difference in the occurrence of bleeding events, one-year all-cause mortality risk, and neurological functional outcomes between aspirin and clopidogrel (all P>0.05).

CONCLUSIONS

For non-cardioembolic mild stroke patients with thrombocytopenia, antiplatelet therapy is still reasonable. Mono-antiplatelet therapy has the same efficiency as dual-antiplatelet therapy in neurological outcome improvement with lower risk of gastrointestinal bleeding.

Influencing factors of futile recanalization after endovascular intervention in patients with acute basilar artery occlusion

OBJECTIVES

To explore the influence factors for futile recanalization following endovascular treatment (EVT) in patients with acute basilar artery occlusion (BAO).

METHODS

Clinical data of patients with acute BAO, who underwent endovascular treatment within 24 h of onset from January 2017 to November 2022, were retrospectively analyzed. The futile recanalization was defined as modified Thrombolysis in Cerebral Infarction (mTICI)≥2b or 3 after successful reperfusion, but the modified Rankin Scale score >2 at 90d after EVT. Binary logistic regression model was used to analyze the influencing factors of futile recanalization.

RESULTS

A total of 471 BAO patients with a median age of 68 (57-74) years were included and 68.9% were males, among whom 298 (63.27%) experienced futile recanalization. Multivariate analysis revealed that concomitant atrial fibrillation (OR=0.456, 95%CI: 0.287-0.737, P<0.01), bridging thrombolysis (OR=0.640, 95%CI: 0.416-0.985, P<0.05), achieving mTICI grade 3 (OR=0.554, 95%CI: 0.334-0.918, P<0.05), arterial occlusive lesion (AOL) grade 3 (OR=0.521, 95%CI: 0.326-0.834, P<0.01), and early postoperative statin therapy (OR=0.509, 95%CI: 0.273-0.948, P<0.05) were protective factors for futile recanalization after EVT in acute BAO patients; while high baseline National Institutes of Health Stroke Scale (NIHSS) score (OR=1.068, 95%CI: 1.049-1.087, P<0.01), coexisting hypertension (OR=1.571, 95%CI: 1.017-2.427, P<0.05), multiple retrieval attempts (OR=1.237, 95%CI: 1.029-1.488, P<0.05) and postoperative hemorrhagic transformation (OR=8.497, 95%CI: 2.879-25.076, P<0.01) were risk factors. For TOAST classification, cardiogenic embolism (OR=0.321, 95% CI: 0.193-0.534, P<0.01) and other types (OR=0.499, 95% CI: 0.260-0.961, P<0.05) were also an independent risk factors for futile recanalization after EVT in acute BAO.

CONCLUSIONS

The incidence of futile recanalization after EVT in patients with acute BAO is high. Bridging venous thrombolysis before operation and an early postoperative statin therapy may reduce the incidence of futile recanalization.

Effect of anesthesia mode during endovascular treatment on neurological functional outcomes in patients with acute posterior circulation stroke

OBJECTIVES

To compare the effect of anesthesia mode on the neurological functional outcomes in patients undergoing endovascular treatment for acute posterior circulation ischemic stroke.

METHODS

Conscious sedation and general anesthesia clinical data of 656 patients undergoing intravascular therapy for acute posterior circulation ischemic stroke registered in online Acute Stroke Patients for Stroke Management Quality Evaluation Database from January 2017 to December 2022 were retrospectively analyzed, including 163 cases received conscious sedation and 493 cases received general anesthesia during the procedure. After propensity score matching, 428 patients were included in the analysis, including 155 cases in the conscious sedation group and 273 cases in the general anesthesia group. The differences of operation mode, etiology type, vascular recanalization, hemorrhagic transformation at 24 h, mRS score at 3 months and mortality within 3 months were compared between two groups. Binary logistic regression was used to explore the effect of different anesthesia mode on neurological functional outcomes.

RESULTS

There was significant difference in operation mode between two groups (P<0.01), while there were no significant differences in etiology type, good vascular recanalization, hemorrhagic transformation at 24 h, mRS score at 3 months or mortality within 3 months (all P>0.05). Binary logistic regression analysis revealed that anesthesia modes were not significantly associated with functional outcomes of patients (OR=1.151, 95%CI: 0.751-1.765, P=0.519).

CONCLUSIONS

Anesthesia mode (conscious sedation or general anesthesia) will not affect the neurological functional outcomes in patients with acute posterior circulation ischemic stroke undergoing endovascular treatment. The anesthesia mode can be chosen according to the condition of the treatment center and patients.

Association between baseline hemoglobin level and early neurological deterioration after intravenous thrombolysis in patients with acute ischemic stroke

OBJECTIVES

To investigate the association between baseline hemoglobin level and early neurologic deterioration (END) after intravenous thrombolysis in patients with acute ischemic stroke (AIS).

METHODS

Data of AIS patients who received intravenous thrombolytic therapy at multiple hospitals across the country between January 2017 and July 2020 were collected from the online database Acute Stroke Patients for stroke Management Quality Evaluation (CASE-Ⅱ, NCT04487340). Binary logistic regression analysis was used to study the factors affecting the occurrence of END after intravenous thrombolytic therapy, and the correlation between baseline hemoglobin level and END was investigated by limiting cubic spline curve.

RESULTS

A total of 8162 patients were included. Patients with END had lower baseline hemoglobin levels (136 and 140 g/L, P<0.01) and higher rates of anemia (24.2% and 16.9%, P<0.01) compared with non-END patients. Binary logistic regression analysis showed that baseline hemoglobin level (OR=0.995, 95%CI: 0.991-0.999, P<0.05) and anemia (OR=1.238, 95%CI: 1.055-1.454, P<0.01) were independently correlated with the occurrence of END after intravenous thrombolysis in AIS patients. Restricted cubic spline regression showed that there was a U-shaped relationship between hemoglobin level and the risk of END after intravenous thrombolysis in AIS patients (P<0.01); while the relationship only existed in male patients (P<0.05), not in female patients (P>0.05).

CONCLUSIONS

There is a U-shaped correlation between baseline hemoglobin level and the risk of END in AIS patients after intravenous thrombolysis, that is, both lower and higher hemoglobin level may increase the risk of END.

Presence of Residual Cardiac Thrombus Predicts Poor Outcome in Cardioembolic Stroke After Reperfusion Therapy

BACKGROUND

In patients with acute cardiogenic cerebral embolism, a residual thrombus may still be present in the cardiac cavity even after reperfusion therapy. We aimed to investigate the occurrence of a residual cardiac thrombus in cardioembolic stroke after reperfusion therapy and analyze its impact on clinical outcome.

METHODS AND RESULTS

We enrolled patients with cardioembolic stroke from our prospectively collected database who underwent 2-phase cardiac computed tomography within 7 days after reperfusion therapy. Residual cardiac thrombus was defined as a filling defect on both early- and late-phase images, whereas circulatory stasis was defined as a filling defect only on the early-phase images in the left atrial appendage. The primary outcome was a poor clinical outcome (modified Rankin Scale score, 3-6) at 90 days. The secondary outcome was a composite end point event (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke) at 90 days. A total of 303 patients were included, of whom 94 (31.0%) had a residual cardiac thrombus. Binary logistic regression analysis showed that the presence of a residual cardiac thrombus was associated with a poor clinical outcome (odds ratio, 1.951 [95% CI, 1.027-3.707]; P=0.041) but not circulatory stasis in the left atrial appendage (odds ratio, 1.096 [95% CI, 0.542-2.217]; P=0.798). Furthermore, there was no correlation between a residual cardiac thrombus and the composite end point event (30.0% versus 31.1%; P=1.000).

CONCLUSIONS

Residual cardiac thrombus occurs in approximately one-third of patients with cardioembolic stroke after reperfusion therapy and is often indicative of a poor clinical outcome.

The Association of Allergy-Related and Non-Allergy-Related Olfactory Impairment with Cognitive Function in Older Adults: Two Cross-Sectional Studies

BACKGROUND

Evidence on the association of Olfactory Impairment (OI) with age-related cognitive decline is inconclusive, and the potential influence of allergy remains unclear.

OBJECTIVE

We aimed to evaluate the cross-sectional associations of allergy-related and non-allergy- related OI to cognitive function.

METHODS

We included 2,499 participants from the Health and Retirement Study (HRS)-Harmonized Cognitive Assessment Protocol (HCAP) sub-study and 1,086 participants from the English Longitudinal Study of Ageing (ELSA)-HCAP. The Olfactory Function Field Exam (OFFE) using Sniffin' Stick odor pens was used to objectively assess olfactory function and an olfactory score <6/11 indicated OI. Mini-Mental Status Examination (MMSE) was used to assess global cognitive function and define cognitive impairment (<24/30). A neuropsychologic battery was used to assess five cognitive domains.

RESULTS

Compared to non-OI participants, individuals with OI had lower MMSE z-score [βHRS = -0.33, 95% Confidence Interval (CI): -0.41 to -0.24; βELSA = -0.31, -0.43 to -0.18] and higher prevalence of cognitive impairment [Prevalence Ratio (PR)HRS = 1.46, 1.06 to 2.01; PRELSA = 1.63, 1.26 to 2.11]. The associations were stronger for non-allergy-related OI (βHRS = -0.36; βELSA = -0.34) than for allergy-related OI (βHRS = -0.26; βELSA = 0.13). Similar associations were observed with domain- specific cognitive function measures.

CONCLUSION

OI, particularly non-allergy-related OI, was related to poorer cognitive function in older adults. Although the current cross-sectional study is subject to several limitations, such as reverse causality and residual confounding, the findings will provide insights into the OI-cognition association and enlighten future attention to non-allergy-related OI for the prevention of potential cognitive impairment.

Association of Atrial Fibrillation with Remote Intracerebral Hemorrhage After Intravenous Thrombolysis: Results from a Multicenter Study in China

INTRODUCTION

This study aimed to investigate the association between atrial fibrillation (AF), particularly newly diagnosed AF, and remote intracerebral hemorrhage (rICH) in patients with ischemic stroke who were treated with intravenous thrombolysis (IVT).

METHODS

This observational study was conducted on patients with ischemic stroke who received IVT with recombinant tissue-type plasminogen activator. The data were taken from a multicenter prospective registry of a Chinese population. rICH was defined as any extraischemic hemorrhage detected on computerized tomography (CT) 24 h after intravenous thrombolysis. We collected and compared the demographic data and clinical characteristics of all the patients with rICH to those of patients without any type of hemorrhagic transformation. The association between AF and rICH was analyzed using univariate analysis and binary logistic regression.

RESULTS

A total of 20,697 patients were included in the study, with 1566 (7.6%) experiencing intracerebral hemorrhage (ICH), 586 (2.8%) experiencing rICH, and 19,131 (92.4%) not experiencing any form of hemorrhagic transformation. Univariate analysis revealed significant differences in age, pre-thrombolysis systolic blood pressure, baseline National Institute of Health Stroke Scale score, previously known AF, newly diagnosed AF, coronary heart disease, congestive heart failure, hyperhomocysteinemia, and history of thrombolysis between the rICH and control groups (P < 0.05). Further multivariate logistic regression analysis indicated that total AF (OR 1.821, 95% CI 1.082-3.065, P < 0.05), previously known AF (OR 1.470, 95% CI 1.170-1.847), and newly diagnosed AF (OR 1.920, 95% CI 1.304-2.825) were independently associated with rICH.

CONCLUSIONS

This study suggests that AF, regardless of whether it is newly diagnosed or previously known, may be associated with the occurrence of rICH following intravenous thrombolysis. Interestingly, our findings suggest that newly diagnosed AF may have a stronger impact on rICH than previously known AF, although confirmation from more studies is needed.

Argatroban in Patients With Acute Ischemic Stroke With Early Neurological Deterioration: A Randomized Clinical Trial

Importance

The effect of argatroban in patients with acute ischemic stroke (AIS) and early neurological deterioration (END) is unknown.

Objective

To assess the efficacy of argatroban for END in AIS.

Design, Setting, and Participants

This open-label, blinded-end point, randomized clinical trial was conducted from April 4, 2020, through July 31, 2022. The date of final follow-up was October 31, 2022. This was a multicenter trial. Eligible patients were adults with AIS who experienced END, which was defined as an increase of 2 or more points on the National Institutes of Health Stroke Scale within 48 hours from symptom onset. Patients who withdrew consent, experienced duplicate randomization, or were lost to follow-up were excluded from the study.

Interventions

Patients were randomly assigned to the argatroban group and control group within 48 hours of symptom onset. Both groups received standard therapy based on guidelines, including oral mono or dual antiplatelet therapy. The argatroban group received intravenous argatroban for 7 days (continuous infusion at a dose of 60 mg per day for 2 days, followed by 20 mg per day for 5 days) in addition to standard therapy.

Main Outcome and Measure

The primary end point was good functional outcome at 90 days, defined as a modified Rankin Scale score of 0 to 3.

Results

A total of 628 patients (mean [SD] age, 65 [11.9] years; 400 male [63.7%]) were included in this study (argatroban group, 314 [50%] and control group, 314 [50%]). Of these, 18 withdrew consent, 1 had duplicate randomization, and 8 were lost to follow-up. A total of 601 patients with stroke were included in the intention-to-treat analysis. Finally, 564 patients were included in the per-protocol analysis as 6 participants in the argatroban group and 31 participants in the control group did not follow the complete protocol. The number of patients with good functional outcome at 90 days was 240 (80.5%) in the argatroban group and 222 (73.3%) in the control group (risk difference, 7.2%; 95% CI, 0.6%-14.0%; risk ratio, 1.10; 95% CI, 1.01-1.20; P = .04). The proportion of symptomatic intracranial hemorrhage was 3 of 317 (0.9%) in the argatroban group and 2 of 272 (0.7%) in the control group (P = .78).

Conclusions and Relevance

Among patients with AIS with END, treatment with argatroban and antiplatelet therapy resulted in a better functional outcome at 90 days. This trial provided evidence to support the use of argatroban in reducing disability for patients with END.

Trial Registration

ClinicalTrials.gov Identifier: NCT04275180.

Effect of computed tomography vs. computed tomography perfusion on mechanical thrombectomy outcomes within 6 hours

OBJECTIVES

It is unclear which selection strategy, plain CT vs. CT perfusion (CTP), is more powerful in predicting outcome after mechanical thrombectomy (MT). We aimed to compare the effect of plain CT and CTP in predicting outcome after MT within 6 h.

METHODS

We conducted a prospective analysis of a retrospective cohort from our single-center study, which had occlusion of the internal carotid artery and middle cerebral artery up to the proximal M2 segment and received MT within 6 h. According to the Alberta Stroke Program Early CT Score (ASPECTS), patients were divided into a high-ASPECTS group (≥ 6) and a low ASPECTS group (< 6). Similarly, patients were divided into mismatch and no-mismatch groups according to the DEFUSE3 criteria for CTP. A good outcome was defined as a 90-day modified Rankin Scale (mRS) score of ≤ 3. Univariate and binary logistic regression analyses were used to investigate the association between different imaging modality and 90-day mRS score, and mortalities, respectively.

RESULTS

The high ASPECTS group included 307 patients (89.2%). The mismatch group included 189 (54.9%) patients meeting the DEFUSE3 criterion. Compared to the low ASPECTS group, the high ASPECTS group had a good outcome (odds ratio (OR), 2.285; [95% confidence interval (CI) (1.106, 4.723)], p = 0.026) and lower mortality (OR, 0.350; [95% CI (0.163, 0.752)], p = 0.007). However, there were no significant differences in good outcomes and mortality between the mismatch and no-mismatch groups.

CONCLUSIONS

Compared with plain CT, CTP does not provide additional benefits in the selection of patients suitable for MT within 6 h.

CLINICAL RELEVANCE STATEMENT

CT perfusion is not superior to plain CT for the prediction of clinical outcomes when selecting patients for mechanical thrombectomy in the first 6 h. In that clinical setting, plain CT may be safe in the absence of perfusion data.

KEY POINTS

• The advantage of CT perfusion (CTP) over CT in pre-mechanical thrombectomy (MT) screening has not been proven for patients with a large infarct core. • CTP is not better than plain CT in predicting good outcome following MT within 6 h. • Plain CT is sufficient for selecting patients suitable for MT within 6 h of large artery occlusion.

Higher Functional Connectivity of Ventral Attention and Visual Network to Maintain Cognitive Performance in White Matter Hyperintensity

Ventral attention network (VAN), associated with cognitive performance, is one of the functional networks that are most vulnerable in white matter hyperintensity (WMH). Considering the global interaction of networks for cognitive performance, we hypothesized that VAN-related between-network connectivity might play a role in maintaining cognition in patients with WMH. We included 139 participants for both cross-sectional and longitudinal analysis from CIRCLE study (ClinicalTrials.gov ID: NCT03542734) between January 2014 and January 2021. Differences of VAN-related between-network connectivity were compared between normal-cognition (NC) and cognitive-impairment (CI) groups cross-sectionally, and between cognitive-decline (CD) and cognitive non-decline (CND) groups longitudinally by using t-test. False Discovery Rate was used for multiple comparison correction. The relationship between the network connectivity and WMH was tested on linear and quadratic models. Subgroup analysis of different WMH burdens were performed to test the difference of network connectivity between NC and CI groups. Among VAN-related between-network connectivity, only VAN-Visual Network (VN) connectivity was higher both in NC (n = 106) and CND (n = 113) groups versus CI (n = 33) and CD groups (n = 26), respectively. There was an inverted U-shaped relation between periventricular WMH (PWMH) burden and VAN-VN connectivity. Normal-cognition participants had higher VAN-VN connectivity among high, but not low PWMH burden subgroups. These findings suggest that the VAN-VN connectivity plays an important role in maintaining cognitive performance in WMH patients. It may serve as a unique marker for cognitive prediction and a potential target for intervention to prevent cognitive decline in WMH patients.

Effect of bleeding risk prediction on decision making of intravenous thrombolysis before thrombectomy: a subgroup analysis of DIRECT-MT

BACKGROUND

The major concern for bridging intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) is the potentially increased risk of symptomatic intracerebral hemorrhage (sICH). Thus we conducted this study to clarify whether evaluation of individual bleeding risk could assist in the decision to perform IVT before EVT.

METHODS

The study was a subgroup analysis of a randomized trial evaluating the safety and efficacy of IVT before EVT. The SEDAN (blood Sugar, Early infarct signs and (hyper) Dense cerebral artery sign, Age, and National Institutes of Health Stroke Score) score, GRASPS (Glucose, Race, Age, Sex, systolic blood Pressure, and Severity of stroke) score, and SITS-SICH (Safe Implementation of Thrombolysis in Stroke-Symptomatic Intracerebral Hemorrhage) score were used to evaluate individual bleeding risk. The primary outcome was functional independence, defined as a modified Rankin Scale (mRS) score of 0-2 at 90 days. Binary logistic regression with an interaction term was used to estimate treatment effect modification to clarify whether direct EVT was more beneficial in patients with a higher sICH risk, while adjunctive IVT before EVT was more beneficial in patients with a lower sICH risk.

RESULTS

Among 658 randomized patients, 639 (361 men, 56.5%; median age 69 (IQR 61-76) years) were included in the study. With the SITS-SICH score as an example, adjusted OR for functional independence with EVT alone was 1.12 (95% CI 0.68 to 1.82) in patients with a lower sICH risk (SITS-SICH score 0-4) and 0.92 (0.53 to 1.60) in those with a higher sICH risk (SITS-SICH score 5-15). There were no treatment-by-bleeding-risk interactions for all dichotomized mRS outcomes based on the three scores (all p>0.05).

CONCLUSIONS

We found no evidence that clinicians can decide whether to omit IVT before EVT based on an individualized assessment of bleeding risk.

Prevalent stroke, age of its onset, and post-stroke lifestyle in relation to dementia: A prospective cohort study

INTRODUCTION

The association of age at stroke onset with dementia and the role of post-stroke lifestyle on dementia risk remains unclear.

METHODS

We leveraged data of 496,251 dementia-free participants from UK Biobank and explored the relationship between age at stroke onset and incident dementia. Among 8328 participants with stroke history, we further investigated the association of a healthy lifestyle with risk of dementia.

RESULTS

Participants with stroke history had a higher risk of dementia (hazard ratio [HR], 2.02). The association was stronger among participants with stroke onset at a younger age (≤50: HR, 2.63) compared with those at the age > 50 years (50-60: HR, 2.17; ≥60: HR, 1.58). Among participants with stroke history, a favorable lifestyle was associated with a lower risk of incident dementia.

DISCUSSION

Stroke onset in earlier life stage predicted a higher risk for dementia, but a favorable post-stroke lifestyle may protect against dementia.

Low-density lipoprotein cholesterol, statin therapy, and cerebral microbleeds: The CIRCLE study

BACKGROUND

Current evidence suggests a potential association between cerebral microbleeds (CMBs), low-density lipoprotein cholesterol (LDL-C) levels, and statin use, but the exact relationship remains unclear. This study aims to prospectively examine these relationships in a stroke-free population.

METHODS

From January 2010 to January 2020, we enrolled stroke-free individuals with at least one cerebral small vessel disease imaging marker from the CIRCLE study (ClinicalTrials.gov ID: NCT03542734). Participants underwent baseline and 1-year follow-up susceptibility-weighted imaging (SWI), and baseline LDL-C testing. New CMBs were categorized as strictly lobar and deep CMBs based on location.

RESULTS

A total of 209 individuals were included. Baseline serum LDL-C levels were divided into quartiles: Q1 (≤1.76 mmol/L), Q2 (1.77-2.36 mmol/L), Q3 (2.37-2.93 mmol/L), and Q4 (>2.93 mmol/L). The incidence of new deep CMBs was 30.0%, 11.1%, 10.9%, 8.2% in Q1, Q2, Q3, Q4, respectively. Multivariate logistic model revealed that only LDL-C in Q1 was associated with increased incidence of new deep CMBs (OR = 4.256; 95% CI: 1.156-15.666; p = 0.029). In a subset of 169 participants without prior statin use, the use of atorvastatin was associated with reduced occurrence of new deep CMBs (OR = 0.181; 95% CI: 0.035-0.928; p = 0.040), while it was not found with rosuvastatin (OR = 0.808; 95% CI: 0.174-3.741; p = 0.785).

CONCLUSIONS

While lower LDL-C levels were associated with higher CMB development, statin therapy did not increase the risk of new CMBs. Atorvastatin even demonstrated a protective effect.

Treatment with intravenous alteplase in ischaemic stroke patients with onset time between 4.5 and 24 hours (HOPE): protocol for a randomised, controlled, multicentre study

BACKGROUND

While intravenous thrombolysis is recommended for patients who had an acute ischaemic stroke (AIS) within 4.5 hours of symptom onset, there are few randomised trials investigating the benefits of thrombolysis beyond this therapeutic window.

AIM

To determine whether patients who had an AIS selected with the presence of potentially salvageable tissue on CT perfusion at 4.5-24 hours after stroke onset (for stroke with unknown onset time, the midpoint of the time last known to be well and symptom recognition time; for wake-up stroke, the midpoint of the time last known to be well or sleep onset and wake up time) will benefit from intravenous thrombolysis.

DESIGN

HOPE is a prospective, multicentre, randomised, open-label blinded endpoint trial with the stage of phase III. The treatment allocation employs 1:1 randomisation. The treatment arm under investigation is alteplase with standard therapy, the control arm is standard therapy. Eligibility imaging criteria include ischaemic core volume ≤70 mL, penumbra ≥10 mL and mismatch ≥20%.

STUDY OUTCOMES

The primary outcome is non-disabled functional outcome (assessed as modified Rankin Scale score of 0-1 at 90 days).

DISCUSSION

HOPE is the first trial to investigate whether intravenous thrombolysis with alteplase offers benefits in patients who had an AIS presenting within 4.5-24 hours, which has the potential to extend time window and expand eligible population for thrombolysis therapy.

Impact of Cerebral Microbleeds in Stroke Patients with Atrial Fibrillation

OBJECTIVES

Cerebral microbleeds are associated with the risks of ischemic stroke and intracranial hemorrhage, causing clinical dilemmas for antithrombotic treatment decisions. We aimed to evaluate the risks of intracranial hemorrhage and ischemic stroke associated with microbleeds in patients with atrial fibrillation treated with vitamin K antagonists, direct oral anticoagulants, antiplatelets, and combination therapy (i.e. concurrent oral anticoagulant and antiplatelet).

METHODS

We included patients with documented atrial fibrillation from the pooled individual patient data analysis by the Microbleeds International Collaborative Network. Risks of subsequent intracranial hemorrhage and ischemic stroke were compared between patients with and without microbleeds, stratified by antithrombotic use.

RESULTS

A total of 7,839 patients were included. The presence of microbleeds was associated with an increased relative risk of intracranial hemorrhage (adjusted hazard ratio [aHR] = 2.74, 95% confidence interval = 1.76-4.26) and ischemic stroke (aHR = 1.29, 95% confidence interval = 1.04-1.59). For the entire cohort, the absolute incidence of ischemic stroke was higher than intracranial hemorrhage regardless of microbleed burden. However, for the subgroup of patients taking combination of anticoagulant and antiplatelet therapy, the absolute risk of intracranial hemorrhage exceeded that of ischemic stroke in those with 2 to 4 microbleeds (25 vs 12 per 1,000 patient-years) and ≥ 11 microbleeds (94 vs 48 per 1,000 patient-years).

INTERPRETATION

Patients with atrial fibrillation and high burden of microbleeds receiving combination therapy have a tendency of higher rate of intracranial hemorrhage than ischemic stroke, with potential for net harm. Further studies are needed to help optimize stroke preventive strategies in this high-risk group. ANN NEUROL 2023;94:61-74.

Glymphatic function plays a protective role in ageing-related cognitive decline

OBJECTIVE

The glymphatic pathway, characterised as a cerebral drainage system, influences cognitive function in neurodegenerative diseases; however, evidence is limited in a normal ageing population. The aim of this study was to investigate the effect of glymphatic function on ageing-related cognitive decline.

METHODS

We retrospectively reviewed the Cognitive Impairment, Retinopathy, and Cerebrovascular Lesions in the Elderly (CIRCLE) study, and participants with multi-model magnetic resonance imaging (MRI) scans and Mini-Mental State Examinations (MMSE) were enrolled. Glymphatic function was evaluated via the diffusion tensor imaging along the perivascular space (DTI-ALPS) index. Regression models were used to estimate the impact of the DTI-ALPS index on cognitive decline cross-sectionally and longitudinally. We further analysed the mediation effect of the DTI-ALPS on age and cognitive function.

RESULTS

A total of 633 participants were included in this study (48.2% female; mean age, 62.8 ± 8.9 years). The DTI-ALPS index was positively associated with cognitive function cross-sectionally (β = 0.108, P = 0.003), and was an independent protective factor for cognitive decline longitudinally (odds ratio (OR) = 0.029, P = 0.007). The DTI-ALPS index declined progressively with ageing (r = -0.319, P <0.001), and the decrease was more pronounced after 65 years of age. Furthermore, the DTI-ALPS index mediated the relationship between age and MMSE score (β = -0.016, P <0.001). The mediation effect accounted for 21.3%, which was higher in subjects aged over 65 years (25.3%) compared with those aged under 65 years (5.3%).

CONCLUSION

Glymphatic function played a protective role in normal ageing-related cognitive decline, which may serve as a potential therapeutic target against cognitive decline in future.

Age- and time-of-day dependence of glymphatic function in the human brain measured via two diffusion MRI methods

Advanced age, accompanied by impaired glymphatic function, is a key risk factor for many neurodegenerative diseases. To study age-related differences in the human glymphatic system, we measured the influx and efflux activities of the glymphatic system via two non-invasive diffusion magnetic resonance imaging (MRI) methods, ultra-long echo time and low-b diffusion tensor imaging (DTI_low-b) measuring the subarachnoid space (SAS) flow along the middle cerebral artery and DTI analysis along the perivascular space (DTI-ALPS) along medullary veins in 22 healthy volunteers (aged 21-75 years). We first evaluated the circadian rhythm dependence of the glymphatic activity by repeating the MRI measurements at five time points from 8:00 to 23:00 and found no time-of-day dependence in the awake state under the current sensitivity of MRI measurements. Further test-retest analysis demonstrated high repeatability of both diffusion MRI measurements, suggesting their reliability. Additionally, the influx rate of the glymphatic system was significantly higher in participants aged >45 years than in participants aged 21-38, while the efflux rate was significantly lower in those aged >45 years. The mismatched influx and efflux activities in the glymphatic system might be due to age-related changes in arterial pulsation and aquaporin-4 polarization.

Impaired intracranial venous outflow profiles are associated with poor outcome in stroke after reperfusion therapy: A hypoperfusion-matched intracranial venous scale

PURPOSE

Arterial blood flow provided prognostic information in acute ischemic stroke (AIS). However, part of the patients with favorable arterial blood flow still suffered from poor outcomes after reperfusion therapy. We aimed to verify the hypothesis that intracranial venous outflow profiles (both cortical and deep) within the hypoperfusion area were associated with clinical outcome in AIS patients who received reperfusion therapy.

METHOD

We performed a retrospective analysis of prospectively collected data from anterior circulation AIS patients. All patients underwent pretreatment CTP and received reperfusion therapy. We constructed a 5-point hypoperfusion-matched Intracranial Venous Scale (hypo-IVS) from the sum of the contrast enhancement degree (1, attenuated contrast enhancement; 0, complete contrast enhancement) of 4 typical veins (superficial middle cerebral vein, vein of Labbé, vein of Trolard, and internal cerebral vein) whose outflow territories had matched hypoperfusion. Logistic and ordinal regression were used to analyze the association between hypo-IVS and clinical outcome.

RESULTS

A total of 751 patients were included. Higher Hypo-IVS was significantly associated with poor outcome (3-month mRS of >2; OR = 1.194; 95 % CI: 1.014-1.407; p = 0.033). The adjusted ORs for poor outcome and high 24-hour NIHSS were 1.172 (95 %CI: 1.035-1.328; p = 0.012) and 1.176 (95 %CI: 1.030-1.330; p = 0.010) in ordinal regression, respectively. Hypo-IVS > 2 was an independent risk factor of poor outcome (75.2 % vs 40.8 %; OR = 1.932; 95 %CI: 1.158-3.224; p = 0.012).

CONCLUSIONS

Intracranial venous outflow profiles deliver prognostic information in AIS and the hypo-IVS is a helpful tool to predict clinical outcomes after reperfusion therapy.

Choroid Plexus Enlargement Exacerbates White Matter Hyperintensity Growth through Glymphatic Impairment

OBJECTIVE

Choroid plexus (CP) is a key regulator in cerebrospinal fluid production, but its contribution to glymphatic clearance function and association with white matter hyperintensity (WMH) remains unclear.

METHODS

This retrospective study included 2 prospective 3.0-T magnetic resonance imaging (MRI) cohorts. In cohort 1, patients with indications for lumbar puncture underwent 3-dimensional T1-weighted sequence (3D-T1) before and at 39 hours after intrathecal administration of contrast agent (glymphatic MRI). In cohort 2, patients with WMH were enrolled from the CIRCLE study and had a median follow-up time of 1.4 years. WMH and CP of the lateral ventricles were automatically segmented on T2 fluid-attenuated inversion recovery (FLAIR) and 3D-T1, respectively. CP volume was expressed as a ratio to intracranial volume. Glymphatic clearance was measured as signal percentage change from baseline to 39 hours at 8 brain locations based on glymphatic MRI in the first cohort, or as noninvasive diffusion tensor image analysis along the perivascular space (DTI-ALPS) index based on DTI in the second cohort.

RESULTS

In cohort 1, a total of 52 patients were included. Higher CP volume was correlated with slower glymphatic clearance rate in all brain locations. In cohort 2, a total of 197 patients were included. Baseline CP volume was positively associated with WMH volume and its growth. Furthermore, DTI-ALPS index partially mediated the association of CP with both WMH load and growth.

INTERPRETATIONS

Enlarged CP volume could be an indicator for larger growth of WMH, potentially involving impaired glymphatic clearance function. The exploration of CP may provide a novel perspective to clarify the mechanism of WMH pathogenesis, as well as other glymphatic-related disorders. ANN NEUROL 2023.

Estimated Burden of Stroke in China in 2020

IMPORTANCE

Stroke is the leading cause of death in China. However, recent data about the up-to-date stroke burden in China are limited.

OBJECTIVE

To investigate the urban-rural disparity of stroke burden in the Chinese adult population, including prevalence, incidence, and mortality rate, and disparities between urban and rural populations.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was based on a nationally representative survey that included 676 394 participants aged 40 years and older. It was conducted from July 2020 to December 2020 in 31 provinces in mainland China.

MAIN OUTCOMES AND MEASURES

Primary outcome was self-reported stroke verified by trained neurologists during a face-to-face interviews using a standardized protocol. Stroke incidence were assessed by defining first-ever strokes that occurred during 1 year preceding the survey. Strokes causing death that occurred during the 1 year preceding the survey were considered as death cases.

RESULTS

The study included 676 394 Chinese adults (395 122 [58.4%] females; mean [SD] age, 59.7 [11.0] years). In 2020, the weighted prevalence, incidence, and mortality rates of stroke in China were 2.6% (95% CI, 2.6%-2.6%), 505.2 (95% CI, 488.5-522.0) per 100 000 person-years, and 343.4 (95% CI, 329.6-357.2) per 100 000 person-years, respectively. It was estimated that among the Chinese population aged 40 years and older in 2020, there were 3.4 (95% CI, 3.3-3.6) million incident cases of stroke, 17.8 (95% CI, 17.5-18.0) million prevalent cases of stroke, and 2.3 (95% CI, 2.2-2.4) million deaths from stroke. Ischemic stroke constituted 15.5 (95% CI, 15.2-15.6) million (86.8%) of all incident strokes in 2020, while intracerebral hemorrhage constituted 2.1 (95% CI, 2.1-2.1) million (11.9%) and subarachnoid hemorrhage constituted 0.2 (95% CI, 0.2-0.2) million (1.3%). The prevalence of stroke was higher in urban than in rural areas (2.7% [95% CI, 2.6%-2.7%] vs 2.5% [95% CI, 2.5%-2.6%]; P = .02), but the incidence rate (485.5 [95% CI, 462.8-508.3] vs 520.8 [95% CI, 496.3-545.2] per 100 000 person-years; P < .001) and mortality rate (309.9 [95% CI, 291.7-328.1] vs 369.7 [95% CI, 349.1-390.3] per 100 000 person-years; P < .001) were lower in urban areas than in rural areas. In 2020, the leading risk factor for stroke was hypertension (OR, 3.20 [95% CI, 3.09-3.32]).

CONCLUSIONS AND RELEVANCE

In a large, nationally representative sample of adults aged 40 years or older, the estimated prevalence, incidence, and mortality rate of stroke in China in 2020 were 2.6%, 505.2 per 100 000 person-years, and 343.4 per 100 000 person-years, respectively, indicating the need for an improved stroke prevention strategy in the general Chinese population.

[Effect of methylene blue labeling on therapeutic effect and prognosis of gastric cancer patients in D2 radical gastrectomy under laparoscope]

Objective: To investigate the effect of methylene blue tracing on the effect of surgical resection and the prognosis of gastric cancer patients in D2 radical surgery under laparoscope. Methods: In this retrospective cohort study, 160 patients with advanced gastric cancer who underwent surgical treatment in Xinxiang Central Hospital, the 4th Clinical College of Xinxiang Medical College from January 2016 to January 2019 were selected for retrospective analysis. Among them, 84 patients underwent laparoscopic D2 radical gastrectomy for gastric cancer combined with methylene blue labeling operation (labeling group), and the other 76 patients underwent only laparoscopic D2 radical gastrectomy for gastric cancer (control group). The difference of intraoperative and postoperative recovery, lymph node dissection, and postoperative 3-year cumulative survival rate between the two groups were analyzed. Results: The age of patients in the labeled group and the control group were (64.9±7.8) and (66.0±8.3) years old, respectively (P=0.389); And the male patients accounted for 61.9% (52 cases) and 55.3% (42 cases), respectively (P=0.394); The operation time in the labeled group was (218.5±19.6) min, which was shorter than that in the control group (230.1±17.4) min (P<0.001). There was no significant difference between the labeled group and the control group in the amount of bleeding during operation, the time of anal exhaust after operation, the time of eating after operation, the time of hospitalization after operation, and the average diameter of lymph nodes (P>0.05). The total number of dissected lymph nodes, D1 lymph nodes and D2 lymph nodes in the labeled group were significantly higher than those in the control group (all P values<0.05). The operative complication rate in the labeled group was 11.9% (10 cases), which was lower than that in the control group (25.0%, 19 cases) (P=0.032); There was no statistical significance in 3-year cumulative survival rates of patients between the labeled group (61.9%) and the control group (52.6%) (χ²=3.46,P=0.065). Conclusion: The use of methylene blue tracing in laparoscopic D2 radical surgery for gastric cancer is beneficial to reduce the operation time, improve the lymph node clearance rate, and reduce surgical complications.

Non-porous thrombi are less pervious and easier to be retrieved: implication from scanning electron microscopy study

BACKGROUND

Scanning electron microscopy (SEM) studies found that the porosity of thrombi might vary among individuals. However, its relationship with the clinical presentation and efficacy of mechanical thrombectomy (MT) remains unknown. We aimed to characterize the ultrastructure of thrombi and explore its association with the complexity of MT and clot perviousness.

METHODS

SEM was used to observe the morphological features of different components of thrombi obtained from patients with anterior circulation large vessel occlusion undergoing MT and to determine the porosity of thrombi by semi-quantitative analysis. Non-porous thrombi were defined as thrombi with porosity <2%. Clot perviousness was also evaluated using thrombus attenuation increase on CT perfusion (TAI_ctp). We assessed the complexity of MT by attempts of retrieval >3 and procedural duration >60 min, defined as the time interval between groin puncture and recanalization.

RESULTS

A total of 49 thrombi were analyzed and 31 (63.3%) were classified as non-porous thrombi. The presence of non-porous thrombi was negatively associated with procedure >60 min (OR 0.152, 95% CI 0.031 to 0.734, p=0.019) and attempts >3 (OR 0.194, 95% CI 0.046 to 0.822, p=0.026) after adjustment. Additionally, receiver operating characteristic curve analysis indicated that TAI_ctp <17.9 Hounsfield units could predict the presence of non-porous thrombi with an area under the curve of 0.915.

CONCLUSIONS

Non-porous thrombi on SEM are easier to be retrieved during MT and could be identified as less pervious clots on CT images.

Multiple Sensory Impairments in Relation to Cognitive Function: Two Nationwide Cross-sectional Studies

INTRODUCTION

Sensory impairments (SIs, including visual, hearing, olfactory, and taste impairments) have been individually associated with age-related cognitive function. Little is known regarding their combined associations with cognitive function.

METHODS

We included 2,931 participants (mean age of 69.1 years) from the National Health and Nutrition Examination Survey (NHANES, 2011-2014) and 10,785 participants (mean age of 70.2 years) from the National Health Interview Survey (NHIS, 2021). Status of visual, hearing, olfactory, and taste functions were self-reported in structured questionnaires. In NHANES, cognitive function was objectively measured by a battery of tests, including memory, verbal fluency, and processing speed. NHIS participants answered a single question about subjective cognitive complaints (SCC). We used regression models to assess the relation of the total number and the individual sensory impairments to z-scores of cognitive domains (linear regression) in NHANES and to SCC (logistic regression) in NHIS.

RESULTS

A larger number of SI was related to poorer domain-specific cognitive function (all Ptrend <0.05), including memory (beta each additional SI = -0.12, 95% confidence interval: -0.17 to -0.08), verbal fluency (-0.05, -0.10 to -0.01), and processing speed (-0.13, -0.16 to -0.09). In NHIS, each additional SI was related to 96% higher odds of SCC. We also observed independent associations of sensory impairments (except olfactory impairment) with specific cognitive domains. In addition, each individual SI was associated with higher odds of SCC (the odds ratios ranged from 1.30 to 1.78).

CONCLUSION

A larger number of SI was related to worse cognitive function and higher odds of SCC.

Reperfusion Injury Is Associated With Poor Outcome in Patients With Recanalization After Thrombectomy

BACKGROUND

The existence of cerebral reperfusion injury in human beings remains controversial. Thus, we aimed to explore the presence of reperfusion injury in acute ischemic stroke patients with recanalization after mechanical thrombectomy and analyzed its impact on neurological outcome.

METHODS

We reviewed our prospectively collected database CIPPIS (Comparison Influence to Prognosis of CTP and MRP in AIS Patients, NCT03367286), and enrolled anterior circulation large artery occlusion patients with recanalization after mechanical thrombectomy who underwent (1) computed tomography (CT) perfusion on admission and immediately after recanalization to determine reperfusion region, and (2) CT and/or magnetic resonance imaging (MRI) immediately and 24 hours after recanalization to determine lesion areas. The expansion of lesion between recanalization and 24 hours within reperfusion region was potentially caused by reperfusion, thus termed as radiological observed reperfusion injury (RORI). Based on the imaging modality immediately after recanalization, RORI was further divided into RORI_CT and RORI_MRI. We first included a small cohort who had performed both CT and MRI immediately after recanalization to validate the consistency between RORI_CT and RORI_MRI (Study 1). Then the association with RORI_CT and poor outcome, defined as 3-month modified Rankin Scale score of 3 to 6, was explored in a larger cohort (Study 2).

RESULTS

Study 1 included 23 patients and good consistency was found between RORI_CT and RORI_MRI (intraclass correlation=0.97, P<0.001). Among 226 patients included in Study 2, a total of 106 (46.9%) were identified with RORI. The ratio of RORI to reperfusion region was 30.1 (16.2, 51.0)% and was independently associated with poor outcome (odds ratio=1.55 per 10% [95% CI' 1.30-1.84]; P<0.001).

CONCLUSIONS

Our findings suggested that RORI was relatively frequent in stroke patients with recanalization after mechanical thrombectomy and associated with poor outcome despite successful recanalization.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03367286.

Endovascular Treatment for Minor Acute Ischemic Strokes With Large Vessel Occlusion

Background It remains uncertain whether patients with minor acute ischemic stroke with large vessel occlusion benefit from endovascular treatment (EVT). We aim to evaluate the outcomes of EVT in minor acute ischemic stroke with anterior circulation large vessel occlusion. Methods and Results Based on a nationwide prospective stroke registry, patients with minor acute ischemic stroke with anterior circulation large vessel occlusion within 24 hours of onset were divided into groups receiving standard medical treatment plus EVT or standard medical treatment alone. Primary outcome was excellent functional outcome defined as modified Rankin Scale score 0 to 1 at 90 days. In addition, a multivariable logistic regression model was used to analyze the effect of EVT guided by perfusion imaging. A total of 572 patients with median age 68 years (interquartile range=60-77) and median National Institutes of Health Stroke score 3 (interquartile range =2-4) were identified and 123 patients were treated with standard medical treatment plus EVT. EVT was not associated with excellent functional outcome (unadjusted odds ratio [OR], 0.771 [95% CI, 0.516-1.151]; adjusted OR, 0.793 [95% CI, 0.515-1.219]; P=0.290). However, therapy selection guided by perfusion imaging was a modifier of EVT effect on outcomes, as EVT was significantly associated with excellent functional outcome (60.0% versus 50.8%, unadjusted OR, 1.451 [95% CI, 0.643-3.272]; adjusted OR, 2.849 [95% CI, 1.006-8.067]; P=0.049) but not with symptomatic intracerebral hemorrhage in the imaging-guided group. Conclusions Although functional outcomes in minor acute ischemic stroke caused by anterior circulation large vessel occlusion were not improved from the routine use of EVT, our results suggested that EVT guided by perfusion imaging could be beneficial for those patients. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04487340.

Association of Elevated Serum Uric Acid with Nerve Conduction Function and Peripheral Neuropathy Stratified by Gender and Age in Type 2 Diabetes Patients

Background: The relationship between serum uric acid (SUA) level and diabetic peripheral neuropathy (DPN) remains controversial. We aimed to investigate the association between SUA level and DPN and evaluate the effects of SUA level on nerve conduction function via electromyography in patients with type 2 diabetes (T2DM), stratified by gender and age. Methods: This cross-sectional study included 647 inpatients with T2DM from the First Affiliated Hospital of Wenzhou Medical University between February 2017 and October 2020. The diagnosis of DPN was confirmed according to the Toronto Expert Consensus. Clinical data, SUA level, and nerve conduction parameters were obtained from electronic medical records. Results: A total of 647 patients with T2DM were included, and 471 patients were diagnosed with DPN. The level of SUA was higher in the DPN group than in the Non-DPN group (330.58 ± 99.67 vs. 309.16 ± 87.04, p < 0.05). After adjustment, a higher SUA level was associated with the presence of DPN [odds ratio (OR) 1.003, 95% confidence interval (CI), 1.001−1.005; p = 0.017]. The area under the curve for the prediction of DPN was 0.558 (95% CI, 0.509−0.608; p = 0.022), and the optimized cut-off of SUA level was 297.5 µmol/L. The SUA > 297.5 µmol/L level was independently associated with DPN in the male subgroup (OR 2.507, 95% CI, 1.405−4.473; p = 0.002) rather than in the female subgroup. Besides, SUA > 297.5 µmol/L was independently associated with DPN in the younger subgroup (age < 65 years) (OR 2.070, 95% CI, 1.278−3.352; p = 0.003) rather than in the older subgroup. In multiple linear regression analysis, SUA was significantly correlated with certain nerve conduction study parameters in the all patients group, and was also observed in the male and younger subgroups. Conclusions: Elevated SUA was independently associated with poorer nerve conduction functions, and hyperuricemia was also significantly associated with a higher risk of developing DPN in T2DM patients, especially in male and younger patients.

Prediction of Acute Myocardial Infarction in Asian Patients With Acute Ischemic Stroke: The CTRAN Score

BACKGROUND

Patients with acute ischemic stroke (AIS) are susceptible to acute myocardial infarction (AMI), which would lead to a dramatic increase of in-hospital mortality.

OBJECTIVES

The authors established and validated an easy-used model to stratify the risk of in-hospital AMI among patients with AIS.

METHODS

We consecutively included patients with AIS who were admitted within 7 days from symptom onset in our prospectively maintained database (NCT04487340) from January 2016 to December 2020. In the derivation cohort from 70 centers, we developed a score to predict in-hospital AMI by integrating the bedside-accessible predictors identified via multivariable logistic regression. Then in the validation cohort from 22 centers, we externally evaluated the performance of this score.

RESULTS

Overall, 96,367 patients were included. In-hospital AMI occurred in 392 (0.41%) patients. The final model, named CTRAN, incorporated 5 predictors including the history of coronary heart disease, malignant tumor, renal insufficiency, age, and baseline National Institutes of Health Stroke Scale score. The CTRAN score was confirmed in the validation cohort using receiver operating characteristic curve, which yielded an area under the curve of 0.758 (95% CI: 0.718-0.798).

CONCLUSIONS

The CTRAN score could be a good tool for clinicians to identify patients with AIS at high in-hospital AMI risk.

Impaired peri-olfactory cerebrospinal fluid clearance is associated with ageing, cognitive decline and dyssomnia

BACKGROUND

Animal experiments have demonstrated the dependency of cerebrospinal fluid clearance function on age and sleep, which partially underlay the cognitive decline in the elderly. However, human evidence is lacking, which could be mainly attributed to the limited methods of cerebrospinal fluid clearance function assessment.

METHOD

Serial T1-weighted and T2-fluid attenuated inversion recovery imaging were performed in 92 patients before and at multiple time points including 4.5 h, 15 h and 39 h after intrathecal injection of contrast agent to visualize the putative meningeal lymphatic pathway, peri-olfactory nerve pathway, and peri-optic nerve pathway. We defined the clearance function as the percentage change in signal unit ratio of critical locations in these pathways from baseline to 39 h after intrathecal injection, and further analysed their relationships with age, sleep, and cognitive function.

FINDINGS

Cerebrospinal fluid clearance through the putative meningeal lymphatic and perineural pathways were clearly visualized. The clearance function of putative meningeal lymphatic and perineural pathways were impaired with ageing (all P < 0.05). The clearance function through peri-olfactory nerve pathway in inferior turbinate was positively correlated with sleep quality and cognitive function (both P < 0.05), and mediated the association of sleep quality with cognitive function (percent change in β [bootstrap 95% CI]: 33% [-0.220, -0.007]).

INTERPRETATION

The impaired clearance through putative peri-olfactory nerve pathway may explain the cognitive decline in patients with sleep disturbance. The study shows a promising method to assess cerebrospinal fluid clearance function of putative peri-neural pathways via dynamic magnetic resonance imaging with intrathecal injection of contrast agent.

FUNDING

This work was supported by the National Natural Science Foundation of China (81971101, 82171276 and 82101365).

Mild and moderate cardioembolic stroke patients may benefit more from direct mechanical thrombectomy than bridging therapy: A subgroup analysis of a randomized clinical trial (DIRECT-MT)

Background

The benefit of intravenous alteplase before endovascular thrombectomy is unclear in patients with acute cardioembolic stroke.

Methods

We collected cardioembolic (CE) stroke patient data from the multicentre randomized clinical trial of Direct Intra-arterial Thrombectomy to Revascularize Acute Ischaemic Stroke Patients with Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals (DIRECT-MT). The primary outcome was the 90-day modified Rankin Scale (mRS) score. Five subgroups of cardioembolic stroke patients were analyzed. A multivariable ordinal logistic regression analysis analyzed the difference in the primary outcome between the direct mechanical thrombectomy (MT) and bridging therapy groups. An interaction term was entered into the model to test for subgroup interaction. The DIRECT-MT trial is registered with clinicaltrials.gov Identifier: NCT03469206.

Results

A total of 290 CE stroke patients from the DIRECT-MT trial were enrolled in this study: 146 patients in the direct MT group and 144 patients in the bridging therapy group. No difference between the two treatment groups in the primary outcome was found (adjusted common odds ratio, 1.218; 95% confidence interval, 0.806 to 1.841; P = 0.34). In the subgroup analysis, CE stroke patients with an NIHSS ≤ 15 in the direct MT group were associated with better outcomes (47 vs. 53, acOR, 3.14 [1.497, 6.585]) and lower mortality (47 vs. 53, aOR, 0.16 [0.026, 0.986]) than those in the bridging therapy group, while there were no significant differences between the two treatment groups in the outcome and mortality of CE stroke patients with an NIHSS >15.

Conclusion

Mild and moderate cardioembolic stroke patients may benefit more from direct mechanical thrombectomy than bridging therapy. This need to be confirmed by further prospective studies in a larger number of patients.

Associations of lipid profiles with the risk of ischemic and hemorrhagic stroke: A systematic review and meta-analysis of prospective cohort studies

Background and purpose

The associations of lipid profiles with the risk of ischemic stroke (IS) or hemorrhagic stroke (HS) are controversial. In this study, we aimed to illustrate the optimal level for lipid levels in the risk of IS and HS.

Materials and methods

We searched the electronic database of PubMed, Embase, and the Cochrane library from inception until November 2020. Prospective cohort studies published in English for the associations of lipid profiles (TC, TG, LDL-C, HDL-C, and non–HDL-C) with the risk of IS and HS were eligible for this study, and the publication status was not restricted. We calculated the pooled effect estimates using the random-effects model. We tested the associations of lipid profiles with IS and HS and compared their differences.

Results

We retrieved 50 prospective cohort studies containing 3,301,613 individuals. An increase in total cholesterol (TC) is associated with an increased IS risk (P &lt; 0.001) and a reduced HS risk (P &lt; 0.001). Similarly, an increase in triglyceride links with a greater IS risk (P &lt; 0.001) but with a lower HS risk (P = 0.014). On the opposite, high-density lipoprotein cholesterol (HDL-C) correlates with a reduced IS risk (P = 0.004) but has no significant association with the HS risk (P = 0.571). Moreover, an increase in low-density lipoprotein cholesterol (LDL-C) or non–high-density lipoprotein cholesterol has no statistically significant effect on both IS and HS. The pooled effect estimates on the risk of IS and HS revealed that TC and LDL-C levels should be controlled under 6.0 and 3.5 mmol/L, respectively, to reduce worsening effects on the IS risk while maintaining potential beneficial effects on reducing the HS risk.

Conclusion

We revealed comprehensive relationships between lipid profiles and the risk of stroke, suggesting controlling the TC and LDL-C levels under 6.0 and 3.5 mmol/L, respectively, to balance both the IS and HS risk.

Different mechanisms in periventricular and deep white matter hyperintensities in old subjects

Objective

Although multiple pieces of evidence have suggested that there are different mechanisms in periventricular white matter hyperintensities (PWMHs) and deep white matter hyperintensities (DWMHs), the exact mechanism remains uncertain.

Methods

We reviewed clinical and imaging data of old participants from a local She Ethnic group. We assessed the cerebral blood flow of white matter (WM-CBF) on arterial spin-labeling, deep medullary veins (DMVs) visual score on susceptibility-weighted imaging, and index for diffusion tensor image analysis along the perivascular space (ALPS index), indicating glymphatic function on diffusion tensor imaging. Furthermore, we investigated their relationships with volumes of PWMHs and DWMHs.

Results

A total of 152 subjects were included, with an average age of 63 ± 8 years old. We found that higher age and history of hypertension were independently related to higher volumes of both PWMHs and DWMHs (all p &lt; 0.05). Lower ALPS index was independently associated with higher PWMHs volumes (β = 0.305, p &lt; 0.001), and this relationship was accounted for by the indirect pathway via DMVs score (β = 0.176, p = 0.017). Both lower ALPS index and WM-CBF were independent risk factors for higher DWMHs volumes (β = −0.146, p = 0.041; β = −0.147, p = 0.036).

Conclusions

Our study indicated that there were different mechanisms in PWMHs and DWMHs. PWMHs were mainly attributed to the damage of veins due to the dysfunction of the glymphatic pathway, while DWMHs could be affected by both ischemia-hypoperfusion and dysfunction of the glymphatic pathway.

Advances in knowledge

The relationship between glymphatic dysfunction and PWMHs might be accounted for by the indirect pathway via venous abnormalities, a glymphatic dysfunction, and lower CBF in white matter were independent risk factors for DWMHs.

Prevalence of stroke in China, 2013-2019: A population-based study

Background

The stroke burden in China has increased during the past 40 years. The present study aimed to determine the recent trends in the prevalence of stroke from 2013 to 2019 stratified by sociodemographic characteristics, including sex, age, residence, ethnicity, and province within a population-based screening project in China.

Methods

We made use of data generated from 2013 to 2019 in the China Stroke High-risk Population Screening Program. All living subjects with confirmed stroke at interview were considered to have prevalent stroke. All analyses of prevalence of stroke were weighted and results were presented as percentage and 95% confidence interval (CI).

Findings

A total of 4229,616 Chinese adults aged ≥40 years from 227 cities in the 31 provinces were finally included. The enrollment rate ranged from 58.8% (2017) to 67.8% (2013). The weighted prevalence of stroke increased annually from 2013 to 2019, being 2.28% (95% CI: 2.28-2.28%) in 2013, 2.34% (2.34-2.35%) in 2014, 2.43% (2.43-2.43%) in 2015, 2.48% (2.48-2.48%) in 2016, 2.52% (2.52-2.52%) in 2017, 2.55% (2.55-2.55%) in 2018, and 2.58% (2.58-2.58%) in 2019 (p for trend <0.001). The weighted prevalence of stroke was higher for male sex, older age, and residence in rural and northeast areas.

Interpretation

The prevalence of stroke in China and most provinces has continued to increase in the past 7 years (2013-2019). These findings, especially in provinces with high stroke prevalence, can help public health officials to increase province capacity for stroke and related risk factors prevention.

Fundings

This study was supported by grants from the National Major Public Health Service Projects.

Superficial white matter microstructure affects processing speed in cerebral small vessel disease

White matter hyperintensities (WMH) are a typical feature of cerebral small vessel disease (CSVD), which contributes to about 50% of dementias worldwide. Microstructural alterations in deep white matter (DWM) have been widely examined in CSVD. However, little is known about abnormalities in superficial white matter (SWM) and their relevance for processing speed, the main cognitive deficit in CSVD. In 141 CSVD patients, processing speed was assessed using Trail Making Test Part A. White matter abnormalities were assessed by WMH burden (volume on T2-FLAIR) and diffusion MRI measures. SWM imaging measures had a large contribution to processing speed, despite a relatively low SWM WMH burden. Across all imaging measures, SWM free water (FW) had the strongest association with processing speed, followed by SWM mean diffusivity (MD). SWM FW was the only marker to significantly increase between two subgroups with the lowest WMH burdens. When comparing two subgroups with the highest WMH burdens, the involvement of WMH in the SWM was accompanied by significant differences in processing speed and white matter microstructure. Mediation analysis revealed that SWM FW fully mediated the association between WMH volume and processing speed, while no mediation effect of MD or DWM FW was observed. Overall, results suggest that the SWM has an important contribution to processing speed, while SWM FW is a sensitive imaging marker associated with cognition in CSVD. This study extends the current understanding of CSVD-related dysfunction and suggests that the SWM, as an understudied region, can be a potential target for monitoring pathophysiological processes.

Evaluation of a multicomponent intervention to shorten thrombolytic door-to-needle time in stroke patients in China (MISSION): A cluster-randomized controlled trial

BACKGROUND

Rapid intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) is crucial for improving outcomes. However, few randomized trials of interventions aimed at reducing in-hospital delay have been carried out in China. We aimed to evaluate the effect of a multicomponent intervention on thrombolytic door-to-needle time (DNT) of AIS patients via video teleconference based on the Behavior Change Wheel (BCW) method.

METHODS AND FINDINGS

This cluster-randomized trial, conducted between January 1, 2019 and December 31, 2019, randomly allocated 22 hospitals equally to PEITEM (Persuasion Environment reconstruction Incentivization Training Education Modeling) intervention or routine care plus stroke registry and subsequently enrolled 1,634 AIS patients receiving IVT within 4.5 hours upon stroke onset from participant hospitals. The PEITEM group received a 1-year PEITEM 6-component intervention based on the behavioral theory monthly via video teleconference. The primary outcome was the proportion of patients with a DNT of 60 minutes or less. A total of 987 patients participated in the PEITEM group (mean age, 69 years; female, 411 [41.6%]) and 647 patients in the control group (mean age, 70 years; female, 238 [36.8%]). Of all participants, the proportion of DNT ≤60 minutes in the PEITEM group was higher than in the control group (82.0% versus 73.3%; adjusted odds ratio, 1.77; 95% confidence interval (CI), 1.17 to 2.70; ICC, 0.04; P = 0.007). Among secondary outcomes, the average DNT was 43 minutes in the PEITEM group and 50 minutes in the control group (adjusted mean difference: -8.83; 95% CI, -14.03 to -3.64; ICC, 0.12; P = 0.001). Favorable functional outcome (score of 0 to 1 on the modified Rankin scale (mRS)) was achieved in 55.6% patients of the PEITEM group and 50.4% of the control group (adjusted odds ratio, 1.38; 95% CI, 1.00 to 1.90; ICC, 0.01; P = 0.049). Main study limitations include non-blinding of clinicians, and that specific interventions component responsible for the observed changes could not be determined.

CONCLUSIONS

The teleconference-delivered PEITEM intervention resulted in a moderate but clinically relevant shorter DNT and better functional outcome in AIS patients receiving IVT.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03317639.

Quantitative Collateral Assessment on CTP in the Prediction of Stroke Etiology

BACKGROUND AND PURPOSE

Patients with stroke etiology of large-artery atherosclerosis were thought to have better collateral circulation compared with patients with other stroke etiologies. We aimed to investigate the association between stroke etiology and collateral circulation with a new quantitative collateral assessment method.

MATERIALS AND METHODS

This retrospective study reviewed data from consecutive patients with proximal anterior artery occlusion who underwent CTP before reperfusion therapy. CBF maps were derived from CTP. A new indicator, maximum CBF of collateral vessels within the Sylvian fissure (cCBF_max), was applied to quantitatively assess the collateral status. The relationship between collateral status and stroke etiology was investigated.

RESULTS

A total of 296 patients were finally analyzed. The median cCBF_max was significantly higher in patients with large-artery atherosclerosis than in those without it (92 [interquartile range, 65-123] mL/100 g/min versus 62 [interquartile range, 46-82] mL/100 g/min; P < .001). Multivariable analysis revealed that a higher cCBF_max score was independently associated with large-artery atherosclerosis etiology (OR, 1.010; 95% CI, 1.002-1.018; P = .017) after adjustment. The area under the curve, sensitivity, and specificity of the final model in predicting the etiology of large-artery atherosclerosis were 0.870, 89.7%, and 75.2%, respectively.

CONCLUSIONS

Patients with large-artery atherosclerosis had a more adequate collateral perfusion supply with the new quantitative collateral assessment. The new quantitative collateral measurement might contribute to the prediction of stroke etiology in the acute clinical scenario for patients with acute ischemic stroke.

Multi-Mode Imaging Scale for Endovascular Therapy in Patients with Acute Ischemic Stroke (META)

Background: With the guidance of multi-mode imaging, the time window for endovascular thrombectomy (EVT) has been expanded to 24 h. However, poor clinical outcomes are still not uncommon. We aimed to develop a multi-mode imaging scale for endovascular therapy in patients with acute ischemic stroke (META) to predict the neurological outcome in patients receiving endovascular thrombectomy (EVT). Methods: We included consecutive acute ischemic stroke patients with occlusion of middle cerebral artery and/or internal carotid artery who underwent EVT. Poor outcome was defined as modified Rankin Scale (mRS) score of 3−6 at 3 months. A five-point META score was constructed based on clot burden score, multi-segment clot, the Alberta Stroke Program early computed tomography score of cerebral blood volume (CBV-ASPECTS), and collateral status. We evaluated the META score performance using area under the curve (AUC) calculations. Results: A total of 259 patients were included. A higher META score was independently correlated with poor outcomes at 3 months (odds ratio, 1.690, 95% CI, 1.340 to 2.132, p < 0.001) after adjusting for age, hypertension, baseline National Institutes of Health Stroke Scale (NIHSS) score, and baseline blood glucose. Patients with a META score ≥ 2 were less likely to benefit from EVT (mRS 3−6: 60.8% vs. 29.2%, p < 0.001). The META score predicted poor outcomes with an AUC of 0.714, higher than the Pittsburgh Response to Endovascular therapy (PRE) score, the totaled health risks in vascular events (THRIVE) score (AUC: 0.566, 0.706), and the single imaging marker in the scale. Conclusions: The novel META score could refine the predictive accuracy of prognosis after EVT, which might provide a promising avenue for future automatic imaging analysis to help decision making.

Filling Defect of Ipsilateral Transverse Sinus in Acute Large Artery Occlusion

Background and Purpose

Cerebral venous systems play a key role in regulating stroke outcomes. We aimed to elucidate the effect of the transverse sinus (TS) filling patterns on edema expansion and neurological outcomes in patients with acute large artery occlusion (LAO).

Materials and Methods

We recruited consecutive patients with acute M1 middle cerebral artery and/or internal carotid artery occlusion who underwent pretreatment computed tomographic perfusion (CTP). On the reconstructed 4-dimensional computed tomographic angiography derived from CTP, the filling defect of the ipsilateral transverse sinus (FDITS) was defined as the length of contrast filling defect occupying at least half of the ipsilateral TS. An unfavorable outcome was defined as having a modified Rankin Scale (mRS) score of 3–6 at 3 months.

Results

A total of 318 patients were enrolled in the final analysis and 70 (22.0%) patients had baseline FDITS. The presence of FDITS was associated with the baseline NIHSS (odds ratio [OR] 1.119; 95% CI, 1.051–1.192; p < 0.001) and poor arterial collaterals (OR 3.665; 95% CI 1.730–7.766; p = 0.001). In addition, FDITS was associated with 24-h brain edema expansion (OR 7.188; 95% CI, 3.095–16.696; p < 0.001) and 3-month unfavorable outcome (OR 8.143; 95% CI 2.547–26.041; p < 0.001) independent of arterial collateral status. In the subgroup analysis of patients with FDITS who received reperfusion therapy, no significant difference was found in the rate of edema expansion and unfavorable outcome between non-reperfusion and reperfusion subgroups (both p > 0.05).

Conclusion

Filling defect of the ipsilateral transverse sinus was associated with edema expansion and an unfavorable outcome irrespective of the baseline arterial collateral status in patients with acute LAO, indicating that FDITS may be an important stroke-related prognostic imaging marker.

Decreased Cerebral Blood Flow and Delayed Arterial Transit Are Independently Associated With White Matter Hyperintensity

Aim

White matter hyperintensities (WMH) and lacunes were important features of cerebral small vessel disease (CSVD), which contributes to 25% of ischemic strokes and 45% of dementias. Currently, the underlying mechanisms of WMH and lacunes are not clear, and the role of hemodynamic changes is not fully investigated. In this study, we aimed to measure the cerebral blood flow (CBF) and arterial transit in CSVD patients and to investigate their association with WMH and lacunes.

Methods

We retrospectively analyzed the prospectively collected database of CSVD patients. Ninety-two CSVD patients with complete imaging data were included. We used arterial spin labeling (ASL) with post-labeling delay time (PLD) of 1,525 ms and 2,025 ms to measure CBF respectively, and the difference between CBFPLD1.5 and CBFPLD2.0 was recorded as δCBF. We performed regression analysis to understand the contribution of CBF, δCBF to CSVD imaging markers.

Results

We found that CBF derived from both PLDs was associated with WMH volume and the presence of lacune. CBFPLD1.5 was significantly lower than CBFPLD2.0 in CSVD patients, and δCBF was correlated with WMH volume but not the presence of lacune. Furthermore, CBFPLD2.0 and δCBF were both associated with WMH in multiple regression analyses, suggesting an independent effect of delayed arterial transit. On an exploratory basis, we also investigated the relationship between venous disruption on δCBF, and we found that δCBF correlated with deep medullary veins score.

Conclusion

Both CBF and arterial transit were associated with WMH. ASL with multiple PLDs could provide additional hemodynamic information to CSVD-related studies.

Impact of different white matter hyperintensities patterns on cognition: A cross-sectional and longitudinal study

OBJECTIVES

White matter hyperintensities (WMH) are highly prevalent in older adults and considered to be a contributor to cognition impairment. However, the strategic WMH lesion distribution related to cognitive impairment is still debated. The aim of this study was to characterize the spatial patterns of WMH associated with cognitive impairment and explore its risk factors.

METHODS

We retrospectively analyzed patients who underwent T2 fluid attenuated inversion recovery (FLAIR) and mini-mental state examination (MMSE) in two centers. WHM was classified into four patterns based on T2 FLAIR as follows: (1) multiple subcortical spots (multi-spots); (2) peri-basal ganglia (peri-BG); (3) anterior subcortical patches (anterior SC patches); and (4) posterior subcortical patches (posterior SC patches). We cross-sectionally and longitudinally estimated associations between different WMH patterns and all-cause dementia and cognitive decline. Multivariable logistic regression analysis was followed to identify risk factors of WMH patterns related to cognitive impairment.

RESULTS

A total of 442 patients with WMH were enrolled, with average age of 71.6 ± 11.3 years, and MMSE score of 24.1 ± 5.4. Among them, 281 (63.6%), 66 (14.9%), 163 (36.9%) and 197 (44.6%) patients presented multi-spots, peri-BG, anterior SC patches and posterior SC patches, respectively. Patients with anterior SC patches were more likely to have all-cause dementia in cross-sectional study (OR 2.002; 95% CI 1.098-3.649; p = 0.024), and have cognitive decline in longitudinal analysis (OR 3.029; 95% CI 1.270-7.223; p = 0.012). Four patterns of WMH referred to different cognitive domains, and anterior SC patches had the most significant and extensive impact on cognition after Bonferroni multiple comparison correction (all p < 0.0125). In addition, older age (OR 1.054; 95% CI 1.027-1.082; p < 0.001), hypertension (OR 1.956; 95% CI 1.145-3.341; p = 0.014), higher percentage of neutrophils (OR 1.046; 95% CI 1.014-1.080; p = 0.005) and lower concentration of hemoglobin (OR 0.983; 95% CI 0.967-1.000; p = 0.044) were risk factors for the presence of anterior SC patches.

CONCLUSIONS

Different patterns of subcortical leukoaraiosis visually identified on MRI might have different impacts on cognitive impairment. Further studies should be undertaken to validate this simple visual classification of WMH in different population.

Evaluation of a Multilevel Program to Improve Clinician Adherence to Management Guidelines for Acute Ischemic Stroke

IMPORTANCE

Promotion of clinician adherence to stroke guidelines can improve stroke outcomes.

OBJECTIVE

To investigate the outcomes of a multilevel system program on clinician adherence to guidelines for treatment of patients with acute ischemic stroke (AIS).

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study used a prospective interrupted time series (ITS) and difference-in-difference (DID) design, from August 1, 2018, to January 31, 2020, divided into preprogram term and short and long postprogram terms; each term had 6 months. Data were collected during hospitalization and at discharge with an automated medical record data capture system in 58 public hospitals in Zhejiang province, China. Data were analyzed from August 2018 to January 2020.

EXPOSURES

The multilevel system program included a modularized standard template for medical records, centrally supported continuing education, continuous monitoring and feedback, and collaborative workshops.

MAIN OUTCOMES AND MEASURES

The primary outcome was adherence to 12 key performance indicators (KPIs), expressed as (1) percentage of patient-applicable KPIs achieved in each participant and (2) percentage of participants among whom all applicable KPIs were achieved (dichotomous all-or-none measure). The secondary outcome was severe disability or death (modified Rankin Scale 5-6) at discharge.

RESULTS

Among 45 091 patients (mean [SD] age, 69 [12] years; 18 347 female [40.7%]), 28 721 from 30 hospitals received the program and 16 370 from 28 hospitals continued routine care. In adjusted DID analysis, the program was associated with an increase in the absolute percentage of KPIs achieved per patient (6.46%; 95% CI, 5.49% to 7.43%), absolute rate of all-or-none success (8.29%; 95% CI, 6.99% to 9.60%), and decreased rate of severe disability or death at discharge (-1.68%; 95% CI, -2.99% to -0.38%). The ITS result showed the program was associated with an increase in KPIs achieved per patient per week (slope change in short-term period, 0.36%; 95% CI, 0.20% to 0.52%; level change in long-term period, (9.64%; 95% CI, 4.58% to 14.69%) and in all-or-none success (slope change in short-term period 0.34%; 95% CI, 0.23% to 0.46%; level change in long-term period 5.89%; 95% CI, 0.19% to 11.59%).

CONCLUSIONS AND RELEVANCE

The centrally supported program was associated with increases in clinician adherence to guidelines and reduced the proportion of severely disabled or deceased patients with AIS at discharge, providing support for its wider implementation.

Stroke outcome of early antiplatelet in post-thrombolysis haemorrhagic infarction

BACKGROUND AND PURPOSE

Initiation of early antiplatelet (EA) therapy after acute ischaemic stroke (AIS) is essential. We aimed to investigate the safety and effectiveness of EA therapy in patients who had an AIS with haemorrhagic infarction (HI) after intravenous thrombolysis (IVT).

METHODS

Based on a multicentre stroke registry database, patients who had an AIS with post-thrombolysis HI at 24 hours were identified. EA users and non-EA users were defined as patients with HI who received or did not receive antiplatelet therapy between 24 and 48 hours after IVT. Primary outcome was favourable outcome defined as modified Rankin Scale scores 0-2 at 3 months. Secondary outcomes were early neurological deterioration (END) and haemorrhagic transformation expansion.

RESULTS

A total of 842 patients with HI were identified from 24 061 thrombolytic patients within 4.5 hours, and 341 (40.5%) received EA therapy. EA users were more likely to have a favourable outcome (55.7% vs 39.5%, OR 1.565; 95% CI 1.122 to 2.182; p=0.008) and lower rate of END (12.6% vs 21.4%, OR 0.585; 95% CI 0.391 to 0.875; p=0.009) compared with non-EA users. EA therapy was not associated with haemorrhagic transformation expansion (p=0.125). After propensity score matching, EA therapy was still independently associated with favourable outcome (54.3% vs 46.3%, OR 1.495; 95% CI 1.031 to 2.167; p=0.038) and lower risk of END (13.5% vs 21.2%, OR 0.544; 95% CI 0.350 to 0.845; p=0.007).

CONCLUSIONS

Antiplatelet therapy can be safely used between 24 and 48 hours when HI occurs after IVT, and such therapy is associated with reduced risk of END and improved neurological outcome in patients who had an AIS.

Effect of Imaging Markers on Reperfusion Therapy in Basilar Artery Occlusion

Objective

We aimed to investigate the effectiveness of endovascular therapy (EVT) versus intravenous thrombolysis (IVT) in patients with basilar artery occlusion (BAO), based on the information of advanced imaging.

Methods

We analyzed data of stroke patients with radiologically confirmed BAO within 24 hours. BAO subjects were categorized into “top‐of‐the‐basilar” syndrome (TOBS) and other types. An initial infarct size of <70ml and a ratio of ischemic tissue to infarct volume of ≥1.8 was defined as “target mismatch.” The primary outcome was a good outcome, defined as a modified Rankin Scale score of 0 to 3 at 3 months. Propensity score adjustment and inverse probability of treatment weighting (IPTW) propensity score methods were used.

Results

Among 474 BAO patients, 93 (19.6%) were treated with IVT prior to EVT, 91 (19.2%) were treated with IVT alone, 95 (20.0%) were treated with EVT alone, and 195 (41.1%) were treated with antithrombotic therapy. In IPTW analyses, we found no benefit of EVT over IVT for good outcome in either TOBS patients (odds ratio = 1.08, 95% confidence interval [CI] = 0.88–1.31) or those with other types (odds ratio = 1.13, 95% CI = 0.94–1.36). However, in patients with other types, if there existed a target mismatch, EVT was independently related to good outcome (odds ratio = 1.46, 95% CI = 1.17–1.81).

Interpretation

The “target mismatch profile” seems to be a possible candidate selection standard of EVT for those with other types of BAO. Future studies should separate TOBS from other types of BAO, and try to use advanced imaging. ANN NEUROL 2022;92:97–106

Causative Classification of Ischemic Stroke by the Machine Learning Algorithm Random Forests

Background

Prognosis, recurrence rate, and secondary prevention strategies differ by different etiologies in acute ischemic stroke. However, identifying its cause is challenging.

Objective

This study aimed to develop a model to identify the cause of stroke using machine learning (ML) methods and test its accuracy.

Methods

We retrospectively reviewed the data of patients who had determined etiology defined by the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) from CASE-II (NCT04487340) to train and evaluate six ML models, namely, Random Forests (RF), Logistic Regression (LR), Extreme Gradient Boosting (XGBoost), K-Nearest Neighbor (KNN), Ada Boosting, Gradient Boosting Machine (GBM), for the detection of cardioembolism (CE), large-artery atherosclerosis (LAA), and small-artery occlusion (SAO). Between October 2016 and April 2020, patients were enrolled consecutively for algorithm development (phase one). Between June 2020 and December 2020, patients were enrolled consecutively in a test set for algorithm test (phase two). Area under the curve (AUC), precision, recall, accuracy, and F1 score were calculated for the prediction model.

Results

Finally, a total of 18,209 patients were enrolled in phase one, including 13,590 patients (i.e., 6,089 CE, 4,539 LAA, and 2,962 SAO) in the model, and a total of 3,688 patients were enrolled in phase two, including 3,070 patients (i.e., 1,103 CE, 1,269 LAA, and 698 SAO) in the model. Among the six models, the best models were RF, XGBoost, and GBM, and we chose the RF model as our final model. Based on the test set, the AUC values of the RF model to predict CE, LAA, and SAO were 0.981 (95%CI, 0.978-0.986), 0.919 (95%CI, 0.911-0.928), and 0.918 (95%CI, 0.908-0.927), respectively. The most important items to identify CE, LAA, and SAO were atrial fibrillation and degree of stenosis of intracranial arteries.

Conclusion

The proposed RF model could be a useful diagnostic tool to help neurologists categorize etiologies of stroke.

Clinical Trial Registration

[www.ClinicalTrials.gov], identifier [NCT01274117].

Corticospinal Tract Hypoperfusion Associated With Unexplained Early Neurological Deterioration After Intravenous Thrombolysis

Background and Purpose

Early neurological deterioration (END) occurs in 10% among patients with acute ischemic stroke (AIS) who are receiving intravenous thrombolysis (IVT). Over half of them have no straightforward causes, which is referred to as unexplained END. We aimed to explore whether the presence of baseline corticospinal tract (CST) hypoperfusion could predict the development of unexplained END at 24 h in patients with AIS after receiving IVT.

Methods

We retrospectively analyzed the clinical and imaging data from patients with AIS who received IVT. Unexplained END was defined as ≥ 2-point increase of National Institutes of Health Stroke Scale (NIHSS) from baseline to 24 h without straightforward causes. Hypoperfusion lesions involving CST and other cerebral areas were identified on perfusion maps.

Results

Among 807 patients, CST hypoperfusion and non-CST hypoperfusion occurred in 488 (60.5%) and 319 (39.5%) patients, respectively. Patients with CST hypoperfusion were more likely to have unexplained END compared with patients with non-CST hypoperfusion (16.6 vs. 2.8%, P < 0.001). Binary logistics regression analysis showed that CST hypoperfusion was independently associated with unexplained END after IVT (OR = 5.64; 95% CI: 2.699–11.785; P < 0.001) after adjusting for baseline NIHSS, onset to needle time, baseline hypoperfusion volume, atrial fibrillation, and hypertension.

Conclusions

Patients with CST hypoperfusion were more likely to suffer from unexplained END after IVT, implying potential mechanisms and potential prevention of unexplained END.

Undertreatment of Anticoagulant Therapy in Hospitalized Acute Ischemic Stroke Patients With Atrial Fibrillation

Background

This study aimed to investigate the prevalence and factors associated with the initiation of oral anticoagulation among patients with acute ischemic stroke (AIS) and concurrent atrial fibrillation (AF) at discharge in China.

Methods

We continuously included hospitalized patients with AIS with an AF diagnosis registered in the computer-based Online Database of Acute Stroke Patients for Stroke Management Quality Evaluation (CASE II) from January 2016 to December 2020 and divided them into a and non-anticoagulant groups according to the medications at discharge. Binary logistic regression was used to determine the factors associated with the prescription of anticoagulants in patients with AF.

Results

A total of 16,162 patients were enrolled. The mean age was 77 ± 9 years, 8,596 (53.2%) were males, and the median baseline National Institute of Health Stroke Scale score was 5 (2–12). Of the 14,838 patients without contraindications of antithrombotic therapy, 6,335 (42.7%) patients were initiated with anticoagulation treatment at discharge. Prior history of hemorrhagic stroke (OR 0.647, p < 0.001) and gastrointestinal bleeding (OR 0.607, p = 0.003) were associated with a lower rate of anticoagulation at discharge. Patients with any intracranial hemorrhage (OR 0.268, p < 0.001), gastrointestinal bleeding (OR 0.353, p < 0.001), or pneumonia during hospitalization (OR 0.601, p < 0.001) were less likely to receive anticoagulants at discharge. Among 7,807 patients with previously diagnosed AF and high risk of stroke (CHA₂DS₂-VASc ≥2), only 1,585 (20.3%) had been receiving anticoagulation treatment prior to the onset of stroke. However, the mean international normalized ratio (INR) was 1.5 on the first test during hospitalization in patients receiving warfarin. Patients complicated with a previous history of ischemic stroke/transient ischemic attack (TIA; OR 2.303, p < 0.001) and peripheral artery disease (OR 1.456, p = 0.003) were more common to start anticoagulants.

Conclusions

Less than half of patients with AIS and concurrent AF initiated guideline-recommended oral anticoagulation at discharge, while only 20% of patients with previously diagnosed AF with a high risk of stroke had been using anticoagulants prior to the onset of stroke, which highlights a large care gap in hospitalized stroke patients and the importance of AF management.

Identification of Risk Factors for Stroke in China: A Meta-Analysis of Prospective Cohort Studies

This study aimed to identify independent risk factors for first occurrence of stroke in Chinese individuals based on prospective cohort studies. Forty prospective cohort studies assessing 1,984,552 individuals were selected for the final meta-analysis. The identified risk factors for stroke in the Chinese population included old age (RR = 1.86, 95%CI: 1.47–2.36), hypertension (RR = 2.76, 95%CI: 2.26–3.37), cardiovascular disease history (RR = 1.98, 95%CI: 1.06–3.69), chronic kidney disease (RR = 1.65, 95%CI: 1.36–2.01), diabetes mellitus (RR = 1.71, 95%CI: 1.34–2.18), metabolic syndrome (RR = 1.59, 95%CI: 1.33–1.90), hyperglycemia (RR = 1.49, 95% CI: 1.31–1.69), obesity (RR = 1.45, 95%CI: 1.29–1.63), smoking (RR = 1.42, 95% CI: 1.27–1.58), prolonged sleep time (> 7.5 h, RR = 1.44, 95%CI: 1.19–1.75), higher levels of triglyceride (RR = 1.19, 95%CI: 1.07-1.32), C-reactive protein (RR = 1.34, 95%CI: 1.07-1.69). High fruit-rich diet (RR = 0.68, 95%CI: 0.58-0.80) was associated with a lower risk of stroke. The spectrum and power of risk factors varied among different cohort inclusion years. These findings provide a comprehensive tool for the primary prevention of stroke in Chinese individuals.

Effect of baseline infarct size on endovascular thrombectomy with or without intravenous alteplase in stroke patients: a subgroup analysis of a randomized trial (DIRECT-MT)

BACKGROUND

DIRECT-MT showed that endovascular thrombectomy was non-inferior to thrombectomy preceded by intravenous alteplase with regard to functional outcome in patients with acute ischemic stroke. In this post-hoc analysis, we examined whether infarct size modified the effect of alteplase.

METHODS

All patients with baseline Alberta Stroke Program Early Computed Tomography Score (ASPECTS) grade were included. The primary outcome was the 90-day modified Rankin Scale (mRS) score. Multivariable ordinal logistic regression analysis was used to calculate the adjusted common odds ratio (OR) for better functional outcome based on the mRS for thrombectomy alone versus combination therapy. An interaction term was entered to test for an interaction with baseline ASPECTS subgroups: 0-4 versus 5-7 versus 8-10.

RESULTS

Of 649 patients, 323 (49.8%) were in the thrombectomy-alone group and 326 (50.2%) in the combination-therapy group. There was no significant treatment-by-trichotomized ASPECTS interaction with alteplase prior to endovascular treatment for the primary endpoint of ordinal mRS (p-value interaction term relative to ASPECTS 8-10: ASPECTS 0-4, p=0.386; ASPECTS 5-7, p=0.936). Adjusted common OR for improvement in the 90-day mRS with thrombectomy alone compared with combination therapy were 1.99 (95% confidence intervals, 0.72-5.46) for ASPECTS 0-4, 1.07 (0.62-1.86) for ASPECTS 5-7, and 1.03 (0.74-1.45) for ASPECTS 8-10. There was no significant difference in the safety outcomes between the two groups.

CONCLUSIONS

Baseline infarct size may not modify the effect of alteplase prior to endovascular thrombectomy with regard to favorable functional outcomes and adverse events.

Patient-Reported Anxiety/Depression After Endovascular Thrombectomy: A post-hoc Analysis of Direct-MT Trial

Objective

To analyze the effect of endovascular thrombectomy (EVT) alone vs. EVT after an intravenous (IV) alteplase of ischemic stroke on a patient-reported anxiety/depression, and to identify predictors of patient-reported anxiety/depression by analyzing data from Direct Intraarterial Thrombectomy in Order to Revascularize the patients with Acute Ischemic Stroke with a Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals: a Multicenter Randomized Clinical Trial (DIRECT-MT).

Methods

Patients with acute ischemic stroke (AIS), triggered by a large-vessel occlusion in the anterior circulation, were randomly allocated to undergo an EVT after IV alteplase (combination-therapy group) or an EVT alone (EVT-alone group) at a 1:1 ratio in DIRECT-MT. Patients in both groups were followed up for 90 days (±14 days) after stroke using a structured modified Ranking Scale (mRS), a Barthel Index (BI), and a 5-Dimensional European Quality of Life Scale (EQ-5D-5L). Patients who returned EQ-5D-5L were included. The EQ-5D-5L anxiety/depression dimension was used to analyze the patient-reported anxiety/depression. First, differences in patient-reported anxiety/depression were compared between the combination-therapy group and the EVT-alone group. Then, the baseline and influencing factors between the anxiety/depression group and no anxiety/depression group were analyzed using univariate regression analysis. Finally, variables with p < 0.1 in univariate regression were subjected to multivariable binary regression analysis to screen independent predictors for patient-reported anxiety /depression after ischemic stroke.

Results

: Five hundred fifteen patients returned the EQ-5D-5L in Direct-MT. Of these patients, 226 (43.88%) reported a level of anxiety/depression, and about 7% reported a severe or extremely severe anxiety/depression. The patient-reported anxiety/depression in the EVT-alone group was significantly higher than that in the combination-therapy group (48.26% vs. 39.45%, p = 0.04). The clinical outcomes were significantly different between the no Anxiety/Depression Group and the anxiety/depression group (mRS at 90 days:2 vs 3, p < 0.001; BI of 95 or 100 at 90 days: 73.36% vs 42.04%, p < 0.001; EQ-5D-5l utility indexes at 90 days:0.96 vs.57, p < 0.001). Logistic regression analysis showed that allocation to thrombolysis before EVT strategy was inversely associated with anxiety/depression [0.61(0.40, 0.94), p = 0.03], an insular cortex ischemia, and National Institute of Health Strocke Scale (NIHSS) at 7 days were positively associated with anxiety/depression [2.04(1.07, 3.90), p = 0.03; 1.07(1.03, 1.12), p < 0.001].

Conclusions

Patient-reported anxiety/depression may suggest that there is a benefit to administering intravenous alteplase before EVT. It may also indicate that it is better to provide IV alteplase before EVT, rather than EVT alone according to patient-reported anxiety/depression. Future research should consider not only the motor function impairments but also the patient-reported mental problems as measures of treatment efficacy in patients with stroke (DIRECT-MT ClinicalTrials.gov number, NCT03469206).