Recent reports showing the favorable role of patent foramen ovale (PFO) closure in patients with cryptogenic stroke have raised the issue of selecting optimal candidates.
This study, DEFENSE-PFO ...(Device Closure Versus Medical Therapy for Cryptogenic Stroke Patients With High-Risk Patent Foramen Ovale), evaluated whether the benefits of PFO closure can be determined on the basis of the morphologic characteristics of the PFO, as evaluated by transesophageal echocardiography.
Patients with cryptogenic stroke and high-risk PFO were divided between a transcatheter PFO closure and a medication-only group. High-risk PFO included PFO with atrial septal aneurysm, hypermobility (phasic septal excursion into either atrium ≥10 mm), or PFO size (maximum separation of the septum primum from the secundum) ≥2 mm. The primary endpoint was a composite of stroke, vascular death, or Thrombolysis In Myocardial Infarction-defined major bleeding during 2 years of follow-up.
From September 2011 until October 2017, 120 patients (mean age: 51.8 years) underwent randomization. PFO size, frequency of septal aneurysm (13.3% vs. 8.3%; p = 0.56), and hypermobility (45.0% vs. 46.7%; p > 0.99) were similar between the groups. All PFO closures were successful. The primary endpoint occurred exclusively in the medication-only group (6 of 60 patients; 2-year event rate: 12.9% log-rank p = 0.013; 2-year rate of ischemic stroke: 10.5% p = 0.023). The events in the medication-only group included ischemic stroke (n = 5), cerebral hemorrhage (n = 1), Thrombolysis In Myocardial Infarction-defined major bleeding (n = 2), and transient ischemic attack (n = 1). Nonfatal procedural complications included development of atrial fibrillation (n = 2), pericardial effusion (n = 1), and pseudoaneurysm (n = 1).
PFO closure in patients with high-risk PFO characteristics resulted in a lower rate of the primary endpoint as well as stroke recurrence. (Device Closure Versus Medical Therapy for Cryptogenic Stroke Patients With High-Risk Patent Foramen Ovale DEFENSE-PFO; NCT01550588).
The risk of ischemic stroke with intracranial stenosis is associated with various serum lipid levels. However, the effects of changes in the lipid profile on the risk of in-stent restenosis have not ...been verified. Therefore, we investigated the association between the occurrence of in-stent restenosis at 12-month follow-up and changes in various lipid profiles.
In this retrospective cohort study, we included ischemic stroke patients who had undergone intracranial stenting for symptomatic intracranial stenosis between February 2010 and May 2020. We collected data about serum low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), total cholesterol (TC), and triglyceride (TG) levels, and calculated the TC/HDL-C and LDL-C/HDL-C ratios at baseline and after 12 months. We conducted multivariable logistic regression analyses to verify the association between various lipid profile changes and in-stent restenosis at 12 months.
Among the 100 patients included in the study (mean age, 60.8 ± 10.0 years; male: 80 80.0%), in-stent restenosis was found in 13 (13.0%) patients. The risk of in-stent restenosis of more than 50% was significantly decreased when TC/HDL-C ratio (odds ratio OR 0.22, 95% confidence interval (CI) 0.05-0.87) and LDL-C/HDL-C ratio (OR 0.23, 95% CI 0.06-0.93) decreased or when HDL-C levels (OR 0.10, 95% CI 0.02-0.63) were increased at 12 months compared with baseline measurements.
Improvement of HDL-C levels, TC/HDL-C ratio, and LDL-C/HDL-C ratio were associated with decreased risk of in-stent restenosis at 12-month follow-up. Management and careful monitoring of various lipid profiles including HDL-C levels, TC/HDL-C ratio, and LDL-C/HDL-C ratio may be important to prevent in-stent restenosis in patients with intracranial stenting.
Abstract
BACKGROUND
Early brain injury (EBI) after subarachnoid hemorrhage (SAH) is an important determinant of clinical outcomes. However, a major hindrance to studies of EBI is the lack of ...radiographic surrogate marker.
OBJECTIVE
To propose a scoring system based on early changes in clinically obtained computed tomography (CT), called the Subarachnoid hemorrhage Early Brain Edema Score (SEBES).
METHODS
Patients with spontaneous aneurysmal SAH and a CT within 24 h of ictus were included. We defined SEBES as a scale of 0 to 4 points according to the (1) absence of visible sulci caused by effacement of sulci or (2) absence of visible sulci with disruption of the gray–white matter junction at 2 predetermined levels in each hemisphere. Prognostic value of the SEBES grade for the prediction of delayed cerebral ischemia (DCI) and unfavorable outcomes was assessed. A separate cohort of patients was used as a validation cohort.
RESULTS
Of the 164 subjects in our study, high-grade SEBES (3 or 4 points) was identified in 48 patients (29.3%). CT interobserver reliability of SEBES grades was high with a Kappa value of 0.89. After adjusting for covariables, SEBES was identified as an independent predictor of DCI (OR = 2.24, 95% CI: 1.58–3.17) and unfavorable outcome (OR = 3.45, 95% CI: 1.95–6.07). In our validation cohort, 84 subjects showed similar predictive power of SEBES for a prediction of DCI and unfavorable long-term outcome.
CONCLUSION
SEBES may be a surrogate marker of EBI and predicts DCI and clinical outcomes after SAH.
Abstract
Prior intracerebral hemorrhage (ICH) is associated with increased risk of ischemic stroke. Since white matter hyperintensity (WMH) is associated with ischemic stroke and ICH, this study ...aimed to evaluate the relationship between ICH and the risk of recurrent stroke by WMH severity. From a prospective multicenter database comprising 1454 noncardioembolic stroke patients with cerebral small-vessel disease, patients were categorized by presence or absence of prior ICH and WMH severity: mild-moderate WMH (reference); advanced WMH; ICH with mild-moderate WMH; and ICH with advanced WMH. Among patients with ICH, the association with stroke outcomes by WMH burden was further assessed. The primary endpoint was ischemic stroke and hemorrhagic stroke. The secondary endpoint was major adverse cardiovascular events (MACE): stroke/coronary heart disease/vascular death. During the mean 1.9-year follow-up period, the ischemic stroke incidence rate per 100 person-years was 2.7, 4.0, 2.5, and 8.1 in increasing severity, and the rate of hemorrhagic stroke was 0.7, 1.3, 0.6, and 2.1, respectively. The risk of ischemic stroke was higher in ICH with advanced WMH (adjusted HR 2.62; 95% CI 1.22−5.60) than the reference group, while the risk of hemorrhagic stroke trended higher (3.75, 0.85–16.53). The risk of MACE showed a similar pattern in ICH with advanced WMH. Among ICH patients, compared with mild WMH, the risk of ischemic stroke trended to be higher in advanced WMH (HR 3.37; 95% CI 0.90‒12.61). Advanced WMH was independently associated with an increased risk of hemorrhagic stroke (HR 33.96; 95% CI 1.52−760.95). Given the fewer rate of hemorrhagic stroke, the risk of hemorrhagic stroke might not outweigh the benefits of antiplatelet therapy for secondary prevention.
We aimed to investigate the impact of diabetes duration and carotid artery stenosis (CAS) on the occurrence of major adverse cardiovascular events (MACE) in patients with type 2 diabetes mellitus ...(T2DM) without clinical cardiovascular disease.
A total of 2006 patients with T2DM, without clinical cardiovascular disease, aged >50 years, and who underwent baseline carotid Doppler ultrasound screening with regular follow-ups at the outpatient clinic of our diabetes center, were stratified into four subgroups according to diabetes duration and CAS degree. The primary outcomes included the occurrence of MACE, defined as fatal or nonfatal stroke and myocardial infarction, and all-cause mortality.
The difference in the MACE incidence was significantly greater in patients with a longer diabetes duration (≥10 years) and significant CAS (50-69% luminal narrowing) (p < 0.001). Analysis of individual MACE components indicated a trend towards an increased incidence of stroke (p < 0.001), parallel to a longer diabetes duration and significant CAS. In contrast, the risk of myocardial infarction was significantly higher in patients with a diabetes duration <10 years and significant CAS (p = 0.039). Multivariate regression analysis showed that patients with both a longer diabetes duration and significant CAS demonstrated additive and very high risks of MACE (hazard ratio HR, 2.07; 95% confidence interval CI 1.17-3.66; p = 0.012) and stroke (HR, 3.38; 95% CI 1.54-7.44; p = 0.002).
The risk of MACE is significantly greater in patients with T2DM, without clinical cardiovascular disease, who have both a longer diabetes duration and significant CAS, compared with those who have a shorter duration and/or nonsignificant CAS.
BACKGROUND AND PURPOSE—We aimed to investigate the ability of machine learning (ML) techniques analyzing diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) magnetic ...resonance imaging to identify patients within the recommended time window for thrombolysis.
METHODS—We analyzed DWI and FLAIR images of consecutive patients with acute ischemic stroke within 24 hours of clear symptom onset by applying automatic image processing approaches. These processes included infarct segmentation, DWI, and FLAIR imaging registration and image feature extraction. A total of 89 vector features from each image sequence were captured and used in the ML. Three ML models were developed to estimate stroke onset time for binary classification (≤4.5 hours)logistic regression, support vector machine, and random forest. To evaluate the performance of ML models, the sensitivity and specificity for identifying patients within 4.5 hours were compared with the sensitivity and specificity of human readings of DWI-FLAIR mismatch.
RESULTS—Data from a total of 355 patients were analyzed. DWI-FLAIR mismatch from human readings identified patients within 4.5 hours of symptom onset with 48.5% sensitivity and 91.3% specificity. ML algorithms had significantly greater sensitivities than human readers (75.8% for logistic regression, P=0.020; 72.7% for support vector machine, P=0.033; 75.8% for random forest, P=0.013) in detecting patients within 4.5 hours, but their specificities were comparable (82.6% for logistic regression, P=0.157; 82.6% for support vector machine, P=0.157; 82.6% for random forest, P=0.157).
CONCLUSIONS—ML algorithms using multiple magnetic resonance imaging features were feasible even more sensitive than human readings in identifying patients with stroke within the time window for acute thrombolysis.
The mechanism and characteristics of a post-transplantation stroke may differ between liver (LT) and kidney transplantation (KT), as the associated comorbidities and peri-surgical conditions are ...different. Herein, we investigated the characteristics and etiologies of stroke occurring after LT and KT.
Consecutive patients who received LT or KT between January 2005 to December 2020 who were diagnosed with ischemic or hemorrhagic stroke after transplantation were enrolled. Ischemic strokes were further classified according to the etiologies. The characteristics of stroke, including in-hospital stroke, perioperative stroke, stroke etiology, and timing of stroke, were compared between the LT and KT groups.
There were 105 (1.8%) and 58 (1.3%) post-transplantation stroke patients in 5,950 LT and 4,475 KT recipients, respectively. Diabetes, hypertension, and coronary arterial disease were less frequent in the LT than the KT group. In-hospital and perioperative strokes were more common in LT than in the KT group (LT, 57.9%; KT, 39.7%;
= 0.03, and LT, 43.9%; KT, 27.6%;
= 0.04, respectively). Hemorrhagic strokes were also more common in the LT group (LT, 25.2%; KT, 8.6%;
= 0.01). Analysis of ischemic stroke etiology did not reveal significant difference between the two groups; undetermined etiology was the most common, followed by small vessel occlusion and cardioembolism. The 3-month mortality was similar between the two groups (both LT and KT, 10.3%) and was independently associated with in-hospital stroke and elevated C-reactive protein.
In-hospital, perioperative, and hemorrhagic strokes were more common in the LT group than in the KT group. Ischemic stroke subtypes did not differ significantly between the two groups and undetermined etiology was the most common cause of ischemic stroke in both groups. High mortality after stroke was noted in transplantation patients and was associated with in-hospital stroke.
Background We investigated the association between the reaction time (R), a thromboelastography (TEG) parameter for hypercoagulability, and functional outcomes based on the occurrence of hemorrhagic ...transformation (HT) and early neurological deterioration (END).
Methods We enrolled ischemic stroke patients and performed TEG immediately after the patients' arrival. The baseline characteristics, occurrence of HT and END, stroke severity, and etiology were compared according to the R. END was defined as an increase of ≥1 point in motor or ≥2 points in the total National Institute of Health Stroke Scale within 3 days after admission. The outcome was the achievement of functional independence (modified Rankin scale mRS: 0–2) at 3 months after stroke. Logistic regression analyses were performed to verify the association between R and outcome.
Results HT and END were frequently observed in patients with an R of <5 minutes compared with the group with an R of ≥5 minutes (15 8.1% vs. 56 21.0%, p < 0.001; 16 8.6% vs. 65 24.3%, p = 0.001, respectively). In multivariable analysis, an R of <5 minutes was associated with decreased odds of achieving functional independence (0.58 0.34–0.97, p = 0.038). This association was maintained when the outcome was changed to disability free (mRS 0–1) and when mRS was analyzed as an ordinal variable.
Conclusion Hypercoagulability on TEG (R <5 minutes) may be a negative predictor for functional outcome of stroke after 3 months, with more frequent HT, END, and different stroke etiologies. This study highlights the potential of TEG parameters as biomarkers for predicting functional outcomes in ischemic stroke patients.
Optimal blood pressure (BP) control after successful reperfusion with endovascular thrombectomy (EVT) for patients with acute ischemic stroke is unclear.
To determine whether intensive BP management ...during the first 24 hours after successful reperfusion leads to better clinical outcomes than conventional BP management in patients who underwent EVT.
Multicenter, randomized, open-label trial with a blinded end-point evaluation, conducted across 19 stroke centers in South Korea from June 2020 to November 2022 (final follow-up, March 8, 2023). It included 306 patients with large vessel occlusion acute ischemic stroke treated with EVT and with a modified Thrombolysis in Cerebral Infarction score of 2b or greater (partial or complete reperfusion).
Participants were randomly assigned to receive intensive BP management (systolic BP target <140 mm Hg; n = 155) or conventional management (systolic BP target 140-180 mm Hg; n = 150) for 24 hours after enrollment.
The primary outcome was functional independence at 3 months (modified Rankin Scale score of 0-2). The primary safety outcomes were symptomatic intracerebral hemorrhage within 36 hours and death related to the index stroke within 3 months.
The trial was terminated early based on the recommendation of the data and safety monitoring board, which noted safety concerns. Among 306 randomized patients, 305 were confirmed eligible and 302 (99.0%) completed the trial (mean age, 73.0 years; 122 women 40.4%). The intensive management group had a lower proportion achieving functional independence (39.4%) than the conventional management group (54.4%), with a significant risk difference (-15.1% 95% CI, -26.2% to -3.9%) and adjusted odds ratio (0.56 95% CI, 0.33-0.96; P = .03). Rates of symptomatic intracerebral hemorrhage were 9.0% in the intensive group and 8.1% in the conventional group (risk difference, 1.0% 95% CI, -5.3% to 7.3%; adjusted odds ratio, 1.10 95% CI, 0.48-2.53; P = .82). Death related to the index stroke within 3 months occurred in 7.7% of the intensive group and 5.4% of the conventional group (risk difference, 2.3% 95% CI, -3.3% to 7.9%; adjusted odds ratio, 1.73 95% CI, 0.61-4.92; P = .31).
Among patients who achieved successful reperfusion with EVT for acute ischemic stroke with large vessel occlusion, intensive BP management for 24 hours led to a lower likelihood of functional independence at 3 months compared with conventional BP management. These results suggest that intensive BP management should be avoided after successful EVT in acute ischemic stroke.
ClinicalTrials.gov Identifier: NCT04205305.
OBJECTIVE Controversy persists regarding the optimal management of subclinical coronary artery disease (CAD) prior to carotid endarterectomy (CEA) and the impact of CAD on clinical outcomes after ...CEA. This study aimed to evaluate the short-term surgical risks and long-term outcomes of patients with subclinical CAD who underwent CEA. METHODS The authors performed a retrospective study of data from a prospective CEA registry. They analyzed a total of 702 cases involving patients without a history of CAD who received preoperative cardiac risk assessment by radionuclide myocardial perfusion imaging (MPI) and underwent CEA over a 10-year period. The management strategy (the necessity, sequence, and treatment modality of coronary revascularization and optimal perioperative medical treatment) was determined according to the presence, severity, and extent of CAD as determined by preoperative MPI and additional coronary computed tomography angiography and/or coronary angiography. Perioperative cardiac damage was defined on the basis of postoperative elevation of the blood level of cardiac troponin I (0.05-0.5 ng/ml) in the absence of myocardial ischemia. The primary endpoint was the composite of any stroke, myocardial infarction, or death during the perioperative period and all-cause mortality within 4 years of CEA. The associations between clinical outcomes after CEA and subclinical CAD were analyzed. RESULTS Concomitant subclinical CAD was observed in 81 patients (11.5%). These patients did have a higher incidence of perioperative cardiac damage (13.6% vs 0.5%, p < 0.01), but they had similar primary endpoint incidences during the perioperative period (2.5% vs.1.8%, p = 0.65) and similar estimated 4-year primary endpoint rates (13.6% vs 12.4%, p = 0.76) as the patients without subclinical CAD. Kaplan-Meier survival analysis showed that the 2 groups had similar rates of overall survival (p = 0.75). CONCLUSIONS Patients with subclinical CAD can undergo CEA with acceptable short- and long-term outcomes provided they receive selective coronary revascularization and optimal perioperative medical treatment.
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