Stroke-free Survival Research Articles

Risk factors of postoperative cerebral hyperperfusion syndrome and its relationship with clinical prognosis in adult patients with moyamoya disease

BackgroundTo investigate the incidence, risk factors, and clinical prognosis of cerebral hyperperfusion syndrome (CHS) after superficial temporal artery-middle cerebral artery anastomosis combined with encephalo-duro-arterio-synangiosis (STA-MCA/EDAS) in adult patients with moyamoya disease (MMD).MethodsThe clinical data of 160 adult patients with MMD treated by STA-MCA/EDAS from January 2016 to January 2017 were retrospectively analyzed. According to CHS diagnosis, MMD patients were divided into CHS and non-CHS group. Univariate and multivariate analysis of risk factors and Kaplan-Meier curve of stroke-free survival for CHS were performed.ResultsA total of 12 patients (7.5%) developed postoperative CHS, of which 4 patients (2.5%) presented with cerebral hemorrhage. Univariate and multivariate analysis showed moyamoya vessel on the surgical hemisphere (OR = 3.04, 95% CI = 1.02–9.03, P = 0.046) and left operated hemisphere (OR = 5.16, 95% CI = 1.09–21.34, P = 0.041) were independent risk factors for CHS. The other variables, such as age, gender, presentation, hypertension, diabetes, smoking, mean mRS score on admission, modified Suzuki stage and pre-infarction stage on surgical hemisphere, and bypass patency, had no association with postoperative CHS (P > 0.05). At final follow-up with average 38 months, there were 18 out of 133 patients (13.5%, 4.91% per person year) presented with newly developed complications. There was no significant difference between newly developed complications, mean mRS scores, and Kaplan-Meier curve of stroke-free survival in patients with and without CHS (P > 0.05).ConclusionThe concentration of moyamoya vessels and left operated hemisphere was independent risk factors for CHS, which could not affect the clinical prognosis if treated timely and properly. The current study offers a new perspective of moyamoya vessels and supporting data for choosing MMD candidates on cerebral revascularization.

Long-term durability and clinical outcome of a prospective randomized trial comparing carotid endarterectomy with ACUSEAL polytetrafluoroethylene patching versus pericardial patching

BackgroundSeveral studies have shown the superiority of carotid endarterectomy (CEA) with patch closure over primary closure. However, no definite study has shown any significant differences in clinical outcome between various types of patches. Because more vascular surgeons have used pericardial patching recently, this study will analyze the late clinical outcome (≥10 years) of our previously reported prospective randomized trial comparing CEA with ACUSEAL (polytetrafluoroethylene) vs pericardial patching. MethodsA total of 200 CEAs were randomized (1:1) to either Vascu-Guard pericardial patching or ACUSEAL patching. All patients had immediate duplex ultrasound imaging, which was repeated at 6 months and annually thereafter. Kaplan-Meier analysis was used to estimate rates of freedom from stroke, stroke-free survival, and rates of freedom from ≥50% and ≥80% restenosis. ResultsOverall demographic and clinical characteristics were somewhat similar with a mean follow-up of 80 months (range: 0-149 months). The rates of freedom from stroke were 97, 97, 97, 96, 93 for ACUSEAL vs 99, 98, 97, 97, 92 for pericardial patching (P = .1112) at 1, 2, 3, 5, and 10 years, respectively. Similarly, the rates of freedom from stroke/death were 94, 93, 90, 76, 50 for ACUSEAL vs 99, 96, 91, 78, 47 for pericardial patching (P = .8591). The rates of freedom from ≥50% restenosis were 98, 98, 96, 89, 79 for ACUSEAL vs 87, 83, 83, 81, 71 for pericardial patching (P = .0489). The rates of freedom from ≥80% restenosis were 99, 99, 99, 96, 85 for ACUSEAL vs 96, 96, 96, 93, 93 for pericardial patching (P = .9407). The overall survival rates were 95, 94, 91, 77, 51 for ACUSEAL vs 100, 98, 93, 79, 50 for pericardial patching (P = .9123). Other patch complications (eg, rupture, aneurysmal dilation, infection, etc) were similar. ConclusionsBoth CEA with ACUSEAL (polytetrafluoroethylene) and pericardial patching are durable and have similar clinical outcomes at 10 years except that ACUSEAL patching has significantly better rates of freedom from ≥50% restenosis.

Same-day versus staged revascularization of bilateral moyamoya arteriopathy in pediatric patients.

To compare the outcomes of conducting left and right hemisphere surgical revascularization on the same day versus different days for bilateral pediatric moyamoya arteriopathy patients. We retrospectively analyzed mortality, stroke, and transient neurologic event (TNE) rates in North American bilateral pediatric moyamoya arteriopathy patients who underwent bilateral cerebral revascularization. A total of 38 pediatric (≤ 18years old) patients at our institution underwent bilateral cerebral revascularization for moyamoya arteriopathy. Of these patients, 24 (63.2%) had both operations on the same day and 14 (36.8%) had the two operations on different days. The average length of stay for patients who underwent same-day bilateral revascularization was 6.9 ± 2.0days and the average length of stay for each operation for patients who underwent staged bilateral revascularization was 4.5 ± 1.4days, p = 0.001. While there were 7 (14.6%) postoperative strokes in patients who had both hemispheres revascularized on the same day, 0 (0%) strokes occurred in hemispheres after they had been operated on in the staged cohort, p = 0.042. Additionally, the postoperative stroke-free survival time in the ipsilateral hemisphere and TNE-free survival time were significantly longer in patients in the staged revascularization cohort. Same-day bilateral revascularization was associated with longer length of stay per operation, higher rate of ipsilateral stroke, and shorter postoperative TNE-free and stroke-free survival time in the revascularized hemisphere.

Matched design for marginal causal effect on restricted mean survival time in observational studies

Abstract Investigating the causal relationship between exposure and time-to-event outcome is an important topic in biomedical research. Previous literature has discussed the potential issues of using hazard ratio (HR) as the marginal causal effect measure due to noncollapsibility. In this article, we advocate using restricted mean survival time (RMST) difference as a marginal causal effect measure, which is collapsible and has a simple interpretation as the difference of area under survival curves over a certain time horizon. To address both measured and unmeasured confounding, a matched design with sensitivity analysis is proposed. Matching is used to pair similar treated and untreated subjects together, which is generally more robust than outcome modeling due to potential misspecifications. Our propensity score matched RMST difference estimator is shown to be asymptotically unbiased, and the corresponding variance estimator is calculated by accounting for the correlation due to matching. Simulation studies also demonstrate that our method has adequate empirical performance and outperforms several competing methods used in practice. To assess the impact of unmeasured confounding, we develop a sensitivity analysis strategy by adapting the E-value approach to matched data. We apply the proposed method to the Atherosclerosis Risk in Communities Study (ARIC) to examine the causal effect of smoking on stroke-free survival.

Advanced age is associated with increased adverse outcomes in patients undergoing middle cerebral artery stenting.

This study tried to evaluate whether advanced age has an increased incidence of major complications in patients undergoing MCA stenting. A total of 348 patients who underwent MCA stenting were reviewed from a prospectively maintained database. Ninety-day ischemic stroke, intracerebral hemorrhage, and death outcomes were compared among the young (≤40 years old), middle (41-60 years old) and old (≥61 years old) groups. Univariate analysis and multivariable logistic regression analysis were used to investigate different variables associated with 90-day major adverse events. Kaplan-Meier analysis was performed to determine long-term outcomes during follow-up. The incidence of 90-day ischemic stroke was 9.26% in the old group, 2.86% in the middle group, and 0% in the young group (P = 0.024). The incidence of all 90-day major adverse events was 3.33% in patients ≤40 years old, 19.90% in patients 41-60 years old, and 24.07% in patients ≥61 years old, with statistical significance (P = 0.04). Advanced age was associated with increased 90-day ischemic stroke (OR = 1.074, 95% CI: 1.019-1.132, P = 0.007; adjusted OR: 1.071, 95% CI: 1.008-1.138, P = 0.026) and 90-day death (OR = 1.072, 95% CI: 1.012-1.135, P = 0.018; adjusted OR: 1.095, 95% CI: 1.015-1.182, P = 0.018). Meanwhile, advanced age was also associated with decreased long-term survival and ischemic stroke-free survival during follow-up. Our data indicated that MCA stenting in elderly patients is associated with a high risk of adverse events and should be cautiously considered.

Carotid endarterectomy is safe for octogenarians

Carotid endarterectomy (CEA) has demonstrated superior results in stroke risk reduction for patients with symptomatic and asymptomatic high-grade carotid stenosis. However, this benefit has long been questioned for the elderly and high-risk populations. In the present study, we aimed to provide high-volume, single-institution data with long-term follow-up examining the risk factors for postoperative stroke and stroke-free survival stratified by age for asymptomatic and symptomatic patients undergoing CEA. A single-institution retrospective review of 840 consecutive patients who had undergone CEA from 2011 to 2018 was performed, inclusive of both symptomatic and asymptomatic operative indications. The primary end point was perioperative stroke within 30days of surgery. The secondary end points were late stroke, death, and myocardial infarction. Patients aged >80years were compared with those aged<80years to examine freedom from stroke and death. Statistically significant differences were defined as those with P< .05. A total of 840 patients were evaluated with a median follow-up of 416± 1244days. Of the 840 patients, 499 (59%) were men, and 604 (72%) were White. The mean age was 72± 9years, with 202 (24%) aged ≥80years. CEA was performed for symptomatic disease in 305 patients (36%), of whom 143 (47%) had had strokes and 162 (53%) had had transient ischemic attacks. The overall 30-day postoperative stroke rate was 1.0% (eight patients; 0.6% for asymptomatic and 1.6% for symptomatic; P= .147). Compared with younger patients, octogenarians had had a similar stroke rate after CEA (1.5% vs 0.8%; P= .407). Hispanic race was an independent risk factor for postoperative stroke. White race and preoperative statin use both appeared to be protective. Kaplan-Meier survival curves demonstrated decreased a 5-year stroke-free survival in patients aged ≥80years (P= .031). However, overall, the estimated 5-year survival was similar to the U.S. general population across both age groups. CEA for octogenarians is safe and effective for both symptomatic and asymptomatic populations with excellent 30-day outcomes and long-term survival mirroring that of the general population.

Elective or Urgent Carotid Endarterectomy in Symptomatic Patients: Analysis Based on the Type and Timing of Neurological Symptoms

The aim of this study was to retrospectively analyse perioperative and long-term outcomes of carotid endarterectomy (CEA) performed in symptomatic patients in a high-volume academic vascular centre, stratifying them according to the type of preoperative symptoms and the timing of surgery with respect to the indexed neurological event. From January 2014 to December 2020, 1,369 consecutive CEAs were performed at our institution. Data concerning these interventions were prospectively collected in a dedicated database including data concerning preoperative assessment, surgical details, perioperative (<30days) outcomes, and long-term outcomes. A retrospective analysis of the database was performed, and 213 interventions performed in symptomatic patients were found. We identified 2 subgroups of patients: patients with stable neurological symptoms (not recent transient ischemic attack (TIA) or stable major disabling stroke, stable group, and 157 patients) and patients with unstable neurological symptoms (recent TIA, crescendo TIAs, stroke in evolution, acute/recent minor stroke, unstable group, and 56 patients). Perioperative outcomes were analysed in terms of mortality, major neurological events, and local or systemic complications The results were compared using the χ2 test; these were also analysed on the basis of the presenting symptom (isolated TIA, crescendo TIA, stroke in evolution, acute/recent minor stroke, stabilized stroke) and the timing of the intervention relative to the onset of the symptom. Long term results were analysed using the life-table analysis and Kaplan-Meier curves in terms of survival, stroke-free survival, absence of neurological symptoms, and absence of significant restenosis. Overall, 30-day stroke and death rate were 4.2%. (3.1% vs. 7%, P=0.2). Two deaths occurred at 30days, both in the stable group (mortality 1.2%, P=0.4 compared to the unstable group), but no fatal strokes were recorded in the overall sample. No differences were found in terms of new perioperative neurological events and local complications between the 2 groups. We found a trend toward poorer perioperative results in patients operated on within 48hr from the indexed event and in patients operated on for stroke in evolution or acute/recent stroke, whereas we found a trend toward better results in favour of patients operated on between 8 and 14days (P=0.08). The median duration of follow-up was 24.8months (range 1-78); at 5years we did not find significant differences in terms of survival and stroke-free survival rates between 2 groups. In our experience, carotid surgery in symptomatic patients provided satisfactory results, particularly in patients with stable neurological status. Among unstable patients, the rate of complications significantly increases, mainly among treated in the very early (<48hr) period for stroke in evolution or acute/recent stroke. Once the perioperative risk is overcome, the results in the long-term setting are similarly good, both in stable and in unstable patients.

Abstract 334: Cardiogenic Shock In Heart Transplant Candidates - Improved Outcome With Impella 5.5

Background: Heart transplant (HTX) candidates often develop cardiogenic shock (CS) and require mechanical circulatory support (MCS). UNOS criteria prioritize temporary MCS over durable left ventricular assist devices (LVADs). Extracorporeal membrane oxygenation (ECMO) or intra-aortic balloon pump are associated with poor outcome. In early 2020, we transitioned to using axillary Impella 5.5 in CS patients with both isolated LV or biventricular failure as bridge to HTX. This reports our two-year experience. Methods: We performed a retrospective single center chart review. 19 patients treated with Impella 5.5 as bridge to HTX were identified. UNOS criteria were used to classify CS. If inotropes and diuresis failed to resolve CS, Impella 5.5 was placed via a 10 mm graft sewn to the axillary artery. Key endpoints were survival to transplant without disabling stroke, 30-day and 1-year post-HTX survival. Results: Mean age 55 yrs, 89% male, mean Impella support 19 days (2 - 71, total 369). 58% biventricular failure with at least moderate right ventricular dysfunction (RVD). RVD was managed medically, no RV assist device or ECMO was needed. Transient elevation (&gt;40 mg/dl) of free plasma hemoglobin occurred in 42% but resolved with device repositioning and/or fluids. No renal replacement therapy was required. No serious infectious, vascular or bleeding complication occurred. There was no device malfunction, one pump was replaced due to an exposed wire after 22 days of support. 100% of patients were able to ambulate prior to HTX. Overall survival was 100%. 89% patients were successfully bridged to HTX without major morbidity. Two cases received durable LVAD. One developed non-disabling ischemic stroke on day 16 of Impella support. One elected LVAD as destination therapy after 71 days of support. Stroke free survival during Impella support was 95%. There were no disabling strokes. Post-transplant 30-day survival was 100% (n=17). 1-year post-HTX survival data was 100% (n=10). Conclusion: Impella 5.5 successfully restores hemodynamics in CS in HTX eligible patients with both isolated LV and biventricular failure. RVD in this situation can be managed medically. With this strategy, patients are able to ambulate prior to HTX and survival after HTX exceeds national average.

Prognosis of Rotational Angiography-Based Stereotactic Radiosurgery for Dural Arteriovenous Fistulas: A Retrospective Analysis.

Cerebral dural arteriovenous fistulas (DAVFs) are intracranial vascular malformations with fine, abnormal vascular architecture. High-resolution vascular imaging is vital for their visualization. Currently, rotational angiography (RA) provides the finest 3-dimensional visualization of the arteriovenous shunt with high spatial resolution; however, the efficacies of the integration of RA have never been studied in stereotactic radiosurgery (SRS) for DAVFs until now. Since 2015, our institution has integrated RA into SRS (RA-SRS) to provide more conformal planning, thereby decreasing overtreatment and undertreatment. To analyze the outcomes of RA-SRS for DAVFs. We retrospectively analyzed the outcomes of 51 patients with DAVFs and compared those of 20 DAVFs treated with RA-SRS with those of 31 DAVFs treated with conventional SRS (c-SRS). The time to obliteration was shorter in the RA-SRS group (median, 15 months vs 26 months [cumulative rate, 77% vs 33% at 2 years, 77% vs 64% at 4 years]; P = .015). Multivariate Cox proportional hazards analysis demonstrated that RA-SRS (hazard ratio 2.39, 95% CI 1.13-5.05; P = .022) and the absence of cortical venous reflux (hazard ratio 2.12, 95% CI 1.06-4.25; P = .034) were significantly associated with obliteration. The cumulative 5-year post-SRS stroke-free survival rates were 95% and 97% in the RA-SRS and c-SRS groups, respectively ( P = .615). Neurological improvement tended to occur earlier in the RA-SRS group than in the c-SRS group (median time to improvement, 5 months vs 20 months, log-rank test; P = .077). RA-based SRS may facilitate earlier fistula obliteration and may contribute to early neurological improvement.

Primary arterial closure after carotid endarterectomy is a safe and expeditious technique in appropriately selected patients

BackgroundCarotid endarterectomy (CEA) remains a safe and durable operation for both symptomatic and asymptomatic carotid stenosis, however conflicting evidence exists on the benefit of patch angioplasty and its effects on post-operative outcomes. MethodsA retrospective review of all patients undergoing CEA from 2011 to 2018 was performed. ResultsOf 851 patients, primary closure was performed in 277 (33%). Patients with primary closure were older (74 vs 72, p = 0.001), symptomatic (39% vs 34%, p = 0.024), and male (69% vs 31% p < 0.001), with a higher incidence of diabetes mellitus (47% vs 39%, p = 0.046) and ESRD (4% vs 2%, p = 0.015). Restenosis rates were similar (7% vs 8%, p = 0.67). Operative time was shorter for primary closure (87 ± 28 vs 102 ± 26 min, p < 0.001). There were no differences in 30-day ipsilateral stroke rates (1% vs 1%, p = 0.51) or stroke-free survival. ConclusionsPrimary arterial closure is safe and expeditious in appropriately selected high-risk patients.

The impact of mitral regurgitation on the incidence of stroke in patients with atrial fibrillation

Abstract Background Stroke is a significant cause of mortality and a leading cause of disability in elderly patients. Atrial fibrillation (Af) is the most common cardiac disease with assumed embolic stroke. Therefore, patients with Af need anti-coagulant therapy with a Warfarin (vitamin K antagonist) or a DOAC (Direct Oral Anti-Coagulant), also considering the risk and benefit net balance. It has been suggested that significant mitral regurgitation (MR) and its vortex jet in the left atrium might reduce embolic stroke source in patients with Af. However, the effect of MR on the risk of stroke in patients with Af is still controversial. Therefore, we hypothesized whether MR might be associated with a lower risk of thromboembolic events in patients with Af. Purpose This study aims to investigate whether MR was associated with a decreased risk of stroke in patients with Af, especially in the elderly population. Methods We studied 1,714,955 patients in the LIFE Study database, comprising Japanese claims data for public insurance policyholders between 2014 and 2020. We identified 51,939 patients with new-onset Af. Among them, patients with pre-existing stroke patients (N=28,519) were excluded, and new-onset Af patients without stroke (N=23,420) were obtained. Based on the baseline information, the Af patients were stratified into the MR group (N=3,439) and Without-MR group (N=19,981). Propensity score matching (the nearest neighbor method with a caliper of 0.2) was performed to balance baseline features and stroke risk factors between the MR group (N=3439) and the Without-MR group (N=3439). Propensity scores were estimated using logistic regression with age, sex, and all factors in Elixhauser's comorbidity system. The incidence rate of the stroke (events per person-year) was calculated by the event numbers divided by the overall period for the observations months × 12. Kaplan-Meier curves of stroke-free survival were generated, and the two groups' comparisons were performed using the log-rank test. Results As expected, patients' characteristics were comparable between the two groups. The observation period was 3 years for both groups. In the MR group, 136 patients with stroke were detected. On the other hand, 122 patients with stroke were detected in the Without-MR group. The incidence rate of the stroke per person-year was 0.027 and 0.025 events per person-year in patients with the MR and Without-MR groups. In addition, the Kaplan-Meier analysis showed that the incidence rate of stroke was comparable between the two groups (P=0.43). Conclusions The frequency of stroke in patients with atrial fibrillation was similar, despite mitral regurgitation. Therefore, patients with atrial fibrillation should have anti-coagulation therapy, regardless of the presence or absence of mitral regurgitation. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by grants provided by the Japan Science and Technology Agency (JST) Fusion Oriented Research for disruptive Science and Technology (FOREST) Program (Grant Number: JPMJFR205J) and the Japan Society for the Promotion of Science (JSPS) Grants-in-Aid for Scientific Research (KAKENHI) Program (Grant Numbers: JP20H00563 and JP19K21590).

Comparison of Complications and Cost for Transfemoral Versus Transcarotid Stenting of Carotid Artery Stenosis

Options for endovascular treatment of carotid artery disease have been developed to compliment with carotid endarterectomy, transfemoral carotid artery stenting (TFCAS) and a hybrid approach with transcarotid artery revascularization (TCAR). We sought to capture endpoints outside of stroke, myocardial infarction (MI), and death involved with each procedure at our institution as well as evaluate cost. Carotid stent procedures performed from 2014 to 2020 at our institution underwent comparative analysis based upon access site and type of stent procedure performed, TFCAS versus TCAR. Procedural details and outcomes were captured prospectively and included in the National Cardiovascular Data Peripheral Vascular Intervention Registry (NCDR-PVI). Further retrospective review was performed to evaluate endpoints beyond stroke, MI, and death. Total in-hospital cost, including administrative, capital and utilities (fixed cost), and labor and supplies (variable cost) were also evaluated. One hundred thirty-seven patients were reviewed. Seventy-seven were treated with TFCAS and 60 with TCAR. The mean age was 74years, predominantly male (68%) and Caucasian (90%). Patients undergoing TFCAS were more likely to be symptomatic compared to those receiving TCAR (81.8% vs. 50.0%, P = <0.001). There were no statistically significant differences in event rates, including mortality, recurrent cerebrovascular accident / transient ischemic attack, or bleeding. Complications not captured in the NCDR-PVI database were more frequent in the TCAR group (21.7% vs. 5.2%, P=0.004) and included pneumothorax (n=2), neck hematoma (n=8), and common carotid artery stenosis or injury (n=3). Rates of complications in the TFCAS group (n=4) were lower and limited to groin hematoma (n=2), central retinal artery occlusion causing vision loss and a case of postoperative dysphagia. Geographic miss of initial stent placement was identified in 15.0% of TCAR patients and 2.6% (P=0.008) of TFCAS patients. Restenosis rates on duplex ultrasound were similar between the two groups (14.6% of patients) and were not associated with symptoms. The mean follow-up interval was similar for both groups of 31.8months for TCAR and 30.7months for TFCAS (P=0.797). There was a statistically significant difference in total cost with TCAR being more expensive ($22,315 vs. $11,001) driven by direct costs that included devices, imaging, and extended length of stay in the TCAR group (P<0.001). There was no significant difference between stroke free survival (91.1% vs. 88.6%, P=0.69) and mortality (78.1% vs. 85.2%, P=0.677) at 3years follow-up between TCAR and TFCAS, respectively. Both TFCAS and TCAR provide similar 3-year stroke and mortality risk/benefit and are distinctly different procedures. Both should be evaluated independently with analysis of variables beyond stroke, death, and MI. TFCAS is more cost-effective than TCAR in this single institution study.

Spontaneously enlarging pulsatile cervical mass.

Acute spontaneous rupture of unstable carotid plaque with airway compromise is an immediate life-threatening event. We have described a ruptured internal carotid artery requiring emergent intervention with successful stroke-free survival. The patient provided written informed consent for the report of his case details and imaging studies.

Timing of Revascularization in Ischemic Moyamoya Disease: Association of Early Versus Delayed Surgery with Perioperative and Long-Term Outcomes

Patients with nmoyamoya disease (MMD) who present primarily with ischemic stroke are known to have greater rates of perioperative strokes as compared with those who present with nonstroke symptoms. The optimal timing for revascularization for these patients remains unclear. From 1994 to 2015, 91 patients with MMD presented with signs and symptoms of an acute ischemic stroke with diffusion restriction correlate on magnetic resonance imaging, and these patients were subdivided into those who underwent early revascularization (<90 days from last stroke), versus those who underwent delayed revascularization (≥90 days after last stroke), based on evidence that most neurological recovery after stroke occurs during the first three months. Perioperative and long-term outcomes were compared between the 2 surgical cohorts. In total, 27 patients underwent early revascularization, and 64 patients underwent delayed revascularization. Patients who underwent early revascularization had a statistically greater rate of perioperative stroke (P=0.04) and perioperative mortality (P= 0.03), and overall complication rate (P= 0.049). At last follow-up of 5.2 ± 4.3 years, patients who underwent delayed revascularization had a lower mortality rate (P= 0.01) and a lower overall postoperative stroke incidence (P= 0.002). As a function of time, patients with MMD undergoing delayed revascularization had a statistically higher length of stroke-free survival (P= 0.005). Patients with MMD who present with ischemic stroke are more likely to have perioperative strokes, overall perioperative complications, worse long-term mortality rates, and lower rates of stroke-free survival if revascularization surgery occurred within 90 days of last stroke.

Hypo-high density lipoproteinemia is a predictor for recurrent stroke during the long-term follow-up after revascularization in adult moyamoya disease.

ObjectivePrevious studies have reported that hypo-high-density lipoproteinemia (HHDL) was an independent risk factor for the cerebrovascular event. However, the risk of HHDL for stroke recurrence in moyamoya disease (MMD) during long-term follow-up after revascularization remains poorly understood. We aim to investigate the association between HHDL and stroke recurrence in adult patients with MMD.MethodsA total of 138 adult patients with MMD were prospectively recruited from 1 July to 31 December 2019. After excluding 15 patients who did not meet the inclusion criteria, all the 123 patients were enrolled. Participants were grouped according to the stroke recurrence and HHDL presentation, respectively. Clinical data and laboratory examinations were compared by the statistical analysis. The Kaplan–Meier survival analysis was conducted to compare the stroke-free survival rates between participants with HHDL and those without. Univariate and multivariate logistic regression analyses were performed to identify independent factors of the neurological status. Univariate and multivariate Cox regression analyses were conducted to identify the predictors for the recurrent stroke.ResultsParticipants with recurrent stroke group showed a lower level of high-density lipoprotein (HDL) (p = 0.030). More participants in the recurrent stroke group had HHDL (p = 0.045). What is more, there was statistical significance in the Kaplan–Meier curve of stroke incidence between the normal HDL group and the HHDL group (log-rank test, p = 0.034). Univariate logistic analysis results showed that HHDL (OR 0.916, 95% CI 0.237–3.543; p = 0.899) and HDL (OR 0.729, 95% CI 0.094–5.648; p = 0.763) were not predictive factors for the neurological status. In the multivariate Cox regression analysis, diabetes (HR 4.195, 95% CI 1.041–16.899; p = 0.044), HDL (HR 0.061, 95% CI 0.006–0.626; p = 0.019), and HHDL (HR 3.341, 95% CI 1.110–10.051; p = 0.032) were independent risk factors for the recurrent stroke.ConclusionsHypo-high-density lipoproteinemia might be a predictor or the potential therapeutic target for recurrent stroke during the long-term follow-up after revascularization in adult patients with MMD.

Better prediction of stroke in atrial fibrillation with incorporation of cancer in CHA2DS2VASC score: CCHA2DS2VASC score.

IntroductionAtrial fibrillation (AF) is associated with an increased risk of stroke. Despite evidence linking cancer and thrombosis, cancer is not part of the CHA2DS2VASc score.HypothesisCancer is an independent risk factor for thromboembolic stroke in patients with AF.MethodThe SEER database was utilized to identify patients with lung, colon, breast, and prostate cancers with AF and no prior diagnosis of stroke and. compared to controls within the dataset. The primary endpoint was rates of stroke per 100 person-years. Cox regression modeling and a nested model comparing CHA2DS2VASc score (Model 1) with a complete model including cancer diagnosis (Model 2) were performed. Models were compared using Akaike Information Criterion (AIC) and Net Reclassification Index (NRI). A propensity-matched cohort with equivalent CHA2DS2VASc scores determining stroke-free survival was also performed.ResultsA total of 101,185 patients were included in the analysis, with 48,242 in the Cancer and 52,943 in the Non-cancer Group. Stroke rate per 100 person-years was significantly higher in the Cancer Group. The CHA2DS2VASc model (Model 1) was compared against a model including cancer (Model 2) showing improved predictability as assessed by both NRI and AIC. Cox regression analysis calculated a hazard ratio of 1.085 for Cancer, which was comparable to age >75, female sex, and diabetes. Propensity matched Kaplan-Meier curve demonstrated a decreased probability of stroke-free survival in the Cancer Group.ConclusionCancers increase the risk of stroke in patients with AF. Consideration should be given to the addition of cancer to the clinical scoring system.

Institutional Experiences with Transfemoral Compared to Transcarotid Stenting

Transcarotid artery revascularization (TCAR) is a new surgical technique that is gaining popularity over the transfemoral method (TF-CAS) as the preferred strategy to deliver a carotid stent. This investigation was performed to evaluate the real-world perioperative and long-term outcomes of both techniques at the health system level. A retrospective review of prospectively maintained carotid revascularization databases were performed at 2 high-volume TCAR centers in the United States to extract consecutive TF-CAS and TCAR procedures. The characteristics and outcomes associated with these 2 modalities were compared at the preoperative and perioperative points by univariate methods. The Kaplan-Meier methodology was utilized to calculate the long-term stroke and death trends. From 2008-2021, 1,058 carotid stents were implanted at our institutions, consisting of 750 TCARs and 308 TF-CAS procedures. Patients undergoing TF-CAS were older (68.2±0.6 vs. 73.1±0.3years, P<0.01) and unhealthier by Charlson Comorbidity Index (4.9±0.1 vs. 5.5±0.1, P<0.01). Additionally, TF-CAS patients had more high-risk anatomic characteristics, such as restenosis after previous carotid surgery (27.0% vs. 9.5%, P<0.01), previous ipsilateral neck surgery (38.8% vs. 11.5%, P<0.01), irradiated ipsilateral field (20.4% vs. 4.5%, P<0.01), and a contralateral carotid occlusion (10.4% vs. 4.6%, P<0.01). The incidence of symptomatic lesions was the same (40.1% vs. 36.9%, P=0.35). Within the operating room, TCAR outperformed TF-CAS with respect to operative time (83.2±2.6 vs. 64.3±0.9min, P<0.01), radiation exposure (769.9±144.3 vs. 232.7±19.1mGys, P<0.01), fluoroscopic time (17.8±1.1 vs. 4.5±0.1min, P<0.01), and contrast volume (75.2±2.4 vs. 22.6±0.4mLs, P<0.01). In the 30-day perioperative period, ipsilateral stroke (2.8% vs. 2.3%, P=0.65), contralateral stroke (1.0% vs. 0.1%, P=0.07), and death (1.0% vs. 1.2%, P>0.99) were similar between modalities. None of these endpoints, including a composite of stroke and death (4.8% vs. 3.6%, P=0.38), reached statistical significance. Additionally, we found no differences with respect to stroke-free survival between modalities during follow-up by Kaplan-Meier analysis (P=0.30). In this combined experience from 2 large health systems, TCAR was associated with less intraoperative complexity, as measured by operative time, radiation exposure, and contrast volume. Although stroke and death seemed to be less frequent in patients undergoing transcervical stenting, this did not reach statistical significance.

Successful HeartMate III LVAD Implantation Despite Large Intra-Atrial Thrombus

<h3>Introduction</h3> Left ventricular assist devices (LVADs) are standard therapy for advanced heart failure patients. It has been shown that patients with congestive heart failure and LVADs are at increased risk of intracardiac thrombus and embolic events. After extensive literature search, there are no reported cases of HeartMate (HM) III implantation in patients with intracardiac thrombus. To date, studies have only looked into HM II implantation with intracardiac thrombus, suggesting an increased incidence of cerebrovascular accidents. To our knowledge, we present the first case of HM III implantation in the setting of large left atrial thrombus. <h3>Case Report</h3> A 55 year-old male with history of advanced heart failure with reduced ejection fraction presented in florid heart failure exacerbation. He quickly progressed to cardiogenic shock, requiring Impella 5.5 support. Transesophageal echocardiography revealed an extensive thrombus, occupying 50% of a severely enlarged left atrium, likely originating from the left atrial appendage and protruding into the left ventricle. After reaching INTERMACS 1 category, an emergent HM III LVAD was successfully implanted with excellent clinical result. Following implantation, the patient was appropriately anticoagulated with Coumadin and concurrent heparin bridging. To date, the patient has not experienced any clinically apparent thrombotic complications related to his extensive atrial thrombus through continued follow-up. <h3>Summary</h3> Studies have demonstrated an increased stroke risk in patients with pre-existing intracardiac thrombus prior to LVAD implantation when compared to those without. This case demonstrates that, should emergent circumstances arise, HM III LVAD implantation can be performed successfully with no clinically apparent thrombotic complications. The available data predominantly involves the older HM II device, and thus more research on the HM III device regarding intracardiac thrombus and long-term stroke-free survival is warranted.

Cerebrovascular Ischemic Events in Patients With Takayasu Arteritis.

Takayasu arteritis (TA) is a large vessel vasculitis that may complicate with cerebrovascular ischemic events. The objective was to describe clinical and vascular features of TA patients with cerebrovascular ischemic events and to identify risk factors for these events. We analyzed the prevalence and type of stroke/transient ischemic attack (TIA), factors associated with cerebrovascular ischemic events, and stroke-free survival in a large cohort fulfilling the American College of Rheumatology or Ishikawa criteria of TA. Among 320 patients with TA (median age at diagnosis, 36 [25-47] years; 261 [86%] women), 63 (20%) had a stroke (n=41; 65%) or TIA (n=22; 35%). Ischemic event localized in the carotid territory for 55 (87%) patients and the vertebral artery territory in 8 (13%) patients. Multiple stenosis were observed in 33 (52%) patients with a median number of stenosis of 2 (minimum, 0 to maximum, 11), and aneurysms were observed in 10 (16%) patients. A history of stroke or TIA before TA diagnosis (hazard ratio [HR], 4.50 [2.45-8.17]; P<0.0001), smoking (HR, 1.75 [1.01-3.02]; P=0.05), myocardial infarction history (HR, 0.21 [0.05-0.89]; P=0.039), thoracic aorta involvement (HR, 2.05 [1.30-3.75]; P=0.023), time from first symptoms to diagnosis >1 year (HR, 2.22 [1.30-3.80]; P=0.005), and aspirin treatment (HR, 1.82 [1.04-3.19]; P=0.035) were associated with cerebrovascular ischemic event. In multivariate analysis, time from first symptoms to TA diagnosis >1 year (HR, 2.16 [1.27-3.70]; P=0.007) was independently associated with cerebrovascular ischemic events in patients with TA. The HR for cerebrovascular ischemic event in patients who already experienced a stroke/TIA was 5.11 (2.91-8.99; P<0.0001), compared with those who had not. Carotid stroke/TIA is frequent in TA. We identified factors associated with cerebrovascular ischemic events.

Revascularization of Hemorrhagic Moyamoya Disease in a North American Cohort: The Role of Timing in Perioperative and Long-Term Outcomes.

Several East Asian studies have examined the role of revascularization in the context of hemorrhagic moyamoya disease (MMD) and found a decrease in postoperative rehemorrhage rates. To date, no data exist comparing revascularization with conservative management in North American patients with hemorrhagic MMD. To compare the clinical outcomes of conservative management vs surgical revascularization for North American patients with hemorrhagic MMD and investigate the effect of revascularization timing. We retrospectively studied the mortality and stroke-free survival of patients with MMD presenting with hemorrhagic stroke between 1994 and 2015. The diagnosis of hemorrhagic MMD was established in 38 patients. Seventeen patients were managed conservatively, and 21 were surgically revascularized. Twelve patients underwent revascularization within 6 months of hemorrhage, and 9 underwent surgery in a delayed fashion. Six conservatively managed patients (35.3%) died within the follow-up period compared with 0 (0%) surgically revascularized patients, P = .004. Conservatively managed patients also experienced an increased number of postoperative strokes, P = .037, and shorter stroke-free survival compared with patients undergoing revascularization, P = .047. On multivariate analysis, increased age, worse baseline modified Rankin score, and conservative management were independently associated with worse neurological outcomes, P < .05. Early revascularization was associated with higher rates of postoperative seizures, P = .033, and wound complications, P = .031, compared with those who underwent delayed surgery. Conservative management in a North American patient cohort was associated with greater mortality and worsened neurological outcomes compared with those undergoing revascularization. Early revascularization was associated with higher rates of postoperative seizures and wound complications, although these risks must be balanced against the risk of rehemorrhage.