Symptomatic Infarction Research Articles

Two‐Piece Craniotomy Is Associated With Improved Postoperative Outcomes of Combined Revascularization in Patients With Moyamoya Disease

Background Revascularization for both anterior cerebral artery (ACA) and middle cerebral artery (MCA) territories in patients with moyamoya disease is often performed in a single operation. The influence of craniotomy type on postoperative outcomes has not been investigated. This study aimed to clarify the effects of craniotomy type on acute postoperative outcomes after combined revascularization by comparing 2‐piece, and large 1‐piece craniotomy approaches. Methods This retrospective study included 337 consecutive combined revascularizations of the ACA and MCA territories in patients with moyamoya disease. Surgeries were classified into 2‐piece and large 1‐piece craniotomy groups. For indirect bypass, the following methods were used: (1) large 1‐piece craniotomy and encephalo‐myo‐galeo‐periosteal‐synangiosis for the MCA and ACA territories; (2) 2‐piece craniotomy and encephalo‐myo‐synangiosis for the MCA territory and encephalo‐periosteal‐synangiosis for the ACA territory. Acute postoperative outcomes were compared between the groups. Results Two‐piece and large 1‐piece craniotomies were performed in 230 and 107 patients, respectively. The incidence of radiological and symptomatic infarction tended to be lower in the 2‐piece craniotomy group than that in the large 1‐piece craniotomy group (3.9% versus 11.2%; P =0.014, and 2.6% versus 6.5%; P =0.12, respectively). Logistic regression adjusted for potential confounders further explained the relationship between craniotomy type and radiological infarction (large 1‐piece/2‐piece craniotomy: odds ratio, 3.1; 95% CI, 1.2–7.6; P =0.015). Conclusion In combined revascularization of the ACA and MCA territories in moyamoya disease, 2‐piece craniotomy may reduce the risk of postoperative cerebral infarction.

Stroke Hospitalization Administration & Monitoring: Routine Or Covid-19 Care (SHAMROCC) (P7-5.006)

<h3>Objective:</h3> We aim to compare the incidence and timing of complications in stroke patients over the first 24 hours post-reperfusion therapies and their association to hospital unit in 2019, 2020 and 2021. <h3>Background:</h3> Monitoring stroke patients in critical-care units for 24 hours after thrombolysis or thrombectomy is considered standard of care but is not evidence-based. Due to the Covid-19 pandemic, our center modified its protocol in April 2021 with 24-hour critical-care monitoring no longer being guaranteed for stroke patients. <h3>Design/Methods:</h3> We retrospectively collected data from stroke patients treated with thrombolysis or thrombectomy at our center in 2019 (pre-Covid-19, standard of care), 2020 (during Covid-19, standard of care) and 2021 (during Covid-19, new protocol). Data extracted included demographics, the nature and timing of complications within the first 24 hours, and the unit at the time of complication. Major complications included symptomatic intracranial hemorrhage (sICH), recurrent stroke, myocardial infarction, systemic bleeding, RACE call, and death. <h3>Results:</h3> Three hundred forty-nine patients were included in our study: 156 patients in 2021, 115 patients in 2020, and 78 patients in 2019. In 2021, 54 (34.6%) patients had, at least, one complication within the first 24 hours compared to 39 (33.9%) in 2020 and 24 (30.8%) in 2019. Forty-eight (88.9%) of the complications in 2021 occurred in a critical-care unit compared to 37 (94.9%) in 2020 and 17 (70.8%) in 2019. Overall, 61.5% of complications and 50.0% of sICH occurred within 12h. In 2021, 74.1% of all complications and 100% of sICH occurred within 12h. <h3>Conclusions:</h3> Despite the change of protocol in April 2021, the incidence and timing of complications did not significantly change compared to prior years and was not associated to hospital units. Most complications occurred in the first 12 hours. Further research is required to evaluate the necessity of intensive care monitoring for 24 hours in this population. <b>Disclosure:</b> Mr. Langlois-Thérien has nothing to disclose. Dr. Shamy has nothing to disclose. Brian Dewar has nothing to disclose. Dr. Lun has nothing to disclose. Dr. Dowlatshahi has nothing to disclose. Dr. Blacquiere has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Roche. Dr. Blacquiere has a non-compensated relationship as a Board of Directors with Canadian Stroke Consortium that is relevant to AAN interests or activities. Dr. Blacquiere has a non-compensated relationship as a Advisory Board Member with Heart and Stroke Foundationof Canada Stroke Best Practice Recommendations that is relevant to AAN interests or activities. Dr. Stotts has nothing to disclose. Dr. Fahed has received personal compensation in the range of $50,000-$99,999 for serving as a Consultant for Stryker Neurovascular. Dr. Fahed has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Yocan Medical Systems. Dr. Ducroux has nothing to disclose.

Biological Mechanism of Sex Difference in Stroke Manifestation and Outcomes.

Female patients tend to have greater disability and worse long-term outcomes after stroke than male patients. To date, the biological basis of sex difference in ischemic stroke remains unclear. We aimed to (1) assess sex differences in clinical manifestation and outcomes of acute ischemic stroke and (2) investigate whether the sex disparity is due to different infarct locations or different impacts of infarct in the same location. This MRI-based multicenter study included 6,464 consecutive patients with acute ischemic stroke (<7 days) from 11 centers in South Korea (May 2011-January 2013). Multivariable statistical and brain mapping methods were used to analyze clinical and imaging data collected prospectively: admission NIH Stroke Scale (NIHSS) score, early neurologic deterioration (END) within 3 weeks, modified Rankin Scale (mRS) score at 3 months, and culprit cerebrovascular lesion (symptomatic large artery steno-occlusion and cerebral infarction) locations. The mean (SD) age was 67.5 (12.6) years, and 2,641 (40.9%) were female patients. Percentage infarct volumes on diffusion-weighted MRI did not differ between female patients and male patients (median 0.14% vs 0.14%, p = 0.35). However, female patients showed higher stroke severity (NIHSS score, median 4 vs 3, p < 0.001) and had more frequent END (adjusted difference 3.5%; p = 0.002) than male patients. Female patients had more frequent striatocapsular lesions (43.6% vs 39.8%, p = 0.001) and less frequent cerebrocortical (48.2% vs. 50.7% in patients older than 52 years, p = 0.06) and cerebellar (9.1% vs. 11.1%, p = 0.009) lesions than male patients, which aligned with angiographic findings: female patients had more prevalent symptomatic steno-occlusion of the middle cerebral artery (MCA) (31.1% vs 25.3%; p < 0.001) compared with male patients, who had more frequent symptomatic steno-occlusion of the extracranial internal carotid artery (14.2% vs 9.3%; p < 0.001) and vertebral artery (6.5% vs 4.7%; p = 0.001). Cortical infarcts in female patients, specifically left-sided parieto-occipital regions, were associated with higher NIHSS scores than expected for similar infarct volumes in male patients. Consequently, female patients had a higher likelihood of unfavorable functional outcome (mRS score >2) than male patients (adjusted absolute difference 4.5%; 95% CI 2.0-7.0; p < 0.001). Female patients have more frequent MCA disease and striatocapsular motor pathway involvement with acute ischemic stroke, along with left parieto-occipital cortical infarcts showing greater severity for equivalent infarct volumes than in male patients. This leads to more severe initial neurologic symptoms, higher susceptibility to neurologic worsening, and less 3-month functional independence, when compared with male patients.

Effects of superficial temporal artery to middle cerebral artery bypass on postoperative infarction rates among young children (≤ 5 years old) with moyamoya disease

Revascularization surgery for young children with moyamoya disease (MMD) is challenging. Although indirect revascularization is preferred because of the technical difficulty in direct anastomosis, higher risks of postoperative infarction remain a problem. We aimed to investigate the effect of superficial temporal artery to middle cerebral artery (STA-MCA) bypass on postoperative outcomes during the acute postoperative period in young children ≤ 5years old with MMD. This retrospective study included consecutive young children with MMD who underwent surgical revascularization of the anterior cerebral circulation. Groups were determined according to the procedures performed, namely, the combined (STA-MCA bypass with indirect revascularization) and the indirect revascularization groups. The incidences of radiological or symptomatic infarction, transient neurological events, and new neurological deficits that remained at discharge were compared between groups. Of 38 surgical procedures, there were 23 combined and 15 indirect revascularizations. The median age of the patients was 3.0years, which was significantly different between groups (P < .01). When comparing the postoperative outcomes between groups, the incidences of radiological and symptomatic infarction and new neurological deficits that remained at discharge were significantly lower in the combined revascularization group (P < .05). Logistic regression analysis adjusted for potential confounders found that surgical modality was a statistically significant independent risk factor associated with radiological and symptomatic infarctions (indirect/combined, odds ratio: 10.2; 95% confidence interval: 1.30-79.7; P < .05). STA-MCA bypass combined with indirect revascularization can reduce the incidence of postoperative infarction in young children with MMD and might lead to better neurological outcomes.

Risk factors and a novel cerebral infarction extent scoring system for postoperative cerebral ischemia in patients with ischemic Moyamoya disease

Postoperative cerebral ischemic complication is the most common complication of revascularization surgery for patients with moyamoya disease (MMD). This retrospective study was conducted on 63 patients with ischemic MMD. Postoperative ischemia occurred in 15 of the 70 revascularization operations performed for patients after surgical revascularization, translating to an incidence of 21.4%. Univariate analysis revealed that onset infarction (p = 0.015), posterior cerebral artery involvement (p = 0.039), strict perioperative management (p = 0.001), interval time between transient ischemic attack (TIA) or infarction presentation and operation (p = 0.002) and preoperatively cerebral infarction extent score (CIES) (p = 0.002) were significantly associated with postoperative cerebral ischemia. Multivariate analysis revealed that strict perioperative management (OR = 0.163; p = 0.047), and preoperatively CIES (OR = 1.505; p = 0.006) were independently associated with postoperative cerebral ischemia-related complications. After comprehensive improvement of perioperative management protocol, the incidence of symptomatic infarction declined to 7.4% (4 out of 54). Analysis of the area under the receiver operating characteristic curve (AUROC) indicated CIES was a predictor for both postoperative ischemia and high follow-up modified Rankin Scale scores. In summary, strict perioperative management and CIES were identified as independent risk factors for postoperative ischemic complications in ischemic MMD, demonstrating that comprehensive and individualized perioperative management improve postoperative outcomes in patients with MMD. Furthermore, application of CIES to evaluate pre-existing cerebral infarction can improve the management of patients.

Long-Term Surgical Outcome of Indirect Bypass Surgery in Young Children With Moyamoya Disease.

The prognosis of moyamoya disease (MMD) in young children (younger than 4 years) is worse than that of older adults. The effectiveness of surgery is still inconclusive. To evaluate long-term outcomes after indirect bypass in young children with MMD. A total of 1417 MMD children underwent indirect bypass from August 1988 to October 2020. This study included 135 patients who were younger than 4 years at the time of surgery. The clinical features and surgical outcomes of these patients were assessed. We analyzed the long-term outcome of 102 children who were followed up for more than 5 years (mean: 18.8 years, range: 5-27.3 years). Cross-sectional analysis was performed to evaluate overall outcomes based on the Lansky Play Performance Scale (LPS). The annual risk of symptomatic stroke after surgery was calculated with a person-year method, and the event-free survival rate was evaluated using the Kaplan-Meier method. The overall clinical outcome was favorable (LPS ≥ 80) in 88% of the patients. The overall postoperative adverse event rate was 15%, including 1 death. At the last follow-up, 86% of patients who had seizures at diagnosis were seizure-free. During the follow-up, there were 3 symptomatic infarctions on the operated hemisphere (postoperative 3, 3, and 10 months each). There was no hemorrhagic event. The annual infarction rate was 0.16% per person-year. The 20-year event-free survival rates for symptomatic infarction were 97%. Indirect bypass could provide a satisfactory long-term outcome and prevent recurrent stroke in young children with MMD.

The role of coronary computed tomography angiography in pregnancy-associated myocardial infarction

Pregnancy-associated coronary artery dissection is one of the critical causes of myocardial infarction in young females. The challenges in the diagnosis and follow-up of pregnancy-associated myocardial infarction prompted us to highlight the potential role of coronary computed angiography in managing this life-threatening medical condition. We describe a case of a 29-year-old female with sudden onset chest discomfort one-week postpartum. She presented to the hospital with an ST-elevation myocardial infarction and was urgently taken to the cath lab for PCI and stent placement. Thirteen months later, with intermittent chest discomfort, an coronary computed tomography was done, demonstrating evidence of SCAD and aneurysm formation in the left main coronary artery and left circumflex coronary artery. Repeat cardiac catheterization confirmed the same diagnosis. Given her refractory chest discomfort and the chance of aneurysm rupture decision was made to proceed with a three-vessel CABG. At 3-month and 1-year followup visits, the patient is doing well and remains pain-free. In this case presentation, we aim to highlight the potential role of Coronary Computed tomography angiography in the diagnosis and follow-up of pregnancy-associated spontaneous coronary artery dissection, given the high accuracy and non invasiveness of this diagnostic modality in the context of the high prevalence of spontaneous coronary artery dissection in symptomatic or asymptomatic pregnancy-associated myocardial infarction.

Prevalence and Prediction of Subclinical Atrial Tachyarrhythmias Detected by Continuous Holter Monitoring in Cryptogenic Stroke.

Background: Cryptogenic stroke (CS) is symptomatic cerebral infarct with no identifiable cause after adequate diagnostic workup. Subclinical atrial arrhythmias are increasingly recognized as a source of CS.

Topical tranexamic acid in intramedullary nailing for the treatment of intertrochanteric fractures in the elderly: A protocol for systematic review and meta-analysis.

Numerous studies have demonstrated that the use of tranexamic acid (TXA) intravenously minimizes bleeding, lowers transfusion rates, and does not raise the risk of complications during major orthopedic surgery. Concerning the effectiveness of the topical application, there are, nevertheless, inconsistent findings. We aimed to develop a protocol for systematic review and meta-analysis on the benefits and safety of topical TXA in intramedullary nailing for the treatment of intertrochanteric fractures in the elderly. PubMed, Embase, and the Cochrane Library will all be searched for randomized controlled trials published from the database inception to October 15, 2022. The primary outcomes will be intraoperative blood loss, hidden blood loss, total blood loss, transfusion rate, transfusion units, operative time, thromboembolic events, and mortality. The risk of bias will be evaluated using the Cochrane risk of bias assessment tool. Review Manager 5.3 will be used for the analysis. The effects and safety of topical TXA in intramedullary nailing for the treatment of intertrochanteric fractures in the elderly will be quantified in this study. The study's findings will assist doctors in determining if topical TXA use is secure and efficient.

Abstract WP188: Relationships Of Hematocrit With Asymptomatic And Symptomatic Lacunar Ischemic Lesions

Introduction: Hematocrit at both low and high extremes can result in both hypoxia and thrombosis respectively. While both scenarios may predispose to ischemia, it is unclear whether hematocrit associates with small vessel cerebrovascular lacunar infarcts. Hypothesis: Hematocrit levels will associate with both asymptomatic and symptomatic cerebrovascular lacunar infarcts in stroke-free participants and ischemic stroke patients, respectively. Methods: A cross sectional observational analysis of a prospective, population-based cohort study of stroke-free, older adult (&gt;50) participants from the Northern Manhattan study (NOMAS) receiving baseline hematocrit testing and MRI between 2003-2008 were analyzed. A second, single center prospective cohort of admitted adult ischemic stroke patients receiving baseline hematocrit testing and MRI between 2005-2018 was evaluated. Associations of hematocrit with covert, asymptomatic chronic lacunar infarcts from stroke-free participants in NOMAS were assessed using general additive models after adjusting for relevant covariates. Separate analyses were performed to assess associations of hematocrit with symptomatic acute lacunar infarct stroke etiology using similar adjusted models for patients admitted and enrolled into the ischemic stroke registry. Results: Of 1218 NOMAS participants analyzed, 6% had covert chronic lacunar infarcts. The association between hematocrit and covert chronic lacunar infarcts was U-shaped (X2: 9.21; p-value: 0.03). In the 1489 patients from the ischemic stroke registry, 23% were identified to have symptomatic acute lacunar infarcts. Linear relationships were identified with higher hematocrit and symptomatic acute lacunar infarct etiology (adjusted coefficient beta: 0.020; standard error: 0.009; p=0.03). Conclusions: We identified relationships of hematocrit with both asymptomatic and symptomatic lacunar infarcts in both stroke-free and ischemic stroke cohorts, respectively. There may be a relevant role of red blood cell volumes with ischemic cerebral small vessel disease pathophysiology. However, further studies are required to clarify the mechanisms behind these relationships.

Abstract TP178: Cerebral Infarction after Hematopoietic Stem Cell Transplantation (HSCT) in Adult Patients with Sickle Cell Disease

Introduction: Symptomatic and silent cerebral infarcts (SCIs) are common in children and adults with sickle cell disease (SCD). SCIs are associated with cognitive performance and risk of future symptomatic stroke. The incidence of overt stroke and SCI post HSCT is low in children, but there is limited information in adults. We sought to determine the impact of HSCT on the rate of new symptomatic and silent cerebral infarcts in adults with SCD. Methods: The study population included patients with SCD (HbSS, HbSC, and HbS/beta-thalassemia) that were enrolled in NIH studies (14-H-0077, 09-H-0225) and underwent HSCT from 2004-19 and received pre- and post-transplant MRI studies. MRI FLAIR, T1, and T2 images were reviewed by two independent readers and scored for presence of prior ischemic stroke and silent cerebral infarct (≥ 3mm on T2 or FLAIR images in 2 imaging planes). Changes in SCIs and ischemic strokes were compared before and after transplantation. Results: Eighty-four patients were included in the study, mean age 32.3 yrs. (range 10-65 yrs.) and 57% male. Median follow-up period was 3.3 yrs. (range: 6 months -17 yrs.) for a total of 412 patient-years. Overall, 60% had evidence of SCI and or prior ischemic stroke at transplant; 54% (45/84) with SCI and 23% with imaging evidence of a prior stroke. During the follow-up period, 13% (11/84) patients developed new ischemic injury, two patients developed a new stroke and nine patients developed new SCIs. The post-HSCT incidence rate of new stroke was 0.49 events/100 patient-years, and SCIs was 2.2 events/100 patient-years. Patients who progressed compared to those who did not were older at transplant (36.1 yrs. vs. 31.2 yrs.; p=0.09), had a prior history of stroke (27% vs. 22%, p=0.71), had a prior history of SCI (64% vs. 52%, p=0.47), and a prior history of stenotic vasculopathy (18% vs. 14%, p= 0.65). Conclusions: The incidence of new ischemic events after HSCT for SCD in adults is low. Our rates are comparable to incidence rates reported in children with SCD after HSCT. While rates of progression were higher in patients with prior stroke, SCI, and vasculopathy, we did not find a significant difference between groups.

Comparison of in-hospital outcomes after coronary artery bypass graft surgery in elders and younger patients: a multicenter retrospective study

ObjectivesWe aimed to identify in-hospital outcomes in young (≤ 65 years) and old (> 65 years) patients after coronary artery bypass grafting (CABG) by analyzing the effect of age on adverse events after on-pump or off-pump CABG.MethodsPatients older than 65 years were defined as older patients and others were defined as younger patients. The qualitative data were compared by chi-square or Fisher's exact tests. The quantitative data were compared by the two-sample independent t-test or Mann–Whitney U test. Multifactor binary logistic regression was used to control for confounders and to investigate the effect of age on dichotomous outcome variables such as death.ResultsIn the on-pump CABG population, the postoperative in-hospital mortality, the incidence of postoperative symptomatic cerebral infarction (POSCI) and postoperative atrial fibrillation (POAF) was higher in older patients than in younger patients (P value < 0.05), and age > 65 years was associated with postoperative in-hospital mortality (OR = 2.370, P value = 0.031), POSCI (OR = 5.033, P value = 0.013), and POAF (OR = 1.499, P value < 0.001). In the off-pump CABG population, the incidence of POAF was higher in older patients than in younger patients (P value < 0.05), and age > 65 years was associated with POAF (OR = 1.392, P value = 0.011).ConclusionIn-hospital outcomes after CABG are strongly influenced by age. In on-pump CABG, the risk of postoperative death, POSCI, and POAF was higher in older patients, and in off-pump CABG, the risk of POAF was higher in older patients.

Comparison of the prognosis of symptomatic cerebral infarction and pulmonary embolism in patients with advanced non-small cell lung cancer.

Lung cancer patients face a high risk of thromboembolism (TE), which is considered to be a poor prognostic factor. However, the impact of symptomatic cerebral infarction (CI) and pulmonary embolism (PE) on the prognosis of advanced non-small cell lung cancer (NSCLC) patients is not fully understood. We retrospectively identified 46 patients with advanced NSCLC who developed symptomatic CI or PE at five hospitals in Japan between January 2010 and December 2019. Prognosis and biomarker levels after incident CI and PE were investigated. Of the 46 patients, 36 developed symptomatic CI, and 10 developed symptomatic PE. The median follow-up duration after incident CI and PE was 18.2months. Although the proportion of Common Terminology Criteria for Adverse Events grade 4 tended to be higher in patients with PE than in those with CI (30% vs. 11%, p=0.16), the overall survival (OS) after incident TE tended to be worse in patients with CI than in those with PE (median 2.3months vs. 9.1 months, log-rank test p=0.17). Multivariate analysis showed that OS after CI was worse in patients with high D-dimer (DD) levels than in those with low DD levels at the time of incident CI (median 1.3months vs. 8.3 months, log-rank p < 0.001). This retrospective study demonstrated that the prognosis of patients tended to be poorer after CI than after PE. The DD levels at the time of incident CI might be a promising predictor of clinical outcomes in advanced NSCLC patients who develop CI.

The risk factors of postoperative infarction after surgical clipping of unruptured anterior communicating artery aneurysms: anatomical consideration and infarction territory.

An anterior communicating artery is a common location for both ruptured and unruptured intracranial aneurysms, and microsurgery is sometimes necessary for their successful treatment. However, postoperative infarction should be considered during clipping due to the complex surrounding structures of anterior communicating artery aneurysms. This study aimed to evaluate the risk factors of postoperative infarction after surgical clipping of unruptured anterior communicating artery aneurysms and its clinical outcomes. The data of patients who underwent microsurgical clipping of an unruptured anterior communicating artery aneurysm in our hospital between January 2008 and December 2020 were retrospectively analyzed. The patients' demographic data, anatomical features of the anterior communicating artery complex and aneurysm, surgical technique, characteristics of postoperative infarction, and its clinical course were evaluated. Notably, among 848 patients, 66 (7.8%) and 34 (4%) patients had radiologic and symptomatic infarctions, respectively. Univariate and multivariate logistic regression analyses showed that hypertension (odds ratio (OR), 1.99; [Formula: see text]), previous stroke (OR, 3.89; [Formula: see text]), posterior projection (OR, 5.58; [Formula: see text]), aneurysm size (OR, 1.17; optimal cut-off value, 6.14mm; [Formula: see text]), and skull base-to-aneurysm distance (OR, 1.15; optimal cut-off value, 11.09mm; [Formula: see text]) were associated with postoperative infarction. In the pterional approach, a closed A2 plane was an additional risk factor (OR, 1.88; [Formula: see text]). Infarction of the subcallosal and hypothalamic branches was significantly associated with symptomatic infarction ([Formula: see text]). Hypertension, previous stroke, posteriorly projecting aneurysms, aneurysm size, and highly positioned aneurysms are independent risk factors for postoperative infarction during surgical clipping of an unruptured anterior communicating artery aneurysm. Additionally, a closed A2 plane is an additional risk factor of postoperative infarction in patients undergoing clipping via the pterional approach.

S-03-1: BRAIN IMAGING FOR THE MANAGEMENT OF HYPERTENSION

Small vessels in the brain is susceptible especially for the effect of hypertension. Therefore, longstanding hypertension may induce cerebral small vessel disease (CSVD) which is designated as hypertensive CSVD. The patients with hypertensive CSVD may exhibit various types of lesions including lacunar infarction, white matter lesion, cerebral hemorrhage and microbleeds in brain magnetic resonance (MR) imaging. White matter lesions (WMLs) are one of the most representative lesions which are closely related to hypertension and aging. They are classified into periventricular hyperintensity (PVH) and deep white matter hyperintensity (DWMH), and the former is more closely involved in cognitive decline than the latter. In the SPRINT MIND trial which examined the significance of intensive blood pressure control, WML volume increased by 0.28 cm3 for 4years in the intensive treatment group whereas by 0.92 cm3 in the standard treatment group, indicating 70% suppression of WML expansion. We quantitatively assessed WML volume in patients with vascular dementia and Alzheimer disease, and as expected, both PVH DWMH were significantly larger in vascular dementia than in Alzheimer disease. The mechanisms for CMBs are not fully understood but may be secondary to blood-brain barrier damages from long-standing hypertension, or alternatively, amyloid deposition in the tissue. In our previous study, we investigated degree of SVD changes using hypertensive arteriopathy SVD (HA SVD) and cerebral amyloid angiopathy SVD (CAA SVD) scores. With the analysis of SVD scores in 53 subjects with CMBs admixed with lobar and deep distributions, mixed CMBs were mainly caused by HA. These neuroimaging markers are crucial for management of hypertension. Small subcortical stroke (SPS3) trial which enrolled patients with symptomatic lacunar infarctions, were divided into two groups: those with a systolic blood pressure target between 130 and 149 mm Hg and those with less than 130 mm Hg. There was no significant difference in the frequency of all strokes, the rate of intracerebral hemorrhage was significantly lower in the group with intensive blood pressure control. This SPS3 trial revealed that a systolic blood pressure target of less than 130 mm Hg is beneficial in reducing risk in lacunar stroke patients. Thus, we overview brain imaging markers in hypertensive patients and their significance for the management of SVD.

Long-Term Follow-up of Dutch Patients with Sickle Cell Disease Diagnosed By Newborn Screening - Effect on the Morbidity and Mortality in the Netherlands

Background: Sickle cell disease (SCD) is associated with increased morbidity and mortality compared to the general population. To enable early preventive measures to improve clinical outcome, newborn screening for SCD was introduced in January 2007 in the Netherlands. The objective of this study is to assess the residual risk of death and the incidence of major disease-related complications during the first fifteen years of life in children diagnosed with SCD by newborn screening. Methods: In this prospective, national multicenter cohort study, all children born after 1 January 2007 and diagnosed with SCD by newborn screening were included. Following informed consent, data were collected from medical files on SCD genotype, treatment, mortality and occurrence of major disease-related complications including hospitalization for vaso-occlusive crises (VOC), severe infections (sepsis, meningitis, osteomyelitis) and neurological complications. Overall survival and survival without specific SCD-related complications were analyzed by Kaplan-Meier curves. Results: Preliminary data of 197 (38%) of the 520 eligible subjects from 8 centers in the Netherlands, with a total follow-up of 1,585 patient-years are presented. The median age on July 1st 2022 was 8.0 years (IQR range: 4.0 - 11.0 years). The majority of children (55%) had severe SCD (genotypes HbSS or HbSβ0 thalassemia), the remainder had another genotype including HbSC or HbSβ+ thalassemia. Survival at the age of 15 years was 99.5%. One patient died at the age of 1 year due to pneumococcal sepsis. Eight patients (4%) had a severe infection (meningitis, sepsis, osteomyelitis) caused by Streptococcus Pneumoniae in 3/8 cases with 1 fatal outcome as described above. Two patients experienced a symptomatic cerebral infarction at the age of 11 months and 1.5 years, respectively. Both patients had comorbidities, increasing the risk of a cerebral infarction. The mean survival time without admission for VOC was 7.3 years (95% CI: 6.2-8.5) for HbSS/HbSβ0 thalassemia and 11.5 years (95% CI: 10.1-12.8) for HbSC/HbSβ+ thalassemia, respectively (p < 0.001) (Figure 1). Conclusion: In this Dutch cohort of neonatally screened patients with SCD, infectious complications were the main cause of severe comorbidity and mortality. Further analysis to identify risk factors for infectious complications will be performed in the final analyses to target additional preventive measures that may lower the risk of infection in this specific group of patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Intra-arterial Thrombolysis for Acute Retinal Ischemia: A Retrospective, Observational, Cohort Study.

To determine whether intra-arterial thrombolysis (IAT) within 16 hours after the onset of symptoms is feasible and associated with better visual outcomes in patients with acute retinal ischemia (ARI). The retrospective cohort study was performed from January 2014 to December 2021 in the Xuanwu Hospital of Capital Medical University. Patients with ARI who initially presented visual acuity of 20/100 or worse were screened in the study. Visual end points were evaluated at one week and at final visit after treatment. Serious adverse events were recorded during operation and within 1 week after IAT treatment. The amount of clinically significant visual improvement (≥0.3 logarithm of the minimum angle of resolution) in the IAT group was significantly higher than that in the conservative treatment group at one week after the treatment (47.8% vs 16.7%; P = 0.014) and at final visit (52.2% vs 20%; P = 0.014). After controlling confounding factors, ARI treatment was the only factor significantly associated with the amount of clinically significant visual improvement (OR, 4.364; 95 CI, 1.298-14.667; P = 0.017). A patient (4.3%) experienced retinal hemorrhage without symptom within 1 week after IAT treatment. No patients experienced new symptomatic cerebral infarction, intracranial hemorrhage, TIA, artery dissection, vascular perforation, and distal embolization during operation and within 1 week after IAT treatment. IAT may be associated with better visual improvement within 16 hours after the onset of symptoms. Besides, IAT is feasible and associated with a low risk of periprocedural complications for ARI. This study will aid in feasibility testing and sample size calculations in advance of future, fully-powered efficacy studies for ARI.

Flow diversion effect of the leo braided stent for aneurysms in the posterior and distal anterior circulations: A multicenter cohort study.

Background and purposeThe treatment of aneurysms located in the posterior and distal anterior circulations remains a challenge. Leo stents with a flow diversion (FD) effect may be a potential option, which needs to be clearly studied.MethodsFrom January 2016 to October 2021, 133 patients with 145 aneurysms in the posterior and distal anterior circulations, treated with Leo stents, were retrospectively analyzed in three neurosurgical centers. Data on demographic information, aneurysm characteristics, procedural outcomes, postoperative course, and aneurysm occlusion were retrospectively analyzed.ResultsAfter immediate surgery, 90 aneurysms (60.1%) were in complete occlusion [Raymond-Ray Occlusion Class (RROC) 1 and O'Kelly Marotta (OKM) grade D], 29 aneurysms (20%) in good occlusion (RROC 2 and OKM grade C), 17.9% in incomplete occlusion (RROC 3a or OKM grade B), and no aneurysms in invalid occlusion (RROC 3b and OKM grade A). A total of 112 patients with 117 aneurysms received angiographic follow-up (mean 11.4 months), and the degree of occlusion showed a significant improvement (Z = 3.900, p < 0.001). The complete occlusion rate increased to 84.6% (99/117), while good and incomplete occlusion decreased to 6.8% (8/117) and 8.6% (10/117), respectively. A total of 14 cases (10.5%) presented narrowing of the parent artery, and nine cases (6.8%) had injured side branches. Cerebral hemorrhage occurred in four patients (3.0%), and symptomatic ischemic infarction occurred in six patients (4.5%). The final permanent morbidity (mCS ≥3) and mortality were 2.8% (3/133) and 0.8% (1/133), respectively. For 82 aneurysms treated by stent-assisted with coiling (SAC), large-sized, ruptured aneurysms (χ2 = 7.767, p = 0.005) occurred. For 63 aneurysms treated by LEO stent monotherapy (LSM), multiple aneurysms, fusiform aneurysms (χ2 = 18.958, p < 0.01), and/or small-sized aneurysms (Z = −2.692, p = 0.007) occurred.ConclusionsLeo stents are safe and effective for aneurysms located in the posterior and distal anterior circulations. The overall degree of occlusion improved during a follow-up because of the FD effect of Leo stents. Aneurysms in these areas should be treated with personalized measures.

The usefulness and safety of dexmedetomidine for postoperative sedation in pediatric patients with moyamoya disease.

After revascularization surgery in pediatric patients with moyamoya disease (MMD), resting and avoiding crying is important. However, this inaction is often difficult because of pain or anxiety. Dexmedetomidine (DEX), which has sedative and analgesic properties, may be useful in reducing those uncomfortable conditions; however, its common side effects include bradycardia and hypotension, which have a risk of decreasing the cerebral blood flow. The aim of this study was to investigate the efficacy and safety of using DEX for pediatric patients with MMD in the acute period after revascularization surgery. This retrospective study included pediatric patients with MMD who underwent revascularization surgery. Based on whether DEX was used for light sedation during postoperative days (PODs) 0-1 after extubation, the patients were divided into DEX or control groups. For neurological outcomes, the incidence of symptomatic cerebral infarction and transient neurological events (TNEs) during PODs 0-1 and the entire hospitalization were investigated. In addition, the Richmond Agitation-Sedation Scale (RASS) was used to assess the effect of DEX, and bradycardia and hypotension were evaluated as side effects. A total of 84 surgical procedures were included in this study (27 in the DEX group and 57 in the control group). During PODs 0-1, symptomatic infarction was not observed in either group. The incidence of TNEs was almost the same in both groups: 2 (7.4%) of the 27 procedures in the DEX group and 4 (7.0%) of the 57 procedures in the control group (p > 0.99). Moreover, the incidences of symptomatic infarction and TNEs during the entire hospitalization did not differ significantly (symptomatic infarction, p > 0.99; TNEs, p = 0.20). Regarding the DEX effect, the median RASS scores during PODs 0-1 were -1.0 (drowsy) in the DEX group and +1.0 (restless) in the control group, showing a significant difference (p < 0.01). Regarding side effects, bradycardia was observed only in 3 (11.1%) of the 27 procedures in the DEX group (p = 0.03), and hypotension was not observed in any of the cases. In pediatric patients with MMD who are extubated after revascularization surgery, DEX produced appropriate light sedation and analgesia. The risk for symptomatic infarction is almost the same in cases in which DEX is used and those in which it is not; however, neurosurgeons should be cautious of bradycardia and TNEs as potential side effects.

Cilostazol Administration for Subarachnoid Hemorrhage: A Meta-analysis of Randomized Controlled Trials.

The efficacy of cilostazol administration to treat subarachnoid hemorrhage remains controversial. We conduct a systematic review and meta-analysis to explore the influence of cilostazol administration on treatment efficacy for subarachnoid hemorrhage. We have searched PubMed, Embase, Web of science, EBSCO, and Cochrane Library databases through July 2020 for randomized controlled trials assessing the effect of cilostazol administration in patients with subarachnoid hemorrhage. This meta-analysis is performed using the random-effect model. Four randomized controlled trials involving 405 patients were included in the meta-analysis. Overall, compared with control group for subarachnoid hemorrhage, cilostazol intervention can significantly reduce symptomatic vasospasm (odds ratio [OR], 0.35; 95% confidence interval [CI], 0.21-0.60; P = 0.0001) and cerebral infarction (OR, 0.40; 95% CI, 0.22-0.73; P = 0.003) and improve no or mild angiographic vasospasm (OR, 2.01; 95% CI, 1.19-3.42; P = 0.01) and an mRS score of 2 or less (OR, 2.70; 95% CI, 1.09-6.71; P = 0.03), but revealed no obvious influence on severe angiographic vasospasm (OR, 0.53; 95% CI, 0.27-1.02; P = 0.06). There were no increase in adverse events (OR, 1.17; 95% CI, 0.54-2.52; P = 0.69), hemorrhagic events (OR, 0.62; 95% CI, 0.06-6.27; P = 0.69), and cardiac events (OR, 2.14; 95% CI, 0.44-10.27; P = 0.34) after the cilostazol intervention than control intervention. Cilostazol treatment may be effective to treat subarachnoid hemorrhage in the terms of symptomatic vasospasm, cerebral infarction, no or mild angiographic vasospasm, and an mRS score of 2 or less.