Ischemic Symptoms Research Articles

Direct Superficial Temporal Artery-Proximal Middle Bypass in Moyamoya Disease: Predicting Postoperative Symptomatic Contralateral Stroke Using Clinical Characteristics and Angiographic Collateralization Patterns.

Moyamoya disease (MMD) is a rare cerebrovascular disorder marked by internal carotid artery narrowing, collateral neovascularization, and symptomatic cerebral ischemia. Select patients can benefit from direct bypass (superficial temporal artery [STA]-proximal middle [MCA] bypass) by restoring blood flow to hypoperfused territories. Symptomatic contralateral stroke (CS) following STA-MCA bypass is a devastating, poorly understood complication. We investigate clinical and radiographic risk factors influencing CS incidence after bypass surgery. A retrospective review of patients with bilateral MMD undergoing STA-MCA bypass at our institution (2018-2022) included demographic details, comorbidities, average preoperative systolic blood pressure (SBP), postoperative SBP goals, and angiographic patterns. Preoperative diagnostic angiograms were analyzed for collateral vascular patterns. Postoperative clinical course was recorded. Statistical analyses employed parametric and nonparametric tests for small sample size. Six of 39 patients (15.4%) experienced CS postbypass. No baseline demographic differences were identified between patients with and without CS. CS patients had higher preoperative SBP (146.2 vs. 131.1, P<0.05), were more likely to have postoperative SBP goals below their average preoperative SBP (66.7% vs. 15.2%, P= 0.018) and had longer time from symptom onset to surgery (51.8 vs. 13 months, P= 0.039). There were no differences in specific angiographic patterns in either hemisphere for patients with CS versus those without CS though overall contralateral Suzuki grade was higher in patients with CS (P < 0.05). Patients with CS following bypass had significantly higher preoperative SBP, postoperative SBP goals below their average preoperative SBP, and longer time from symptom onset to surgery compared to patients without CS. Patient-specific postoperative SBP management and timely surgical revascularization are crucial for preventing CS in patients with MMD undergoing STA-MCA bypass.

Risk Factors and Pharmacological Interventions Impacting Cerebrovascular Ischemic Events in Giant Cell Arteritis: A Narrative Review.

Giant cell arteritis (GCA) is a common vasculitis predominantly affecting larger vessels, especially in individuals aged 70-79. Cerebrovascular ischemic events (CIE), such as stroke and transient ischemic attacks, are serious but rare complications of GCA, with a pooled prevalence of 4%. Some studies found that within 2 weeks of GCA diagnosis, 74% and 34% of patients experience transient or severe ischemic events, respectively. Our study aims to help physicians better manage GCA patients to reduce GCA-related CIE by indicating important risk factors and pharmacological intervention to prevent GCA-related CIE, particularly in the first few days of diagnosis when the risk of CIE is highest. A comprehensive literature search was conducted using Pubmed, Google Scholar, Scopus, and other relevant medical databases. As this study was a narrative review, the literature search was done in a nonsystematic manner. Studies published from 2000 to 2024 were reviewed in a nonsystematic manner for information on incidence, pathology, risk factors, pharmacological intervention, and management of GCA-related CIE. Findings indicate that age, male gender, hypertension, and smoking significantly increase the risk of GCA-related CIE, while factors such as anemia, higher body mass index (BMI), and elevated inflammatory markers (C-reactive protein [CRP] and erythrocyte sedimentation rate [ESR]) appear to have protective effects. Symptoms of ischemia in the ophthalmic artery were identified as the strongest predictors of CIE. Pharmacological treatments, including glucocorticoids and tocilizumab, are instrumental in managing and potentially preventing CIE in GCA patients, with adjunctive therapies such as aspirin and antiplatelet agents also showing promise. GCA-related CIE such as stroke can be very debilitating and deadly conditions, particularly when GCA is initially diagnosed. However, with early diagnosis and proper management of risk factors, GCA-related CIE can be prevented and its severity can be reduced. Ischemia in the ophthalmic artery is found to strongly predict GCA-related CIE while aspirin and antiplatelet agent during the first 3 months may prevent GCA-related CIE. Risk factors such as BMI and smoking may help in stratifying the risk of GCA-related CIE. This review underscores the importance of further studies with detailed, well-designed approaches to risk factor analysis to strengthen these associations. Identifying these risk factors is crucial for reducing morbidity and mortality, equipping physicians to better assess and mitigate the risk of CIE in GCA patients.

Elective Thoracic Surgical Resections for Pulmonary Arteriovenous Malformations - A 16 Year Single-Center Experience.

Pulmonary arteriovenous malformations (PAVMs) cause cerebral abscess and ischemic stroke due to paradoxical emboli, risks that are increasingly recognized. We report the evolving placement of thoracic surgery in multi-disciplinary team management of PAVMs that were sporadic or associated with hereditary hemorrhagic telangiectasia. From 1983 to 2006, all patients receiving elective treatment had embolization. Between January 2006 and July 2022, 24 of 714 (3%) patients reviewed at our institution underwent elective surgical resection of one or more PAVMs. Initially, the bar for elective surgery had been set very high, and only patients with persistent symptoms of cerebral ischemia after maximal embolization and medical therapy were referred. As PAVM natural history, follow-up radiation exposures for residual PAVMs, and good surgical outcomes were appreciated, PAVM resection became part of the discussion for highly localized, very complex PAVMs which we consider are best treated surgically. Elective surgical intervention may be considered for other selected patients.

Comparative analysis of arterial involvement in predominant cranial and isolated extracranial phenotypes of giant cell arteritis using 18F-FDG PET-CT

ObjectiveTo investigate differences in arterial involvement patterns on 18F-FDG PET-CT between predominant cranial and isolated extracranial phenotypes of giant cell arteritis (GCA).MethodsA retrospective review of 18F-FDG PET-CT findings was conducted on 140 patients with confirmed GCA. The patients were divided into two groups: the cranial group, which presented craniofacial ischemic symptoms either at diagnosis or during follow-up, and the isolated extracranial group which never exhibited such manifestations.ResultsOf the 140 patients (90 women), 99 (71%) were considered to have a predominantly cranial phenotype, while 41 (29%) had isolated extracranial GCA. Patients with the extracranial phenotype were younger (p = 0.001), had lower TAB positivity (25%), and experienced longer diagnostic delays (p = 0.004). Polymyalgia rheumatica was more common in the extracranial group (p = 0.029), which also showed fewer constitutional symptoms, milder increases in acute phase reactants, and more frequent limb claudication and aortic complications, although these differences were not statistically significant. When comparing arterial involvement on 18F-FDG PET-CT, we observed statistically significant differences. The extracranial phenotype showed greater involvement across all segments of the thoracic aorta (p = 0.001), as well as in the abdominal aorta (p = 0.005), subclavian (p = 0.021), iliac (p = 0.004), and femoral arteries (p = 0.025). In contrast, the cranial phenotype exhibited a higher frequency of vertebral artery involvement (p < 0.001).ConclusionSignificant differences in arterial involvement patterns on 18F-FDG PET-CT were observed between phenotypes. These findings may explain atypical symptoms such as inflammatory lower back pain or limb claudication and the increased risk of aortic complications in extracranial GCA.

Diagnostic Value and Short-Term Prognosis Assessment of Copeptin in Non-ST-Elevation Acute Coronary Syndrome.

This study explored the early diagnosis and prognostic value of copeptin in non-ST-segment elevation acute coronary syndrome (NSTE-ACS). 171 patients with chest pain or myocardial ischemia symptoms were enrolled. Patients with NSTE-ACS were further divided into the non-ST-elevation myocardial infarction (NSTEMI) and unstable angina (UA). All NSTE-ACS patients were followed up to record the occurrence of Major Adverse Cardiovascular Events (MACEs). Serum copeptin concentration in the NSTE-ACS group was significantly higher than that in the control group. The Area under the curve (AUC) value of copeptin in the diagnosis of NSTE-ACS was 0.798. The combined AUC value of copeptin and hypersensitive troponin I (hs-TnI) to NSTE-ACS increased to 0.930. In addition, copeptin and hs-TnI have been proven to be independent risk factors for MACEs in patients with NSTE-ACS. The use of copeptin in combination with conventional myocardial markers contributes to the early diagnosis and short-term prognosis assessment of NSTE-ACS.

First-in-human experience of sirolimus coated balloon for symptomatic intracranial artery stenosis

BackgroundThe drug coated balloon is a promising endovascular therapy for intracranial atherosclerosis (ICAS), potentially combining the advantages of primary angioplasty and antiproliferative drugs. Previous studies have focused on the paclitaxel...

Transient brain ischemic symptoms and the presence of ischemic lesions at neuroimaging: Results from the READAPT study.

According to the literature, about one third of patients with brain ischemic symptoms lasting <24 h, which are classified as Transient ischemic attacks (TIAs) according to the traditional "time-based" definition, show the presence of acute ischemic lesions at neuroimaging. Recent evidence has shown that the presence of acute ischemic lesions at neuroimaging may impact on the outcome of patients with transient ischemic symptoms treated with dual antiplatelet treatment (DAPT). This uncertainty is even more compelling in recent years as short-term DAPT has become the standard treatment for any non-cardioembolic TIA or minor ischemic stroke. This is a pre-specified subgroup analysis from a prospective multicenter real-world study (READAPT). The analysis included patients with time-based TIA-that is, those with ischemic symptoms lasting <24 h-who started DAPT. In the whole population, we assessed the presence of acute brain ischemic lesions at neuroimaging and their association with the ABCD2 score. To assess the impact of acute brain ischemic lesions on 90-day prognosis, we performed a propensity score matching of patients with and without those lesions. We adopted a primary effectiveness outcome which was a composite of new stroke/TIA events and death due to vascular causes at 90 days. We included 517 patients-324 (62.7%) male-with a median (interquartile range-IQR) age of 74 (IQR = 65-81) years; 144 patients (27.9%) had acute brain ischemic lesions at neuroimaging. The proportion of patients with brain ischemic lesions did not vary according to the ABCD2 score. At follow-up, 4 patients with brain ischemic lesions (2.8%) and 21 patients without lesions (5.6%) reported the primary effectiveness outcome, which was similar between the groups before (p = 0.178) and after matching (p = 0.518). In our population, patients with transient ischemic symptoms and acute ischemic lesions at brain magnetic resonance imaging (MRI) had a risk of recurrent ischemic events similar to those without lesions. The risk of recurrent ischemic events was low in both groups.

Treatment outcomes in patients with median arcuate ligament syndrome

Aim. This article aims to present the author’s experience with laparoscopic decompression of the celiac trunk in a patient diagnosed with celiac trunk compression syndrome (Dunbar syndrome).Methods. This article presents a retrospective analysis of the treatment outcomes in eight patients who underwent surgery between January 2020 and December 2023. The diagnosis was established on the basis of complaints, CT angiography and ultrasound. In all patients, the steps of surgical intervention included access to the abdominal cavity, survey laparoscopy and placement of trocars. Afterwards, the lesser omentum was opened to gain access to the base of the legs of the esophageal opening of the diaphragm. Next, the arcuate ligament was isolated with subsequent intersection, as a result of which the contouring of the celiac trunk was determined.Results. The average operation time was 93.72 minutes, ranging between 60 and 180 minutes; the average blood loss was 36.25 ml. The average hospital stay was 3.25 days. When assessing longterm results, five patients experienced complete recovery, three patients noted a decrease in the intensity and frequency of pain. After surgery, all patients underwent ultrasound scanning of the celiac trunk; expiratory blood flow velocity and PSV in the SN/PSV were within the reference range.Conclusion. The study found that in most patients with this disease, the clinical presentation is characterised by complaints of nausea, vomiting, weight loss, and pain after eating or physical activity, which aligns with data from the literature. In diagnosing the disease, the methods of computed angiography and ultrasound of the celiac trunk are of greatest clinical importance. The indication for surgical treatment of Dunbar syndrome is the presence of stenosis of the celiac trunk and symptoms of chronic abdominal ischemia. The study results indicate that laparoscopic decompression of the celiac trunk with dissection of the celiac plexus is a safe and effective treatment method.

Pathophysiology, Diagnosis, and Management of Coronary Artery Disease inthe Setting of Atrial Fibrillation.

Atrial fibrillation (AF) and coronary artery disease are frequently associated and, when so, lead to a grim prognosis. Recent studies suggest the presence of interconnected pathophysiological pathways between the 2 conditions that can promote and aggravate each other, igniting a vicious cycle. Notwithstanding, in contrast with the attention dedicated to the management of antithrombotic treatment, research on other aspects of coronary artery disease in AF is only recently gaining traction. The clinical impact of correct assessment of coronary artery stenosis in AF is especially high, due to the antithrombotic therapy imposed by both AF and coronary stenting. Until recently, an in-depth characterization of coronary microcirculation in AF was lacking. However, contemporary studies indicate that coronary microvascular dysfunction is a frequent encounter in AF, possibly explaining the ischemic symptoms even in the absence of obstructive coronary artery disease and interfering with the use of pressure-based indices to evaluate the hemodynamic significance of coronary artery stenosis. This comprehensive review addresses our current knowledge on coronary physiology in AF and its repercussion on the invasive management of coronary artery disease in this setting.

Transient cerebral ischemia in pituitary apoplexy-induced internal carotid artery occlusion: illustrative case.

Cerebral ischemia secondary to occlusion or vasospasm of adjacent large vessels is a rare but significant complication of pituitary apoplexy. Misdiagnosis can lead to delays in management and devastating neurological outcomes. This case is the first reported instance of an initial presentation with transient cerebral ischemic symptoms, in addition to a classic pituitary apoplexy syndrome, for this clinical entity of pituitary apoplexy with adjacent large vessel occlusion. A 49-year-old man presented with a classic pituitary apoplexy syndrome of headache, vomiting, and hemianopia, with transient preceding expressive dysphasia and right-hand numbness. Computed tomography (CT) and CT angiography of the brain demonstrated a large apoplectic pituitary tumor and associated occlusion of the left internal carotid artery. Subsequent CT perfusion studies revealed a threatening large ischemic penumbra in the left middle cerebral artery territory. He underwent urgent transsphenoidal resection of the pituitary tumor, resulting in symptom resolution and the prevention of cerebral infarction. The recognition of transient cerebral ischemic symptoms in pituitary apoplexy should encourage the exclusion of any large-vessel complications and resultant cerebral ischemia. Early assessment, particularly with angiography and perfusion studies, can assist in guiding management, which is usually surgical decompression, distinct from traditional treatment for cerebrovascular events. https://thejns.org/doi/10.3171/CASE24566.

The clinical effect of flow-diverting stent for treatment of unruptured internal carotid artery small- and medium-sized wide-neck aneurysms

Objective: To study the feasibility of domestic flow diverter(TFD) for the treatment of unruptured internal carotid artery small- and medium-sized wide-neck aneurysms. Methods: This is a retrospective case series study.The study retrospectively evaluated consecutive 54 patients with unruptured intracranial small- and medium-sized wide-neck aneurysms treated with TFD in the Department of Cerebrovascular Disease,the Second Affiliated Hospital of Kunming Medical University between October 2019 and January 2024. There were 11 males and 43 females, and the age of patients was (54.9±9.6) years (range:36 to 74 years). There were 63 aneurysms in 54 patients,6 of which were tandem multiple small aneurysms. One case had saccular aneurysms of bilateral internal carotid artery. The maximum diameter of aneurysm was (4.1±0.8) mm (range: 1.5 to 10.0 mm).The ratio of the maximum diameter of the aneurysm to the neck width diameter was 1.3±0.4 (range:0.4 to 2.4). The surgical and follow-up data were collected. The aneurysm embolization rate at the immediate operation and follow-up,and the complications were analyzed. The degree of aneurysm embolization was evaluated using the O'Kelly-Marotta (OKM) grading system,with OKM grade D as complete occlusion and grade C and above (C1,C2,C3 and D) as successful occlusion. Clinical outcomes of all patients were evaluated by modified Rankin scale(mRS). Results: For 63 aneurysms, 48 aneurysms were treated with TFD alone,and 15 aneurysms were treated with a combination of TFD and coiling. The immediate postoperative successful occlusion rate was 14.3% (9/63) and the complete occlusion rate was 3.2% (2/63). Follow-up results were obtained for all of the patients. The follow-up time (M(IQR)) was 124 (182) days (range: 85 to 754 days). The time to aneurysm successful occlusion was 140.5 (151.5) days (range: 85 to 308 days). At final follow-up,the successful aneurysm occlusion rate was 68.3% (43/63) and the complete occlusion rate was 58.7% (37/63). The complete occlusion rate of the TFD group was 50.0% (24/48) and the TFD+coiling group was 13/15. All patients had no aneurysm rupture,ischemic complications and no recurrence of the aneurysm needed to retreatment during the intraoperative and follow-up period. A total of 3 mild haemorrhagic complications which were related to dual-antiplatelet agents. Twelve patients had asymptomatic mild-moderate stent stenosis. TFD covered 66 branch vessels totally. Only 6 branches were affected by the time of the last follow-up and none of the patients had relevant ischaemic symptoms. All of 54 patients were evaluated as mRS score<2 points at the last follow-up. Conclusion: Using TFD to treat internal carotid artery unruptured small and medium-sized wide-neck aneurysms can simplify the surgical procedure with low complication rate, which is a clinically optional treatment approach.

Delayed Deep White Matter Ischemia After Resection of Gliomas by Awake Surgery

BACKGROUND AND OBJECTIVES: Deep white matter (DWM) is perfused by the medullary arteries from the cortex, and ischemia sometimes occurs after glioma resection. However, the clinical significance of postoperative medullary artery–related ischemia has not been well studied. We retrospectively reviewed cases of delayed DWM ischemia after awake craniotomy to elucidate the clinical characteristics, mechanisms, and management of delayed ischemia. METHODS: We identified 4 cases of intra-axial brain tumors, mainly gliomas, that underwent tumor resection by awake craniotomy at our hospital and developed DWM ischemic symptoms after surgery, despite no worsening of neurological symptoms at the end of surgery. RESULTS: Four patients (3 men and 1 woman) presented with glioblastoma, oligodendroglioma, astrocytoma, and brain metastasis. The median age at surgery was 47.5 years (41-73 years). The tumors were located in the watershed area in the frontal lobe (n = 2) and the parietal lobe (n = 2), all of which were left-sided (n = 4). DWM ischemic symptoms, such as motor dysfunction, aphasia, dysarthria, and dysgraphia, developed at an average of 24 hours (14-48 hours) after resection by awake craniotomy. All 4 patients showed symptom improvement within a week after surgery and completely recovered within a month. CONCLUSION: DWM ischemia is caused by sacrifice of the medullary artery, which feeds the tumor and adjacent brain tissue during tumor resection, and should be considered when delayed aphasia or paralysis occurs postoperatively. These symptoms are often transient and recovery usually occurs. Tumors located in the frontal or parietal lobes, particularly in the watershed area, should be carefully monitored for postoperative ischemia.

The impact of revascularization strategy on clinical failure, hemodynamic failure, and chronic limb-threatening ischemia symptoms in the BEST-CLI Trial

The impact of revascularization strategy on clinical failure, hemodynamic failure, and chronic limb-threatening ischemia symptoms in the BEST-CLI Trial

Catheter-Directed Arterial Thrombolysis with a Low-Dose Recombinant Tissue Plasminogen Activator Regimen for Acute Lower Limb Ischemia-Results of the First Regional Registry of Acute Limb Ischemia in Romania.

Acute limb ischemia is a limb-threatening condition that is associated with a high degree of mortality and morbidity, with the latter related to acute kidney injury and rhabdomyolysis that can rapidly lead to multiple organ failure. The aim of this study was to assess the efficacy and safety of catheter-directed arterial thrombolysis in acute lower limb ischemia in the Department of Vascular Surgery, Timișoara, Romania. A total of 158 patients (114 males-72.15% and 44 females-27.85%) with symptoms of acute lower limb ischemia were admitted and treated with catheter-directed arterial thrombolysis following our protocol. The amputation-free survival rate at 1 month after the thrombolysis was 82.3%, and at 6 months it was 77.85%. The performance of additional procedures to obtain distal perfusion was predictive of an improved outcome at 30 days. The estimated survival rate at 6 months was 84.81% (SE 0.02). The mean survival time was 158.74 days. We recommend the usage of a thrombolytic regimen in patients with a life expectancy of more than 6 months, even in Rutherford stage IIb patients, if there is no major impairment in the sensorial and mobility function of the ischemic leg.

Brain computed tomography perfusion alterations in patients with Takayasu arteritis with steno-occlusive carotid arteries: a retrospective study.

Data on computed tomography perfusion (CTP) in Takayasu arteritis (TAK) patients are limited. Herein, we used CTP combined with computed tomography angiography (CTA) to investigate the brain hemodynamic status in TAK patients with stenosis/occlusive carotid arteries. We retrospectively analyzed 49 TAK patients with carotid artery stenosis or occlusion who had ischemic manifestations and completed a one-stop aortic CTA and brain CTP at Xijing Hospital between 2021 and 2023. Hemodynamic parameters, including cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time to maximum (Tmax), were compared between groups using independent samples t-test or the Mann-Whitney U test. Relationships among CTP parameters and disease activity were evaluated by correlation analyses. Among 49 patients (43 females; age 38.7 ± 11.1years), 15 had common carotid artery occlusion (four bilateral, six right, and five left). Compared with the non-occlusion group, the occlusion group had longer MTT and Tmax (p < 0.05) but showed no differences in CBV and CBF values. Patients with different degrees of lesions on two sides of the carotid artery (n = 31) had lower mean CBF on the severely affected side than on the contralateral side (p = 0.022). In contrast, mean MTT (p = 0.036) and Tmax (p = 0.024) were longer. Patients with more severe ischemic symptoms had longer Tmax than patients with mild symptoms (p < 0.05). Tmax was moderately correlated with disease activity indices (p < 0.05). Alterations in cerebral hemodynamic perfusion were observed in TAK patients. The implications of these findings in evaluating brain ischemia and dysfunction require further investigation. Key Points • Alterations in cerebral hemodynamic perfusion were observed in TAK patients. • Compared with patients without common carotid artery occlusion, patients with occlusion had longer MTT and Tmax values. • In patients with different degrees of lesions on the two sides of the carotid artery, the severely affected side had a lower CBF and prolonged MTT and Tmax than the contralateral side. • Patients with moderate-to-severe ischemic manifestations had a longer Tmax than patients with mild symptoms, and MTT and Tmax correlated with disease activity indices.

Revascularization with superficial temporal artery-middle cerebral artery anastomosis in spontaneous intracranial internal carotid artery dissection: illustrative case.

Because of ischemic symptoms, intracranial internal carotid artery (IICA) dissection has no established treatment guidelines. The authors report a case of IICA dissection in which an emergency superficial temporal artery-middle cerebral artery (STA-MCA) bypass was performed. A 46-year-old woman presented with a headache and left hemiplegia. Her cortical symptoms appeared on day 10, and an STA-MCA bypass was performed because of cerebral hypoperfusion. Her postoperative patency was good, and cortical symptoms improved. Contrast-enhanced magnetic resonance imaging (MRI) was performed in the acute phase with wall contrast. From day 18, the internal carotid artery delineation improved, and the patient was transferred for rehabilitation without worsening symptoms. A literature review of spontaneous IICA dissection with revascularization procedures was conducted to discuss the indications, timing, treatment modalities, and surgical outcomes. The STA-MCA bypass provides supplemental cerebral blood flow and can prevent critical complications. Contrast-enhanced MRI in the acute phase of dissection can show a wall contrast effect and assist in predicting disease progression. https://thejns.org/doi/10.3171/CASE24332.

Abstract 4137181: High-Intensity Walking Exercise Minutes and Improved Walking Performance in Peripheral Artery Disease: LITE Randomized Clinical Trial

Background: The LITE randomized clinical trial evaluated the effect of high-intensity vs low-intensity walking exercise on walking ability for peripheral artery disease (PAD). In post-hoc analyses, this study evaluated whether people with PAD who walked more exercise minutes per week had greater six-minute walk (6MW) improvement, compared to those who walked fewer exercise minutes per week. Within each quartile of exercise minutes, change in 6MW was compared between high and low-intensity exercise groups. Methods: People with PAD were randomized to walking exercise that induced ischemic leg symptoms (high-intensity), walking exercise at a comfortable pace without ischemic leg symptoms (low-intensity), or a control group that did not exercise for 12 months. Participants randomized to exercise were asked to walk 5 days/week up to 50 minutes/day. High-intensity exercise was defined and objectively measured using an ActiGraph. Participants wore an ActiGraph during exercise to measure exercise minutes/week. The primary outcome was 12-month change in 6MW. Results: Of 305 PAD participants randomized (47% women, 59% Black), 208 were assigned to exercise and had data available for analyses. The high-intensity exercise group walked fewer exercise minutes/week than the low-intensity exercise group (51.95 vs 136.82, P&lt; 0.0001). In each exercise group, greater exercise minutes/week at target intensity were associated with greater 6MW improvement (Table). Within each quartile of exercise minutes/week, high-intensity exercise improved 6MW significantly more than low-intensity (Table). Conclusion: In the LITE randomized trial, among people randomized to high-intensity and low-intensity exercise, respectively, more minutes of exercise per week were associated with greater 6MW improvement. However, within each quartile of exercise minutes/week, high-intensity exercise improved 6MW significantly more than low-intensity exercise.

Cerebrovascular reactivity and response times describe recent ischaemic symptomatology in patients with moyamoya.

Moyamoya is a non-atherosclerotic intracranial steno-occlusive condition that places patients at high risk for ischaemic stroke. Randomized trials of surgical revascularization demonstrating efficacy in ischaemic moyamoya have not been performed, and as such, biomarkers of parenchymal haemodynamic impairment are needed to assist with triage and evaluate post-surgical response. In this prospective study, we test the hypothesis that parenchymal cerebrovascular reactivity (CVR) metrics in response to a fixed-inspired 5% carbon dioxide challenge correlate with recent focal ischaemic symptoms. Hypercapnic reactivity blood oxygenation level-dependent MRI (echo time = 35 ms; spatial resolution = 3.5 × 3.5 × 3.5 mm) and catheter angiography assessments of cortical reserve capacity and vascular patency, respectively, in moyamoya disease and syndromic participants (n = 73) were performed in sequence. Cerebrovascular reactivity uncorrected for response time (CVRRAW) was quantified, and time regression analyses were applied to quantify maximum cerebrovascular reactivity (CVRMAX) and cerebrovascular reactivity response time (CVRDELAY). Symptomatology was categorized by a stroke neurologist by hemisphere: symptomatic (lateralizing ischaemic symptoms < 6 months) or asymptomatic (no ischaemic symptom history). Values are presented as median [interquartile range]; logistic regression assessed the association of cerebrovascular reactivity metrics with symptoms, controlling for age and sex. A total of 109 hemispheres, including 39 symptomatic and 70 asymptomatic hemispheres, met inclusion criteria. Symptomatic hemispheres displayed reduced CVRRAW (P < 0.01) (symptomatic = 0.45 [0.28-0.70] z-statistic/ΔEtCO2 versus asymptomatic = 0.67 [0.44-0.98] z-statistic/ΔEtCO2), lengthened CVRDELAY (P < 0.001) (symptomatic = 47.6 [37.7-57.0] seconds versus asymptomatic = 37.7 [30.4-46.4] seconds), and reduced CVRMAX (P = 0.037) (symptomatic = 1.31 [0.99-1.94] z-statistic/ΔEtCO2 versus asymptomatic = 1.64 [1.29-2.12] z-statistic/ΔEtCO2). CVRDELAY (P < 0.001) was found to be significantly related to age in asymptomatic hemispheres (0.33-unit increase/year). Of assessed measures, the receiver operating characteristic curves suggest that CVRDELAY is associated most closely with recent ischaemic symptoms (P < 0.001). Findings support that cerebrovascular reactivity metrics are uniquely altered in hemispheres with recent ischaemic symptoms, further motivating their utilization as biomarkers of ischaemic symptomatology and potential treatment efficacy in moyamoya disease and syndrome.

Pharmacokinetic Drug-Drug Interaction between Cilostazol and Rosuvastatin in Healthy Participants.

Cilostazol improves ischemic symptoms and prevents recurrence following cerebral infarction, and rosuvastatin reduces cholesterol levels. However, no reports exist on the pharmacokinetic interactions between these two drugs in healthy adults. This study evaluated the pharmacokinetic (PK) interactions and safety of cilostazol and rosuvastatin when co-administered to healthy male participants. A randomized, open-label, multiple-dosing, two-arm, two-period study was conducted. Arm A had 30 participants receiving 200 mg cilostazol daily and arm B had 27 participants receiving 20 mg rosuvastatin daily for 7 days. In period 2, both arms received a combination of 200 mg cilostazol and 20 mg rosuvastatin daily for 7 days following a 7-day washout period. Plasma concentrations of cilostazol, its metabolites, and rosuvastatin were quantified using liquid chromatography-tandem mass spectrometry. Fifty-seven participants were randomized, and 44 completed the study. The geometric mean ratio (GMR) and 90% confidence intervals (CI) for maximum plasma concentration at steady state (Cmax,ss) and area under the plasma concentration-time curve during the dosing interval at steady state (AUCtau,ss) indicated no significant interaction between cilostazol and rosuvastatin. Safety assessments showed comparable profiles to individual drug administration, with no significant adverse events. The repeated co-administration of cilostazol and rosuvastatin in healthy male participants resulted in minor PK interactions and exhibited a safety and tolerability profile similar to those of the individual drugs. This suggested that the combined regimen is well tolerated and does not necessitate dose adjustments. ClinicalTrials.Gov identifier no. NCT06568133.

Abstract 352: Oral Cilostazol and High‐Dose Intravenous Albumin in Aneurysmal Subarachnoid Hemorrhage Patients with Refractory Cerebral Ischemia

Background and Purpose Cerebral ischemia associated with vasospasm in patients with aneurysmal subarachnoid hemorrhage (aSAH) requires a multifaceted approach. We report the use of the combination of enteral cilostazol and intravenous (IV) high‐dose albumin in aSAH patients with cerebral ischemia refractory to other accepted pharmacologic and endovascular treatments. Materials and Methods Three aSAH patients who developed cerebral ischemic symptoms despite treatment with oral nimodipine and endovascular measures (i.e., intraarterial vasodilators and balloon angioplasty) were treated with enteral cilostazol (200 mg/day) and one or more doses of IV (25%) albumin (1.25 g per kg over 8 hours). The patients were monitored by serial neurological examinations, transcranial Doppler imaging (TCDI) ultrasound, and computed tomographic angiography (CTA) and perfusion (CTP) scans. Results Three patients (ages 58, 67 and 56 years) developed symptomatic cerebral ischemia and vasospasm following an aSAH. Due to limited angiographic response to endovascular treatment, including intraarterial vasodilators with or without balloon angioplasty, IV (25%) albumin and enteral cilostazol were administered. CT angiogram and perfusion 2‐3 days post‐treatment demonstrated resolution of the perfusion deficits and angiographic vasospasm. Concurrently, TCDI demonstrated improved vasospasm and resolution of neurological deficits. None of the patients required any additional treatments for cerebral ischemia. Conclusions A combination of oral cilostazol and IV high dose (25%) albumin was associated with amelioration of angiographic vasospasm, reduction of tissue perfusion deficits, and clinical improvement of aSAH patients with severe refractory cerebral ischemia.