Large Cerebral Vessels Research Articles

Acute middle cerebral artery occlusion due to a small internal carotid aneurysm cavity with blood stagnation: illustrative case.

In cerebral large vessel occlusion, even when an aneurysm is close to the target vessel, if the aneurysm is relatively small and angiography shows no thrombus within the aneurysm, it is difficult to identify the aneurysm as the embolic source. A 67-year-old man with a history of two left-sided cerebral infarctions developed a small left-sided cerebral infarction. On hospital day 3, he developed a left M2 occlusion and underwent thrombectomy with retraction of a stent retriever into an aspiration catheter at the proximal end of the thrombus. A red thrombus was retrieved, and M2 recanalization was successfully achieved. Angiography revealed a large partially thrombotic aneurysm with a small cavity with blood stagnation in the left cervical internal carotid artery, which was considered the embolic source. Stent-assisted coil embolization was performed on the aneurysm, and no recurrent cerebral infarction was observed after embolization. In cerebral large vessel occlusion, an aneurysm cavity with blood stagnation may be the embolic source. Using an aspiration catheter alone or retracting a stent retriever into an aspiration catheter could be a useful technique and help to avoid interference between the aneurysm and the stent retriever. https://thejns.org/doi/10.3171/CASE24406.

Carotid artery stenosis is related to cerebral small vessel disease magnetic resonance imaging burden

BackgroundCerebral small vessel disease (CSVD) encompasses conditions that affect small blood vessels of the brain, the most common being atherosclerosis. Magnetic resonance imaging (MRI) CSVD markers include lacunar strokes (LS), white matter hyperintensities (WMH), microbleeds, enlarged perivascular spaces (EPVS), and brain atrophy. Large and small cerebral arteries share an anatomical and functional connection, but the role of large vessel atherosclerosis in atherosclerotic CSVD hasn't been established. The aim of this study was to evaluate the involvement of large vessel pathology in atherosclerotic CSVD. MethodsThis cross-sectional study included 98 patients treated at the Neurology Clinic of the University Clinical Center of Serbia in Belgrade, from February 2018 to December 2023, who had atherosclerotic CSVD confirmed by neuroimaging and underwent extracranial color duplex sonography. Data on patients’ gender, age, cerebrovascular risk factors (dyslipidemia, hypertension, diabetes mellitus, smoking status), ultrasonography findings (intima-media thickness - IMT, carotid and vertebral artery stenosis, and hemodynamics), and CSVD imaging markers were collected, and the CSVD MRI burden score was calculated. ResultsAge correlated with LS and WMH (p < 0.05 for both). Hypertension correlated with WMH (p = 0.016), and smoking with LS (p = 0.043). Brain atrophy was more common in women (p = 0.016). The majority of patients had low-grade (<50 %) carotid stenosis. There was a strong correlation between all morphological parameters of internal carotid artery stenosis and the CSVD burden score (p < 0.05 for all). The hemodynamic parameters of internal carotid artery stenosis and morphological and hemodynamic parameters of vertebral artery stenosis didn't correlate with the CSVD burden score. ConclusionsThis study shows a strong correlation between cerebral large and small vessel pathology. We recommend the use of extracranial color duplex sonography in the evaluation of patients with CSVD as a supplementary method for follow-up, as this would allow the identification of patients whose condition might progress.

МУЛЬТИСИСТЕМНЫЙ ВОСПАЛИТЕЛЬНЫЙ СИНДРОМ, АССОЦИИРОВАННЫЙ С COVID-19 У ДЕТЕЙ, ОСЛОЖНЕННЫЙ ВЕНОЗНЫМИ И АРТЕРИАЛЬНЫМИ ТРОМБОЗАМИ: СЕРИЯ КЛИНИЧЕСКИХ НАБЛЮДЕНИЙ

SARS-CoV-2 causative agent may result in adulthood in hyperinflammatory syndrome and cytokine storm in some patients leading to the microvascular bed thromboses as well as those of large venous and arterial vessels. In the COVID-19 critical form, multisystem inflammatory syndrome in children (MIS-C), thromboses are less common. Authors represent a series of 8 patients’ cases with both thromboses and MIS-C associated with COVID-19 of different localization hospitalized in Nov. 2020-Nov. 2022 aged 4 months to 17 years old (Me 7.5 y/o): 4 aged 4 m/o to 5 y/o and 4 aged 8 to 17 y/o; 6 boys/2 girls. The incidence of thromboses was 13.3% (8/60 pediatric patients with MIS-C); venous thrombosis occurred in 6 (10% of 60), arterial thrombosis in 4 (6.6%), large cerebral vessels thrombosis coupled with the development of bilateral stroke occurred in 2 (3.3%), secondary thrombotic microangiopathy (TMA) in 3 (5%), distal gangrene in a single case (1.7%) and the cerebral venous sinus thrombosis in a single case (1.7%) as well. Treatment was carried out with anticoagulants, aspirin, immunomodulators (intravenous immunoglobulin, glucocorticosteroids, genetically engineered biological drugs). One of 8 patients with thromboses had died from pulmonary embolism (1.7% among all 60 patients with MIS-C), 6 of the 7 survivors continue to be followed up without complications and a single patient continues to have residual severe neurological deficits. Conclusion: venous thrombosis, secondary TMA and large cerebral arteries thrombosis predominated. Treatment of thrombosis with unfractionated heparin intravenously by continuous infusion with a transition to low molecular weight heparins against the background of pathogenetic therapy for MIS-C with immunomodulators was effective in most patients. Acetylsalicylic acid was used in 3 (with coronary dilatation and/or absence of severe thrombocytopenia). Risk factors for thromboses were male gender, severe congenital underlying diseases.

Relationship between ω3 and ω6 polyunsaturated fatty acids and atrial fibrillation in acute ischemic stroke

Some ω3 polyunsaturated fatty acids (PUFAs) are said to demonstrate a dose-related risk of atrial fibrillation (AF), conversely, some ω6 PUFAs might have AF protective potential. However, few investigated the relation among ischemic strokes. Primarily, we aimed to examine a relation between ω3 and ω6 PUFAs and the presence of AF in ischemic strokes. Further, since, some PUFAs are said to affect the cardiac load, we secondarily aimed to investigate the association between ω3 and ω6 PUFAs and brain natriuretic peptide (BNP) and the occurrence of cerebral large vessel occlusion (LVO) in ischemic strokes with AF. Consecutive patients with ischemic stroke admitted between 2012 and 2022 were retrospectively screened. Plasma levels of PUFAs, including eicosapentaenoic acid (EPA), docosahexaenoic acid, dihomo-γ-linolenic acid (DGLA) and arachidonic acid (AA), were assayed. Data were analyzed using a Poisson regression analysis with a robust variance estimator and a multiple linear regression analysis. We screened 2112 consecutive ischemic strokes, including 1574 (1119 [71%] males, median age 69 years). Lower DGLA (prevalence ratio (PR) 0.885, 95% CI 0.811-0.966, p=0.006), lower AA (PR 0.797, 95% CI 0.649-0.978, p=0.030), and higher EPA/AA ratio (PR 1.353, 95% CI 1.036-1.767, p=0.026) were associated with AF. Checking the linearity between AF and PUFAs, negative linear trends were observed between DGLA quartiles (Q1: PR 1.901, Q2: PR 1.550, Q3: PR 1.423, Q4: 1.000, p<0.001 for trend) and AA quartiles (Q1: PR 1.499, Q2: PR 1.204, Q3: PR 1.125, Q4: 1.000, p=0.004 for trend), with positive linear trends between EPA/AA ratio quartiles (Q1: 1.000, Q2: PR 1.555, Q3: PR 1.612, Q4: PR 1.797, p=0.001 for trend). Among patients with AF, a negative association between AA and BNP (unstandardized coefficient-1.316, 95% CI -2.290∼-0.342, p=0.008) was observed, and lower AA was associated with LVO (PR 0.707, 95% CI 0.527-0.950, p=0.021). Lower DGLA and AA and a higher EPA/AA ratio might be related to the development of AF in ischemic strokes. Further, AA might have a cardio-cerebrovascular protective role in ischemic strokes with AF.

The investigation of the frequency of COVID-19 in patients with a history of stroke.

The emergence of the coronavirus in 2019 became a global epidemic disease. According to the World Health Organization, people with a history of chronic diseases such as brain stroke are among the main groups at risk of contracting COVID-19. Therefore, this study was performed with the aim of the determination amount of the frequency of contracting COVID-19 in stroke patients. This descriptive-analytical study was conducted on 100 patients with a history of stroke referred to Imam Hossein Hospital in Tehran (Iran) between 2019 and 2022, which had all the inclusion criteria in the study. The demographic information including (gender, weight, height) and clinical information was collected by a researcher-made questionnaire and analyzed by SPSS version 24 software. The average age of the studied patients was 63 years. Among them, 53 people (53%) were infected with COVID-19. The most of underlying diseases were related to high blood pressure. All cases of stroke in patients with COVID-19 were associated with thrombotic type, and half of the other cases included involvement in large cerebral vessels. Lymphocyte count, CRP, and ESR levels were relatively higher in stroke patients with COVID-19, but there were observed no cases of pleural effusion and pericardial effusion associated with COVID-19 in stroke patients. In all of the patients with COVID-19, pulmonary involvement was observed in the Peripheral/Perihillar area. According to the results and data of this research, the probability of infecting COVID-19 is higher in people with a history of stroke, and these patients have more severe strokes and more mortality than stroke patients without contracting COVID-19.

Acute cerebrovascular accidents in patients with new coronavirus infection COVID-19

The incidence of neurological complications in COVID-19 can reach 8–10% of all cases of new coronavirus infection; acute cerebrovascular accidents (ACA) dominate in their structure, which cause significant social and economic costs due to the high mortality and disability rates in this group of patients. The main pathophysiological mechanism leading to the development of ischemic cerebrovascular accidents (ischemic stroke, transient ischemic attack) is the phenomenon of hypercoagulation, which, together with the systemic inflammatory response to the viral infection, leads to the formation of macro- and microthrombi and the development of ischemic disorders of cerebral circulation. The ischemic stroke associated with COVID-19 is characterized by the onset at a younger age, the predominance of cryptogenic and cardioembolic pathogenetic variants, a more frequent occlusion of large cerebral vessels and thus a more pronounced clinical picture of the disease. The reserves for reducing mortality and disability in patients with cerebrovascular disease, especially stroke, during the spread of COVID-19 lie both in the prevention, treatment and rehabilitation of COVID-19 in patients at high risk of developing cardiovascular diseases and in ensuring specialized medical care for this category of patients.

Differences in impact of current and former shift work on cardiovascular risk factors, carotid atherosclerosis, and white matter integrity.

The association of shift work (SW) and disrupted circadian rhythm with markers of large artery atherosclerosis and cerebral small vessel disease is uncertain. We aimed to study the separate association of current and former SW with these markers. We included participants from the population-based Hamburg City Health Study. SW was defined by monthly working hours between 06:00 pm and 07:00 am containing night shifts for at least 12 months. Cross-sectional data were obtained from structured questionnaires, laboratory analyses, physical examinations, brain magnetic resonance imaging, and carotid ultrasound. We performed multivariable regression analysis with carotid intima-media thickness (CIMT), and peak-width skeletonized mean diffusivity (PSMD) as dependent variables. Three hundred and forty-four current, 238 former, and 7162 never-shift workers were included. The median age was 60 years for both current and former shift workers, and total duration of SW was comparable for the two groups. Current shift workers were less frequently female (27.3% vs. 44.5%; p < .001), had more frequent hyperlipidemia (31.5% vs. 22.3%; p = .024), and diabetes (16.2% vs. 3.2%; p < .001). After adjustment for age and sex, reduced quality of sleep (β = 1.61, p = .001) and low education (β = 2.63, p < .001) were associated with current but not former SW. Adjusted for age and sex, the current SW was associated with higher CIMT (β = 0.02, p = .001) and PSMD (β = 9.06e-06, p = .006), whereas former SW was not. Adjusted for risk factors, current SW remained associated with PSMD (β = 9.91e-06, p = .006) but not with CIMT. Current SW was associated with CIMT and with PSMD, with the latter association remaining after adjustment for risk factors. Former SW showed no associations with CIMT or PSMD. This may indicate that current SW is linked with increased neurovascular risk through disrupted circadian rhythms. The trial was submitted at http://www.clinicaltrials.gov, under NCT03934957 on January 4, 2019. The first participant was enrolled in February 2016.

Reversal of Cerebral Arteriopathy Post-Hematopoietic Stem Cell Transplant for Sickle Cell Disease.

Sickle cell disease (SCD) is a chronic hematologic disorder which causes progressive cerebral arteriopathy beginning in childhood. As a result, arterial ischemic stroke is a major cause of morbidity and mortality in SCD, and SCD is a leading cause of childhood stroke worldwide. Allogenic hematopoietic stem cell transplant (HSCT) may be curative for individuals with SCD. Long-term outcomes and effects are currently being studied. In this report, we describe a child with SCD who presented with arterial ischemic stroke at 6 years of age and was found to have a severe form of cerebral large vessel arteriopathy by catheter-directed angiography. The patient initially underwent revascularization surgery by indirect superficial temporal artery to middle cerebral artery bypass, and 1 year later, he underwent curative HSCT. Approximately 3 years after HSCT, repeat catheter-directed angiography revealed a striking reversal of cerebral large vessel arteriopathy. This article reveals a previously unrecognized and potentially beneficial effect of HSCT that may ameliorate cerebral large vessel arteriopathy and improve cerebrovascular health for children with SCD.

Cincinnati Prehospital Stroke Scale (CPSS) as a Screening Tool for Early Identification of Cerebral Large Vessel Occlusions; a Systematic Review and Meta-analysis.

Large vessel occlusion (LVO) strokes are associated with worse functional outcomes and higher mortality rates. In the present systematic review and meta-analysis, we evaluated the diagnostic yield of the Cincinnati Prehospital Stroke Scale (CPSS) in detecting LVO. We performed an extensive systematic search among online databases including Medline, Embase, Web of Science, and Scopus, until July 31st, 2023. We also conducted a manual search on Google and Google scholar, along with citation tracking to supplement the systematic search in retrieving all studies that evaluated the diagnostic accuracy of the CPSS in detecting LVO among patients suspected to stroke. Fourteen studies were included in the present meta-analysis. CPSS showed the sensitivity of 97% (95% CI: 87%-99%) and the specificity of 17% (95% CI: 4%-54%) at the cut-off point of ≥1. The optimal threshold was determined to be ≥2, with a sensitivity of 82% (95% CI: 74%-88%) and specificity of 62% (95% CI: 48%-74%) in detecting LVO. At the highest cut-off point of ≥3, the CPSS had the lowest sensitivity of 60% (95% CI: 51%-69%) and the highest specificity of 81% (95% CI: 71%-88%). Sensitivity analyses showed the robustness of the results regardless of study population, inclusion of hemorrhagic stroke patients, pre-hospital or in-hospital settings, and the definition of LVO. A very low level of evidence demonstrated that CPSS, with a threshold set at ≥2, is a useful tool for identifying LVO stroke and directing patients to CSCs, both in prehospital and in-hospital settings.

Blood pressure variability and outcome in atherosclerosis versus cardioembolism cerebral large vessel occlusion after successful thrombectomy.

Higher blood pressure variability (BPV) has been proven associated with worse functional outcome after endovascular treatment (EVT). However, this association is not established according to different stroke etiologies. In this study, we compared patients with the two highest proportions of stroke etiologies-cardioembolism (CE) and large-artery atherosclerosis (LAA), aiming to explore appropriate strategies of BP management for different etiologies. We enrolled patients with large vessel occlusion (LVO) in anterior circulation who underwent EVT and achieved successful recanalization retrospectively. 24-h blood pressure (BP) and BPV measured as blood pressure reduction (BPr), standard deviation (SD), coefficient of variation (CV), successive variation (SV), average real variability (ARV) after EVT were collected for systolic blood pressure (SBP) and diastolic blood pressure (DBP). The favorable outcome was defined as functional independence by 90-day modified Rankin Scale (mRS 0-2). In our cohort, higher BPV parameters significantly resulted in 90d functional dependence in CE-LVO patients (SBPSV OR: 1.083, 95%CI = 1.009-1.163; SBPARV OR: 1.121, 95%CI = 1.019-1.233; DBPSD OR: 1.124, 95%CI = 1.007-1.1256; DBPCV OR: 1.078, 95%CI = 1.002-1.161). However, for LAA-LVO patients, no positive results correlated 90d functional dependence with 24-hour BPV. Additionally, 90d functional dependence in CE patients with poor collaterals were significantly dependent on post-procedural BPV (DBPmax OR: 1.044, 95%CI = 1.002-1.087; DBPSD OR: 1.229, 95%CI = 1.022-1.1.479; DBPCV OR: 1.143, 95%CI = 1.009-1.295). Whereas to patients with good collaterals, there did not exist such a correlation. In summary, stroke etiologies should probably be taken into consideration to optimize individualized BP management strategies. In order to achieve better clinical outcomes for patients with acute ischemic stroke due to large vessel occlusion, stricter blood pressure management should be taken in cardioembolic stroke patients in contrast with large artery atherosclerotic stroke patients after successful endovascular therapy.

Expert consensus on technical strategies for interventional treatment of acute large vessel occlusive stroke in China

Ischemic stroke caused by acute large vessel occlusion is associated with high rates of disability and mortality. Endovascular interventional therapy is evidently an effective treatment for occlusion of large cerebral vessels within the relevant time window, but there is no established methodological standard for recanalization interventional therapy. The Professional Committee of Interventional Neurology in Chinese Research Hospital Association organized cerebrovascular disease experts in China and developed the expert consensus described herein, to provide a reference for clinicians to formulate technical strategies for recanalization of acute cerebral vascular occlusion.

Application of Computed Tomography Perfusion Imaging-guided Mechanical Thrombectomy in Ischemic Stroke Patients with Large Vessel Occlusion beyond the Therapeutic Time Window.

To explore the feasibility of applying computed tomography perfusion (CTP) imaging-guided mechanical thrombectomy in acute ischemic stroke patients with large vessel occlusion beyond the therapeutic time window. The clinical data of acute cerebral infarction patients with large vessel occlusion who were beyond the therapeutic time window and admitted to Handan Central Hospital from January 2021 to March 2022 were retrospectively analyzed. All patients were assessed by the National Institutes of Health Stroke Scale (NIHSS) and were examined by one-stop CTP imaging. The preoperative onset time of the disease was more than 6 h. Fourteen patients underwent magnetic resonance imaging examination at the same time. Fifty-four patients were retrospectively divided into two groups based on the treatment methods: the mechanical thrombectomy group had 21 patients and the conservative treatment group had 33 patients. NIHSS scoring and computed tomography scan were performed before treatment, 6 h, 24 h, 7 days, and 30 days after treatment. The NIHSS scores of the patients with acute cerebral large vessel occlusion who underwent CTP imaging-guided mechanical thrombectomy at 6 h, 24 h, 7 days, and 30 days after treatment were compared with those of the conventional treatment group. The NIHSS score of the mechanical thrombectomy group was significantly better, and the difference was statistically significant (P < 0.05). In terms of the prognosis rate and expansion rate of infarct core volume, the patients of the mechanical thrombectomy group had a better prognosis, and the difference was statistically significant (P < 0.05). Artificial intelligence-assisted CTP diagnosis can facilitate the automatic evaluation of diseases and enable quick judgments that are independent of radiologists' evaluation, but it may pose a problem in the determination of infarct core volume (either being too high or too low). It is of great significance to apply CTP imaging in guiding the mechanical thrombectomy procedure in acute stroke patients with large vessel occlusion who are beyond the therapeutic time window.

Temporal trends in results of endovascular treatment of anterior intracranial large cerebral vessel occlusion: A 7-year study.

Technical improvements in devices, changes in angiographic grading scales and various confounding factors have made difficult the detection of the temporal evolution of angiographic and clinical results after endovascular treatment (EVT) for acute ischemic Stroke (AIS). We analyzed this evolution in time using the Endovascular Treatment in Ischemic Stroke (ETIS) registry. We analyzed the efficacy outcomes of EVT performed from January 2015 to January 2022, and modelized the temporal trends using mixed logistic regression models, further adjusted for age, intravenous thrombolysis prior to EVT, general anesthesia, occlusion site, balloon catheter use and the type of first-line EVT strategy. We assessed heterogeneity in temporal trends according to occlusion site, balloon catheter use, cardio embolic etiology, age (<80 years vs ⩾80 years) and first-line EVT strategy. Among 6104 patients treated from 2015 to 2021, the rates of successful reperfusion (71.1%-89.6%) and of complete first pass effect (FPE) (4.6%-28.9%) increase, whereas the rates of patients with >3 EVT device passes (43.1%-17.5%) and favorable outcome (35.8%-28.9%) decrease significantly over time. A significant heterogeneity in temporal trends in successful reperfusion according to the first-line EVT strategy was found (p-het = 0.018). The temporal trend of increasing successful reperfusion rate was only significant in patients treated with contact aspiration in first-line (adjusted overall effect p = 0.010). In this 7-year-old large registry of ischemic stroke cases treated with EVT, we observed a significant increase with time in the rate of recanalization whereas there was a tendency toward a decrease in the rate of favorable outcome over the same period.

Burden of dilated perivascular spaces in patients with moyamoya disease and moyamoya syndrome is related to middle cerebral artery stenosis.

The correlation between intracranial large artery disease and cerebral small vessel disease (CSVD) has become a noteworthy issue. Dilated perivascular spaces (dPVS) are an important marker of CSVD, of which cerebral atrophy has been regarded as one of the pathological mechanisms. DPVS has been found to be associated with vascular stenosis in patients with moyamoya disease (MMD), but the underlying mechanism remains unclear. The purpose of our study was to explore the correlation between the middle cerebral artery (MCA) stenosis and dPVS in the centrum semiovale (CSO-dPVS) in patients with MMD/moyamoya syndrome (MMS) and to determine whether brain atrophy plays a mediating role in this relationship. A total of 177 patients were enrolled in a single-center MMD/MMS cohort. Images of their 354 cerebral hemispheres were divided into three groups according to dPVS burden: mild (dPVS 0-10), moderate (dPVS 11-20), and severe (dPVS > 20). The correlations among cerebral hemisphere volume, MCA stenosis, and CSO-dPVS were analyzed, adjusting for the confounding factors of age, gender, and hypertension. After adjustment for age, gender, and hypertension, the degree of MCA stenosis was independently and positively associated with ipsilateral CSO-dPVS burden (standardized coefficient: β = 0.247, P < 0.001). A stratified analysis found that the subgroup with a severe CSO-dPVS burden exhibited a significantly higher risk of severe stenosis of the MCA [p < 0.001, OR = 6.258, 95% CI (2.347, 16.685)]. No significant correlation between CSO-dPVS and ipsilateral hemisphere volume was found (p = 0.055). In our MMD/MMS cohort, there was a clear correlation between MCA stenosis and CSO-dPVS burden, which may be a direct effect of large vessel stenosis, without a mediating role of brain atrophy.

Computed Tomography Perfusion Parameters Predictive of Symptomatic Intracranial Hemorrhage After Mechanical Thrombectomy in Patients With Cerebral Large Vessel Occlusion

Background Hemorrhagic transformation after recanalization is a severe complication in patients with a large ischemic core due to cerebral large vessel occlusion. Risk assessment using perfusion imaging to predict hemorrhagic infarction has not been established. Thus, we aimed to investigate the association between perfusion imaging findings and hemorrhagic transformation in patients with acute cerebral large vessel occlusion who had undergone preoperative perfusion imaging evaluation and mechanical thrombectomy. Methods We enrolled consecutive patients who received mechanical thrombectomy after undergoing perfusion imaging for anterior large vessel occlusion from May 2019 to March 2022. The patients in whom recanalization were not achieved and who experienced procedure‐related bleeding were excluded. We investigated the predictors of symptomatic intracranial hemorrhage (sICH) by exploring preoperative perfusion imaging parameters (relative cerebral blood flow, relative cerebral blood volume, time of maximum concentration, and hypoperfusion index ratio). Results Among the 167 patients (median age 79 years, 47% female) enrolled, 63 (38%) and 14 (8%) patients had any intracranial hemorrhage and sICH (sICH group), respectively. The sICH group had a shorter puncture‐recanalization time than the non‐sICH group (median [interquartile range (IQR)]; 43 [34–55] versus 61 [37–88]; P =0.046), whereas the modified Rankin scale at 90 days showed a worse prognosis (median [IQR]; 5 [5–6] versus 3 [1–4]; P &lt;0.01). All perfusion imaging parameters were significantly predicting the sICH group in multiple logistic regression analysis. The value of relative cerebral blood volume was the parameter most strongly associated with sICH in receiver operating characteristic curve analysis (area under the curve=0.90, 95% CI [0.83–0.98]; cutoff 43 mL; sensitivity, 86 %; specificity, 87%). Conclusion Among perfusion computed tomography parameters, relative cerebral blood volume is highly associated with sICH after mechanical thrombectomy for cerebral large vessel occlusion. In patients with low relative cerebral blood volume regions, the indication of mechanical thrombectomy should be carefully considered for postoperative intracranial hemorrhage.

Tirofiban for Stroke without Large or Medium-Sized Vessel Occlusion

BackgroundThe effects of the glycoprotein IIb/IIIa receptor inhibitor tirofiban in patients with acute ischemic stroke but who have no evidence of complete occlusion of large or medium-sized vessels have not been extensively studied.MethodsIn a multicenter trial in China, we enrolled patients with ischemic stroke without occlusion of large or medium-sized vessels and with a National Institutes of Health Stroke Scale score of 5 or more and at least one moderately to severely weak limb. Eligible patients had any of four clinical presentations: ineligible for thrombolysis or thrombectomy and within 24 hours after the patient was last known to be well; progression of stroke symptoms 24 to 96 hours after onset; early neurologic deterioration after thrombolysis; or thrombolysis with no improvement at 4 to 24 hours. Patients were assigned to receive intravenous tirofiban (plus oral placebo) or oral aspirin (100 mg per day, plus intravenous placebo) for 2 days; all patients then received oral aspirin until day 90. The primary efficacy end point was an excellent outcome, defined as a score of 0 or 1 on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) at 90 days. Secondary end points included functional independence at 90 days and a quality-of-life score. The primary safety end points were death and symptomatic intracranial hemorrhage.ResultsA total of 606 patients were assigned to the tirofiban group and 571 to the aspirin group. Most patients had small infarctions that were presumed to be atherosclerotic. The percentage of patients with a score of 0 or 1 on the modified Rankin scale at 90 days was 29.1% with tirofiban and 22.2% with aspirin (adjusted risk ratio, 1.26; 95% confidence interval, 1.04 to 1.53, P=0.02). Results for secondary end points were generally not consistent with the results of the primary analysis. Mortality was similar in the two groups. The incidence of symptomatic intracranial hemorrhage was 1.0% in the tirofiban group and 0% in the aspirin group.ConclusionsIn this trial involving heterogeneous groups of patients with stroke of recent onset or progression of stroke symptoms and nonoccluded large and medium-sized cerebral vessels, intravenous tirofiban was associated with a greater likelihood of an excellent outcome than low-dose aspirin. Incidences of intracranial hemorrhages were low but slightly higher with tirofiban. (Funded by the National Natural Science Foundation of China; RESCUE BT2 Chinese Clinical Trial Registry number, ChiCTR2000029502.)

The diagnostic value of the field assessment stroke triage as an emergency destination tool in identifying the obstruction of large cerebral vessels: a systematic review and meta-analysis

Objective: In this study, we investigate the diagnostic value of the field assessment stroke triage for emergency destination (FAST-ED) tool in the diagnosis of large vessels occlusion (LVO) in a systematic review and meta-analysis.&#x0D; Methods: We conducted a search in Medline (PubMed), Embase, Scopus, and Web of Science databases until the 21st of September 2022, as well as a manual search in Google and Google scholar to find related articles. Studies of diagnostic value in adult population were included. Screening, data collection and quality control of articles were done by two independent researchers. The data were entered and analyzed in STATA 17.0 statistical program.&#x0D; Results: The data from 30 articles were entered. The best cut-off points for FAST-ED were 3 or 4. The sensitivity and specificity of FAST-ED at cut-off points 3 were 0.77 (95% CI:0.73,0.80) and 0.76 (95% CI:0.72,0.80), respectively. These values ​​for cut-off point 4 were 0.72 (95% CI:0.65,0.78) and 0.79 (95% CI:0.75,0.82), respectively. Meta-regression showed that the sensitivity and specificity of FAST-ED performed by a neurologist was more accurate compared to emergency physician (P for sensitivity=0.01; P for specificity&lt;0.001) and emergency medical technicians (P for sensitivity=0.03; P for specificity&lt;0.001). Finally, it was found that the sensitivity of FAST-ED performed by the emergency physician and the emergency medical technician has no statistically significant difference (P=0.76). However, the specificity of FAST-ED reported by the emergency physician is significantly higher (P&lt;0.001). The false negative rate of this tool at cut-off points 3 and 4 is 22.5% and 28.8%, respectively. &#x0D; Conclusion: Although FAST-ED has an acceptable sensitivity in identifying LVO, its false negative rate varies between 22.5% and 28.8%. A percentage this high is unacceptable for a screening tool to aid in the diagnosis of strokes considering it has a high rate or morbidity and mortality. Therefore, it is recommended to use another diagnostic tool for the stroke screening.

Granulocytes-Rich Thrombi in Cerebral Large Vessel Occlusion Are Associated with Increased Stiffness and Poorer Revascularization Outcomes.

We aim to identify a profile of intracranial thrombus resistant to recanalization by mechanical thrombectomy (MT) in acute stroke treatment. The first extracted clot of each MT was analyzed by flow cytometry obtaining the composition of the main leukocyte populations: granulocytes, monocytes, and lymphocytes. Demographics, reperfusion treatment, and grade of recanalization were registered. MT failure (MTF) was defined as final thrombolysis in cerebral infarction score IIa or lower and/or need of permanent intracranial stenting as a rescue therapy. To explore the relationship between stiffness of intracranial clots and cellular composition, unconfined compression tests were performed in other cohorts of cases. Thrombi obtained in 225 patients were analyzed. MTF were observed in 30 cases (13%). MTF was associated with atherosclerosis etiology (33.3% vs. 15.9%; p = 0.021) and higher number of passes (3 vs. 2; p < 0.001). Clot analysis of MTF showed higher percentage of granulocytes [82.46 vs. 68.90% p < 0.001] and lower percentage of monocytes [9.18% vs.17.34%, p < 0.001] in comparison to successful MT cases. The proportion of clot granulocytes (aOR 1.07; 95% CI 1.01-1.14) remained an independent marker of MTF. Among thirty-eight clots mechanically tested, there was a positive correlation between granulocyte proportion and thrombi stiffness (Pearson's r = 0.35, p = 0.032), with a median clot stiffness of 30.2 (IQR, 18.9-42.7) kPa. Granulocytes-rich thrombi are harder to capture by mechanical thrombectomy due to increased stiffness, so a proportion of intracranial granulocytes might be useful to guide personalized endovascular procedures in acute stroke treatment.

CT-based thrombus radiomics nomogram for predicting secondary embolization during mechanical thrombectomy for large vessel occlusion.

Secondary embolization (SE) during mechanical thrombectomy (MT) for cerebral large vessel occlusion (LVO) could reduce the anterior blood flow and worsen clinical outcomes. The current SE prediction tools have limited accuracy. In this study, we aimed to develop a nomogram to predict SE following MT for LVO based on clinical features and radiomics extracted from computed tomography (CT) images. A total of 61 patients with LVO stroke treated by MT at Beijing Hospital were included in this retrospective study, of whom 27 developed SE during the MT procedure. The patients were randomly divided (7:3) into training (n = 42) and testing (n = 19) cohorts. The thrombus radiomics features were extracted from the pre-interventional thin-slice CT images, and the conventional clinical and radiological indicators associated with SE were recorded. A support vector machine (SVM) learning model with 5-fold cross-verification was used to obtain the radiomics and clinical signatures. For both signatures, a prediction nomogram for SE was constructed. The signatures were then combined using the logistic regression analysis to construct a combined clinical radiomics nomogram. In the training cohort, the area under the receiver operating characteristic curve (AUC) of the nomograms was 0.963 for the combined model, 0.911 for the radiomics, and 0.891 for the clinical model. Following validation, the AUCs were 0.762 for the combined model, 0.714 for the radiomics model, and 0.637 for the clinical model. The combined clinical and radiomics nomogram had the best prediction accuracy in both the training and test cohort. This nomogram could be used to optimize the surgical MT procedure for LVO based on the risk of developing SE.

Aortic stiffness and impairments in cerebrovascular function in cancer survivorship

An established consequence of anti-cancer treatment is increased aortic stiffness, which impairs the aortic damping of cardiac-generated pulsatile pressure and blood flow. These increased pulsations may result in vascular injury in the microcirculation of target end organs like the brain. The aim of the present study was to determine the ramifications of elevated aortic stiffness on cerebral macro- and microvascular pulsatility and autoregulatory function in cancer survivors. We hypothesized that cerebrovascular pulsatility would be enhanced, and cerebrovascular reactivity (CVR) to elevations in arterial CO 2 would be impaired, both in the large and small cerebral vessels in patients with a history of cancer and anti-cancer treatment versus healthy age- and sex-matched non-cancer controls. Aortic arch pulse wave velocity (aaPWV), a regional measure of stiffness in the proximal aorta, was calculated from echocardiographic views of the aortic valve and the descending aortic arch. Subjects then breathed room air for 60s followed by ~2 minutes of rebreathing with simultaneous collection of end-tidal pressure of CO 2 (P ET CO 2 ). Middle cerebral artery blood flow velocity (MCAv) was assessed using transcranial doppler. Oxygenated (oxy-[Hb]) and deoxygenated (deoxy-[Hb]) cerebral microvascular hemoglobin concentrations were monitored using two near-infrared spectroscopy probes placed over the prefrontal cortices. Pulsatility was assessed at baseline using Gosling’s Pulsatility Index (PI) for both the microvasculature and MCA. To account for changes in perfusion pressure, MAP was collected via finger plethysmography and cerebrovascular conductance indices were calculated for both oxy-[Hb] (CVCi oxy ) and MCAv (CVCi MCA ). CVR was calculated as the slope of CVCi oxy and CVCi MCA over P ET CO 2 during rebreathing. Six women were recruited (n = 3/group). Age was similar between the healthy non-cancer controls (HC) and patients with a history of cancer and anti-cancer treatment (CS) (31.0 ± 7 vs. 32.7 ± 13 years). Baseline ventilatory (P ET CO 2 ), central and cerebral hemodynamics were also similar (all p &gt; 0.05). aaPWV was significantly elevated in CS compared to HC (5.3 ± 0.6 vs. 3.1 ± 1.1 m/s, p = 0.04). Cerebral microcirculation PI in CS was significantly elevated (0.04 ± 0.01 vs. 0.02 ± 0.01, p = 0.02), but MCA PI was not different (p &gt; 0.05). CVR-CVCi oxy was impaired in CS (-3.6 ± 2.8 vs. 1.5 ± 0.5 nM·mmHg -1 /mmHg, p = 0.03), and CVR-CVCi MCA was similarly reduced (-0.05 ± 0.06 vs. 0.15 ± 0.01 mm/sec·mmHg -1 /mmHg, p &lt; 0.01). The increase in MAP during hypercapnia was similar between groups. Consistent with our hypothesis, both CVR-CVCi oxy and CVR-CVCi MCA were attenuated in patients with a history of anti-cancer treatment. Additionally, the microvascular pulsatility was greater in CS. This suggests an impaired cerebrovascular function, possibly related to increased transmission of pulsatility into the brain, in the years following cancer diagnoses and treatment. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.