RESUMO
In the 2024 David G. Sherman Lecture, Steven J. Warach, illustrating with examples from his research, walks through the history of magnetic resonance imaging in acute stroke from the 1990s and early 2000s with the introduction, validation, and application of diffusion-weighted imaging, penumbral imaging (the diffusion-perfusion mismatch), and other imaging markers of the acute stroke pathology into routine clinical practice and stroke trials. The adaptation of diffusion-weighted imaging for clinical scanners in the acute hospital setting began a revolution in ischemic stroke diagnosis as the presence, location, and size of ischemic lesions could now be visualized at the earliest times after stroke onset when computed tomography and conventional magnetic resonance imaging still appeared normal. In combination with perfusion magnetic resonance imaging, diffusion-weighted imaging made imaging of the ischemic penumbra a practical reality for routine clinical use and feasible for integration as a selection tool into clinical trials. It was apparent from the initial use of diffusion-perfusion imaging in acute stroke that many patients had persistence of penumbra as late as 24 hours after stroke onset although the probability of penumbra decreased over time. The therapeutic time window for ischemic stroke selected by clinical and temporal criteria reflected the decreased proportion of patients with the therapeutic target over time rather than the absence of the penumbral target in all patients at later times. This work provided the empirical and conceptual framework for the shift toward selection and evaluation of patients for acute stroke therapies based on direct observation of the target pathology and away from the exclusive dependence on clinical and temporal surrogates to infer the presence of stroke therapeutic targets, a shift that has expanded the indications for acute reperfusion therapies over the last 10 years.
Assuntos
Acidente Vascular Cerebral , Humanos , Acidente Vascular Cerebral/terapia , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/diagnóstico , Imagem de Difusão por Ressonância Magnética , AVC Isquêmico/terapia , AVC Isquêmico/diagnóstico por imagem , AVC Isquêmico/diagnósticoRESUMO
BACKGROUND: Branch atheromatous disease (BAD)-related stroke has emerged as a meaningful subtype of ischemic stroke yet remained understudied. We aimed to investigate the demographic, clinical, therapeutic, and prognostic characteristics of BAD-related stroke. METHODS: The BAD-study was a nationwide, multicenter, prospective, observational cohort study in 20 Chinese hospitals from June 2021 to June 2023, enrolling patients aged 18 to 80 years with BAD-related stroke within 72 hours of onset. Eligible single subcortical infarct in the territory of lenticulostriate artery and paramedian pontine artery was included. Clinical, laboratory, and treatment data were collected at baseline. The primary outcome was a proportion of good outcomes (modified Rankin Scale score, 0-2) at 90 days. Main secondary outcomes included early neurological deterioration (END), cerebrovascular event, major bleeding, and excellent outcome (modified Rankin Scale score, 0-1) during 90-day follow-up. RESULTS: We finally enrolled 476 patients, with a median age of 60 (interquartile range, 53-68) years, and 70.2% were male. The median National Institutes of Health Stroke Scale score was 3 (interquartile range, 2-6) at enrollment. Involvement of the lenticulostriate artery was more common than the paramedian pontine artery (60.7% versus 39.3%). END occurred in 14.7% of patients, with a median time from onset of 38 (interquartile range, 22-62) hours. The rates of good and excellent outcomes were 86.5% and 72%, respectively. Its 90-day stroke recurrence rate was 1.9%. Acute-phase therapy (from onset to 7 days of enrollment) showed heterogeneity and was not associated with prognosis. Multivariable logistic regression analysis identified the National Institutes of Health Stroke Scale score ≥4 at admission and END as negative predictors and extracranial artery stenosis as a positive predictor of good outcomes. Age ≥60 years, National Institutes of Health Stroke Scale score ≥4 at admission, and END were negative predictors of excellent outcomes. CONCLUSIONS: With distinct demographic, clinical, and prognostic characteristics, along with a high incidence of END and a low risk of stroke recurrence, BAD-related stroke could be categorized as a separate disease entity. Moreover, its acute-phase treatment strategies were undetermined, awaiting further high-quality studies.
Assuntos
AVC Isquêmico , Imageamento por Ressonância Magnética , Humanos , Masculino , Pessoa de Meia-Idade , Feminino , Idoso , Estudos Prospectivos , Prognóstico , AVC Isquêmico/diagnóstico por imagem , Adulto , Idoso de 80 Anos ou mais , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/epidemiologiaRESUMO
It is uncertain whether the prognostic power of white matter hyperintensity (WMH) on post-stroke outcomes is modulated as a function of initial neurological severity, a critical determinant of outcome after stroke. This multi-center MRI study tested if higher WMH quintiles were associated with 3-month poor functional outcome (modified Rankin Scale ≥ 3) for mild versus moderate-to-severe ischemic stroke. Mild and moderate-to-severe stroke were defined as admission National Institute of Health Stroke Scale scores of 1-4 and ≥ 5, respectively. Mean age of the enrolled patients (n = 8918) was 67.2 ± 12.6 years and 60.1% male. The association between WMH quintiles and poor functional outcome was modified by stroke severity (p-for-interaction = 0.008). In mild stroke (n = 4994), WMH quintiles associated with the 3-month outcome in a dose-dependent manner for the 2nd to 5th quintile versus the 1st quintile, with adjusted-odds-ratios (aOR [95% confidence interval]) being 1.29 [0.96-1.73], 1.37 [1.02-1.82], 1.60 [1.19-2.13], and 1.89 [1.41-2.53], respectively. In moderate-to-severe stroke (n = 3924), however, there seemed to be a threshold effect: only the highest versus the lowest WMH quintile was significantly associated with poor functional outcome (aOR 1.69 [1.29-2.21]). WMH burden aggravates 3-month functional outcome after mild stroke, but has a lesser modulatory effect for moderate-to-severe stroke, likely due to saturation effects.
Assuntos
AVC Isquêmico , Imageamento por Ressonância Magnética , Índice de Gravidade de Doença , Substância Branca , Humanos , Masculino , Feminino , Idoso , Substância Branca/diagnóstico por imagem , Substância Branca/patologia , AVC Isquêmico/diagnóstico por imagem , AVC Isquêmico/patologia , Pessoa de Meia-Idade , Prognóstico , Idoso de 80 Anos ou mais , Resultado do TratamentoRESUMO
BACKGROUND: We aimed to investigate the relationship between systemic immune-inflammation index (SII) and short-term mortality in acute ischemic stroke (AIS) with internal carotid artery (ICA) severe stenosis and stroke associated pneumonia (SAP) patients. METHODS: Information on general demographic, laboratory data, CT angiography, magnetic resonance angiography, or digital subtraction angiography were obtained. The predictive power was evaluated by assessing the area under the receiver operating characteristic (ROC) curve. The logistic regression was performed to assess the association of SII and short-term mortality in severe stenosis ICA-AIS and SAP patients. RESULT: Among 342 patients with severe stenosis ICA-AIS and SAP, death occurred in 66 patients during 120 days follow-up. Multivariate regression analyses indicated that increased SII predicts higher mortality in 120 days follow-up, and the risk of short-term mortality in SII > 666.31 × 109/L group is increased 4.671-fold. Patients with SII > 666.31 × 109/L had higher proportion of male, hypertension, smoking, higher admission NIHSS score, higher systolic blood pressure, and higher proportion of 120 days mortality. Higher SII predicted a worse 120 days mortality was worked out by Kaplan-Meier methods. CONCLUSION: An elevated SII was remarkably associated with 120 days mortality in severe stenosis ICA-AIS and SAP patients.
Assuntos
Estenose das Carótidas , AVC Isquêmico , Pneumonia , Humanos , Masculino , Feminino , AVC Isquêmico/mortalidade , AVC Isquêmico/imunologia , AVC Isquêmico/diagnóstico por imagem , Pessoa de Meia-Idade , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Estenose das Carótidas/complicações , Idoso , Pneumonia/mortalidade , Pneumonia/diagnóstico por imagem , Artéria Carótida Interna/diagnóstico por imagem , Inflamação/imunologia , Inflamação/mortalidade , Índice de Gravidade de Doença , PrognósticoRESUMO
Most anatomic features of the internal carotid artery (ICA) are described as a straight course to the skull base free of branches. In some cases, the excessive elongation of the internal carotid artery in a confined space results in a curvature showing a "C" or "S" shape, or in an abnormal vascular shape made of a single or double vessel loop. These anatomic variants are called dolichoarteriopathies of the internal carotid artery. The correlation between dolichoarteriopathy of the ICA and stroke is still questionable, however it is believed that it can be associated with cerebral ischemia with a clinical symptomatology that accompanies ischemic stroke. We report a case of a 41-year-old patient, with a history of hypertension, who was admitted for right hemiparesis with Broca's aphasia. The rest of the clinical examination was normal. Radiological investigations confirmed an acute left sylvian ischemic stroke with an abrupt occlusion of the posterior trunk of the left M2 segment on the CT angiogram, an excessive elongation of the ICA on both sides, describing a shape of coils or loops. Etiologic workup for ischemic stroke was negative.
Assuntos
Artéria Carótida Interna , AVC Isquêmico , Humanos , Adulto , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/anormalidades , AVC Isquêmico/etiologia , AVC Isquêmico/diagnóstico por imagem , Masculino , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/complicações , Angiografia por Tomografia Computadorizada , Afasia de Broca/etiologia , Afasia de Broca/diagnóstico por imagemRESUMO
BACKGROUND: The patent foramen ovale (PFO) and interatrial block (IAB) are associated with cryptogenic stroke (CS). However, the role of the interaction between PFO and IAB in CS remains unclear. METHODS: This case-control study enrolled 256 patients with CS and 156 individuals without a history of stroke or transient ischemic attack. IAB was defined as P wave duration > 120 ms. PFO was evaluated by contrast transesophageal echocardiography, and classified as no-PFO, low-risk PFO and high-risk PFO. Multiplicative and additive interaction analysis were used to assess the interaction between PFO and IAB in CS. RESULTS: Multiplicative interaction analysis unveiled a significant interaction between IAB and low-risk PFO in CS (OR for interaction = 3.653, 95% CI, 1.115-12.506; P = 0.037). Additive interaction analysis indicated that 68.4% (95% CI, 0.333-1.050; P < 0.001) of the increased risk of CS related to low-risk PFO was attributed to the interaction with IAB. The results were robust in multivariate analysis. However, but no significant multiplicative or additive interaction was observed between IAB and high-risk PFO. When stratified by IAB, high-risk PFO was associated with CS in both patients with IAB (OR, 4.186; 95% CI, 1.617-10.839; P = 0.003) and without IAB (OR, 3.476; 95% CI, 1.790-6.750; P < 0.001). However, low-risk PFO was only associated with CS in patients with IAB (OR, 2.684; 95% CI, 1.007-7.149; P = 0.048) but not in those without IAB (OR, 0.753; 95% CI, 0.343-1.651; P = 0.479). CONCLUSION: The interaction between IAB and PFO might play an important role in CS, particularly in cases with low-risk PFO.
Assuntos
Forame Oval Patente , Bloqueio Interatrial , Humanos , Forame Oval Patente/complicações , Forame Oval Patente/epidemiologia , Forame Oval Patente/diagnóstico por imagem , Feminino , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estudos de Casos e Controles , Bloqueio Interatrial/complicações , Bloqueio Interatrial/epidemiologia , Bloqueio Interatrial/fisiopatologia , Adulto , AVC Isquêmico/epidemiologia , AVC Isquêmico/complicações , AVC Isquêmico/diagnóstico por imagem , AVC Isquêmico/etiologia , Fatores de Risco , Idoso , Ecocardiografia Transesofagiana/métodosRESUMO
This study aims to explore the utility of ColorViz mapping from dual data sources for assessing arterial collateral circulation and predicting cerebral tissue-level collateral (TLC) in patients with acute ischemic cerebrovascular diseases. A retrospective study was conducted at a single center on a cohort of 79 patients diagnosed with acute ischemic cerebrovascular diseases between November 2021 and April 2022, who had undergone both multi-phase CT angiography (mCTA) and computed tomography perfusion (CTP). The quality of images and arterial collateral status depicted on ColorViz maps from dual data-sets (mCTA and CTP) were assessed using a "5-point scale" and a "10-point scale," respectively. The status of TLC was evaluated by analyzing multilevel hypoperfusion volume and the hypoperfusion intensity ratio (HIR). The Spearman correlation coefficient was employed to examine the association between arterial collateral status derived from dual data sources and TLC. Receiver operating characteristic curve analysis was used to determine the diagnostic efficacy in detecting large vessel occlusive acute ischemic stroke (LVO-AIS). The ColorViz maps derived from dual data sources facilitated comparable image quality, with over 95% of cases meeting diagnostic criteria, for the evaluation of arterial level collateral circulation. Patients with robust arterial collateral circulation, as determined by dual data sources, were more likely to exhibit favorable TLC status, as evidenced by reductions in hypoperfusion volume (Tmaxâ >â 4 seconds, Tmaxâ >â 6 seconds, Tmaxâ >â 8 seconds, and Tmaxâ >â 10 seconds, Pâ <â .05) and HIR (Tmaxâ >â 6 seconds/4 seconds, Tmaxâ >â 8 seconds/4 seconds, Tmaxâ >â 10 seconds/4 seconds, and Tmaxâ >â 8 seconds/6 seconds, Pâ <â .05). The sensitivity and specificity in detecting LVO-AIS was 60.00% and 97.73% for mCTA source maps, while 74.29% and 72.73% for CTP source maps (Pâ >â .05 based on De-Long test). In conclusion, this study indicates that ColorViz maps derived from both data sources are equally important in evaluating arterial collateral circulation and enhancing diagnostic efficiency in patients with LVO-AIS, as well as offering insights into the TLC status based on hypoperfusion volume and HIR.
Assuntos
Circulação Colateral , Humanos , Estudos Retrospectivos , Feminino , Masculino , Circulação Colateral/fisiologia , Idoso , Pessoa de Meia-Idade , Circulação Cerebrovascular/fisiologia , Angiografia por Tomografia Computadorizada/métodos , AVC Isquêmico/diagnóstico por imagem , AVC Isquêmico/fisiopatologia , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/fisiopatologia , Idoso de 80 Anos ou mais , Imagem de Perfusão/métodos , Angiografia Cerebral/métodos , Transtornos Cerebrovasculares/diagnóstico por imagem , Transtornos Cerebrovasculares/fisiopatologia , Transtornos Cerebrovasculares/diagnóstico , Fonte de InformaçãoRESUMO
Stroke related to large vessel occlusion is a leading cause of disability and death worldwide. Advances in endovascular therapy to reopen occluded arteries have been shown to reduce patient disability and mortality. Expanded indications to treat patients with large vessel occlusion in the late window (>6 h from symptom onset), with basilar artery occlusion, and with large ischaemic core at presentation have enabled treatment of more patients with simplified imaging methods. Ongoing knowledge gaps include an understanding of which patients with large ischaemic infarct are more likely to benefit from endovascular therapy, the role of endovascular therapy in patients who present with low National Institutes of Health Stroke Scale scores or medium or distal vessel occlusion, and optimal management of patients with underlying intracranial atherosclerotic disease. As reperfusion can now be facilitated by intravenous thrombolysis, mechanical thrombectomy, or both, the development of cytoprotective or adjunctive drugs to slow infarct growth, enhance reperfusion, or decrease haemorrhagic risk has gained renewed interest with the hope to improve patient outcomes.
Assuntos
Procedimentos Endovasculares , AVC Isquêmico , Trombectomia , Humanos , Procedimentos Endovasculares/métodos , AVC Isquêmico/terapia , AVC Isquêmico/diagnóstico por imagem , AVC Isquêmico/cirurgia , Trombectomia/métodos , Terapia Trombolítica/métodosRESUMO
BACKGROUND AND OBJECTIVES: Ischemic stroke, a leading cause of mortality, necessitates understanding its mechanism for effective prevention. Echocardiography, especially transesophageal echocardiography (TEE), is the gold standard for detection of cardiac sources of stroke including left atrial thrombus, although its invasiveness, operator skill dependence, and limited availability in some centers prompt exploration of alternatives, such as cardiac CT (CCT). We conducted a systematic review and meta-analysis assessing the ability of CCT in the detection of intracardiac thrombus compared with echocardiography. METHODS: We searched 4 databases up through September 8, 2023. Major search terms included a combination of the terms "echocardiograph," "CT," "TEE," "imaging," "stroke," "undetermined," and "cryptogenic." The current systematic literature review of the English language literature was reported in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. We assessed risk of bias using the QUADAS-2 tool and used random-effects meta-analysis to calculate different diagnostic metrics. RESULTS: The meta-analysis investigating CCT vs echocardiography for intracardiac thrombus detection yielded a total of 43 studies of 9,552 patients. Risk-of-bias assessment revealed a predominantly low risk of bias in the flow and timing, index test, and patient selection domains and a predominantly unclear risk of bias in the reference standard domain. The analysis revealed an overall sensitivity of 98.38% (95% CI 89.2-99.78) and specificity of 96.0% (95% CI 92.55-97.88). Subgroup analyses demonstrated that delayed-phase, electrocardiogram-gated CCT had the highest sensitivity (100%; 95% CI 0-100) while early-phase, nongated CCT exhibited a sensitivity of 94.31% (95% CI 28.58-99.85). The diagnostic odds ratio was 98.59 (95% CI 44.05-220.69). Heterogeneity was observed, particularly in specificity and diagnostic odds ratio estimates. DISCUSSION: CCT demonstrates high sensitivity, specificity, and diagnostic odds ratios in detecting intracardiac thrombus compared with traditional echocardiography. Limitations include the lack of randomized controlled studies, and other cardioembolic sources of stroke such as valvular disease, cardiac function, and aortic arch disease were not examined in our analysis. Large-scale studies are warranted to further evaluate CCT as a promising alternative for identifying intracardiac thrombus and other sources of cardioembolic stroke.
Assuntos
Ecocardiografia , Cardiopatias , AVC Isquêmico , Trombose , Humanos , Trombose/diagnóstico por imagem , AVC Isquêmico/diagnóstico por imagem , Ecocardiografia/métodos , Cardiopatias/diagnóstico por imagem , Cardiopatias/complicações , Tomografia Computadorizada por Raios X/métodosRESUMO
This is a case of a young male patient with no known prior risk factors who presented for acute-onset right-sided neurological deficits suspicious for stroke, and magnetic resonance angiography (MRA) identified the development of an occlusion at the level of a basilar artery (BA) fenestration in the setting of right vertebral artery occlusion. The patient was treated with dual-antiplatelet therapy in the hospital and was able to return to work shortly after discharge. The case provides insights into several possibilities for the clinical significance of BA fenestration and its potential causal or contributory relationship with ischaemic stroke of the brainstem.
Assuntos
Artéria Basilar , AVC Isquêmico , Angiografia por Ressonância Magnética , Humanos , Masculino , AVC Isquêmico/diagnóstico por imagem , AVC Isquêmico/etiologia , Artéria Basilar/diagnóstico por imagem , Adulto , Insuficiência Vertebrobasilar/complicações , Insuficiência Vertebrobasilar/diagnóstico por imagem , Inibidores da Agregação Plaquetária/uso terapêuticoRESUMO
OBJECTIVE: Stroke is a chronic health problem that affects all areas of life. The presence of thyroid autoantibodies can augment the severity of stroke. The aim of this work is to investigate whether there is a relationship between the site of stroke involvement and the anti-thyroid peroxidase antibody (anti-TPO) or not. This is the first study in the English-language literature. METHODS: A total of 39 patients with a diagnosis of acute ischemic stroke were included, and the cases under 18 years of age with an infection and the ones with autoimmune diseases other than Hashimoto's thyroiditis were excluded from the study design. The patients' age, gender, smoking status, comorbid conditions, and stroke localization in brain imaging were recorded. The region involving the anterior circulation area originating from the internal carotid artery was evaluated as anterior, and the region possessing the vertebrobasilar circulation area from the vertebral arteries was considered posterior involvement. Thyroid-stimulating hormone (TSH), triiodothyronine (T3), thyroxine (T4), triglyceride, high-density lipoprotein (HDL), low-density lipoprotein (LDL), C-reactive protein (CRP), sedimentation, and anti-TPO were retrospectively analyzed. RESULTS: As a consequence, gender distribution, smoking, comorbid conditions, TSH, T3, T4, triglyceride, HDL, LDL, CRP, and sedimentation did not differ significantly, while the age of the posterior-located stroke was lower than that of the cases with the anterior. The anti-TPO value was significantly lower in posterior-located strokes than in the anterior system. CONCLUSION: In summary, the anti-TPO value was recognized as higher in the anterior stroke localization. Thyroiditis and accompanying anti-TPO autoantibody positivity are conditions that should not be ignored by thyroidologists and thyroid-health providers.
Assuntos
Autoanticorpos , Iodeto Peroxidase , Humanos , Feminino , Masculino , Autoanticorpos/sangue , Pessoa de Meia-Idade , Iodeto Peroxidase/imunologia , Idoso , Estudos Retrospectivos , Acidente Vascular Cerebral/imunologia , Acidente Vascular Cerebral/diagnóstico por imagem , AVC Isquêmico/diagnóstico por imagem , AVC Isquêmico/imunologia , AVC Isquêmico/sangue , Adulto , Idoso de 80 Anos ou mais , Fatores de RiscoRESUMO
Stroke, the second leading cause of mortality globally, predominantly results from ischemic conditions. Immediate attention and diagnosis, related to the characterization of brain lesions, play a crucial role in patient prognosis. Standard stroke protocols include an initial evaluation from a non-contrast CT to discriminate between hemorrhage and ischemia. However, non-contrast CTs lack sensitivity in detecting subtle ischemic changes in this phase. Alternatively, diffusion-weighted MRI studies provide enhanced capabilities, yet are constrained by limited availability and higher costs. Hence, we idealize new approaches that integrate ADC stroke lesion findings into CT, to enhance the analysis and accelerate stroke patient management. This study details a public challenge where scientists applied top computational strategies to delineate stroke lesions on CT scans, utilizing paired ADC information. Also, it constitutes the first effort to build a paired dataset with NCCT and ADC studies of acute ischemic stroke patients. Submitted algorithms were validated with respect to the references of two expert radiologists. The best achieved Dice score was 0.2 over a test study with 36 patient studies. Despite all the teams employing specialized deep learning tools, results reveal limitations of computational approaches to support the segmentation of small lesions with heterogeneous density.
Assuntos
AVC Isquêmico , Tomografia Computadorizada por Raios X , Humanos , AVC Isquêmico/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Imageamento por Ressonância Magnética/métodos , Algoritmos , Imagem de Difusão por Ressonância Magnética/métodos , Isquemia Encefálica/diagnóstico por imagem , Masculino , Feminino , Idoso , Processamento de Imagem Assistida por Computador/métodos , Aprendizado Profundo , Acidente Vascular Cerebral/diagnóstico por imagem , Encéfalo/diagnóstico por imagem , Encéfalo/patologiaRESUMO
This study focuses on predicting the prognosis of acute ischemic stroke patients with focal neurologic symptoms using a combination of diffusion-weighted magnetic resonance imaging (DWI) and clinical information. The primary outcome is a poor functional outcome defined by a modified Rankin Scale (mRS) score of 3-6 after 3 months of stroke. Employing nnUnet for DWI lesion segmentation, the study utilizes both multi-task and multi-modality methodologies, integrating DWI and clinical data for prognosis prediction. Integrating the two modalities was shown to improve performance by 0.04 compared to using DWI only. The model achieves notable performance metrics, with a dice score of 0.7375 for lesion segmentation and an area under the curve of 0.8080 for mRS prediction. These results surpass existing scoring systems, showing a 0.16 improvement over the Totaled Health Risks in Vascular Events score. The study further employs grad-class activation maps to identify critical brain regions influencing mRS scores. Analysis of the feature map reveals the efficacy of the multi-tasking nnUnet in predicting poor outcomes, providing insights into the interplay between DWI and clinical data. In conclusion, the integrated approach demonstrates significant advancements in prognosis prediction for cerebral infarction patients, offering a superior alternative to current scoring systems.
Assuntos
Imagem de Difusão por Ressonância Magnética , Humanos , Imagem de Difusão por Ressonância Magnética/métodos , Prognóstico , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , AVC Isquêmico/diagnóstico por imagem , Encéfalo/diagnóstico por imagem , Encéfalo/patologia , Acidente Vascular Cerebral/diagnóstico por imagemRESUMO
BACKGROUND: Intracranial atherosclerotic stenosis (ICAS) is one of the most important independent risk factors for stroke that is closely related to the occurrence of cognitive impairment. The relationship between ICAS and vascular cognitive impairment (VCI) remains unclear. Cerebral hemodynamic changes are one of the main causes of cognitive impairment. Computed tomographic perfusion (CTP) imaging can quantitatively analyze cerebral blood perfusion and quantify cerebral hemodynamic changes. Previous research on the relationship between hypoperfusion induced by ICAS and cognitive impairment, as well as its underlying mechanisms, remains relatively insufficient. This study is dedicated to elucidating the characteristics and potential mechanisms of cognitive impairment in ICAS patients with abnormal perfusion, utilizing CTP imaging as our primary investigative tool. METHODS: This study recruited 82 patients who suffer from non-disabling ischemic stroke (IS group) and 28 healthy controls. All participants underwent comprehensive neuropsychological assessments both collectively and individually, in addition to CTP imaging. Within the patient group, we further categorized individuals into two subgroups: the ischemic penumbra group (IP, N = 28) and the benign oligemia group (BO, N = 54), based on CTP parameters-Tmax. The correlations between cognitive function and abnormal perfusion were explored. RESULTS: The cognitive function, including the overall cognitive, memory, attention, executive functions, and language, was significantly impaired in the IS group compared with that in the control group. Further, there are statistical differences in the stroop color-word test-dot (Stroop-D) and Montreal Cognitive Assessment (MoCA) sub-items (memory + language) between the BO and IP groups. In the BO group, the score of Stroop-D is lower, and the MoCA sub-items are higher than the IP group. There is no correlation between CTP parameters and cognitive function. CONCLUSION: Cognitive function is significantly impaired in patients with ICAS, which is related to cerebral perfusion. Executive, memory, and language function were better preserved in ICAS patients without IP. Hence, this study posits that managing hypoperfusion induced by ICAS may play a pivotal role in the development of VCI.
Assuntos
Circulação Cerebrovascular , Disfunção Cognitiva , Arteriosclerose Intracraniana , Tomografia Computadorizada por Raios X , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Arteriosclerose Intracraniana/diagnóstico por imagem , Arteriosclerose Intracraniana/fisiopatologia , Circulação Cerebrovascular/fisiologia , Disfunção Cognitiva/fisiopatologia , Disfunção Cognitiva/etiologia , Disfunção Cognitiva/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Imagem de Perfusão/métodos , AVC Isquêmico/diagnóstico por imagem , AVC Isquêmico/fisiopatologia , Constrição Patológica/diagnóstico por imagem , Constrição Patológica/fisiopatologia , Cognição/fisiologia , Testes NeuropsicológicosRESUMO
INTRODUCTION: People living with HIV (PLWH) are at increased risk for cardiovascular disease. Carotid intima media thickness (cIMT) is a validated surrogate marker of atherosclerosis, and an accurate predictor of future cardiovascular events. It is uncertain whether HIV potentiates stroke risk through atherosclerosis in Sub-Saharan Africa and what effect HIV status has on cIMT. We sought to investigate the relationship between HIV status and cIMT in stroke patients in a region that is burdened with dual epidemics of HIV and stroke in the young. METHODS: Consecutive patients with new onset ischaemic stroke were recruited from a quaternary-level hospital in Johannesburg, South Africa, from August 2014 to November 2017. Patients were assessed for the presence of traditional cardiovascular risk factors and HIV infection, and investigated for stroke aetiology. cIMT was measured using high resolution B-mode ultrasound following standardized techniques. RESULTS: 168 patients were included in the study, of which 62 (36.9%) were PLWH. Mean cIMT was higher in HIV-uninfected patients when compared to PLWH (0.79 ± 0.19 mm vs 0.69 ± 0.18 mm, p = 0.0021). However after adjusting for age, sex, hypertension, diabetes mellitus, smoking, total cholesterol, body mass index and stroke aetiology, there was no difference in mean cIMT between the groups (0.76 ± 0.16 mm vs 0.73 ± 0.17 mm, p = 0.29). Regression models revealed the determinants of cIMT to be age (p < 0.0001), hypertension (p = 0.0098) and total cholesterol (p = 0.005), while the determinants of increased cIMT (≥0.70 mm) were only age (p < 0.0001) and hypertension (p = 0.0002). CONCLUSION: HIV status had no effect on cIMT in our cohort of stroke patients. The main determinants of cIMT were age and hypertension.
Assuntos
Espessura Intima-Media Carotídea , Infecções por HIV , Acidente Vascular Cerebral , Humanos , Masculino , Feminino , África do Sul/epidemiologia , Infecções por HIV/epidemiologia , Infecções por HIV/diagnóstico por imagem , Infecções por HIV/complicações , Pessoa de Meia-Idade , Adulto , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/diagnóstico por imagem , Estudos de Coortes , Fatores de Risco , AVC Isquêmico/epidemiologia , AVC Isquêmico/diagnóstico por imagemRESUMO
INTRODUCTION: Screening for patent foramen ovale (PFO) in patients with ischemic neurological events is becoming more common. OBJECTIVES: This study aimed to evaluate clinical characteristics and atrial septum anatomy in relation to age and presence of PFO, as well as factors associated with a history of stroke in patients assessed for cardiac causes of ischemic neurological events. PATIENTS AND METHODS: A total of 817 patients with a history of neurological episodes (stroke, transient ischemic attack [TIA], or migraine) were prescreened using transcranial Doppler ultrasound. Transesophageal contrast echocardiography (TEE) was employed to confirm PFO and assess the anatomy of the atrial septum and right atrium. RESULTS: Among the patients, 28% had ischemic stroke, 31% had TIA, and 49% had migraines. PFO was confirmed in 79% of the patients. Regardless of the analyzed age group, PFO was associated with higher prevalence of TIA, migraine and syncope history, atrial septal aneurysm (ASA), and Chiari network. There were fewer women in the PFO group, but only in the population aged 45 years or under. Patient age, male sex, typical cardiovascular risk factors, and the presence of ASA were associated with a history of stroke. CONCLUSIONS: In patients with ischemic neurological events who were prescreened for PFO, confirmation of PFO on TEE was associated with a higher prevalence of TIA, migraine, syncope, Chiari network, and ASA. Advanced age, typical cardiovascular risk factors, and ASA were associated with stroke history in the study population.
Assuntos
Forame Oval Patente , Ataque Isquêmico Transitório , Ultrassonografia Doppler Transcraniana , Humanos , Feminino , Masculino , Pessoa de Meia-Idade , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/complicações , Forame Oval Patente/epidemiologia , Adulto , Ataque Isquêmico Transitório/etiologia , Ataque Isquêmico Transitório/diagnóstico por imagem , Ataque Isquêmico Transitório/epidemiologia , Idoso , Transtornos de Enxaqueca/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/epidemiologia , AVC Isquêmico/diagnóstico por imagem , AVC Isquêmico/etiologia , AVC Isquêmico/epidemiologia , Fatores de RiscoRESUMO
BACKGROUND: Acute brain infarction detected by diffusion-weighted magnetic resonance imaging (DW-MRI) is common after transcatheter aortic valve replacement (TAVR), but its clinical relevance is uncertain. OBJECTIVES: The authors investigated the relationship between DW-MRI total lesion number (TLN), individual lesion volume (ILV), and total lesion volume (TLV) and clinical stroke outcomes after TAVR. METHODS: Patient-level data were pooled from 4 prospective TAVR embolic protection studies, with consistent predischarge DW-MRI acquisition and core laboratory analysis. C-statistic was used to determine the best DW-MRI measure associated with clinical stroke. RESULTS: A total of 495 of 603 patients undergoing TAVR completed the predischarge DW-MRI. At 30 days, the rate of clinical ischemic stroke was 6.9%. Acute ischemic brain injury was seen in 85% of patients with 5.5 ± 7.3 discrete lesions per patient, mean ILV of 78.2 ± 257.1 mm3, and mean TLV of 555 ± 1,039 mm3. The C-statistic was 0.84 for TLV, 0.81 for number of lesions, and 0.82 for maximum ILV in predicting ischemic stroke. On the basis of the TLV cutpoint as defined by receiver operating characteristic (ROC), patients with a TLV >500 mm3 (vs TLV ≤500 mm3) had more ischemic stroke (18.2% vs 2.3%; P < 0.0001), more disabling strokes (8.8% vs 0.9%; P < 0.0001), and less complete stroke recovery (44% vs 62.5%; P = 0.001) at 30 days. CONCLUSIONS: Our study confirms that the number, size, and total volume of acute brain infarction defined by DW-MRI are each associated with clinical ischemic strokes, disabling strokes, and worse stroke recovery in patients undergoing TAVR and may have value as surrogate outcomes in stroke prevention trials. (A Prospective, Randomized Evaluation of the TriGuard™ HDH Embolic Deflection Device During TAVI [DEFLECT III]; NCT02070731) (A Study to Evaluate the Neuro-embolic Consequences of TAVR [NeuroTAVR]; NCT02073864) (The REFLECT Trial: Cerebral Protection to Reduce Cerebral Embolic Lesions After Transcatheter Aortic Valve Implantation [REFLECT I]; NCT02536196) (The REFLECT Trial: Cerebral Protection to Reduce Cerebral Embolic Lesions After Transcatheter Aortic Valve Implantation [REFLECT II]; NCT02536196).
Assuntos
Imagem de Difusão por Ressonância Magnética , Substituição da Valva Aórtica Transcateter , Humanos , Imagem de Difusão por Ressonância Magnética/métodos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Masculino , Feminino , Idoso de 80 Anos ou mais , Idoso , Estenose da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estudos Prospectivos , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , AVC Isquêmico/etiologia , AVC Isquêmico/diagnóstico por imagem , Relevância ClínicaRESUMO
BACKGROUND: Acute ischemic stroke presents significant challenges in healthcare, notably due to the risk and poor prognosis associated with hemorrhagic transformation (HT). Currently, there is a notable gap in the early clinical stage for a valid and reliable predictive model for HT. METHODS: This single-center retrospective study analyzed data from 224 patients with acute ischemic stroke due to large vessel occlusion. We collected comprehensive clinical data, CT, and CTP parameters. A predictive model for HT was developed, incorporating clinical indicators alongside imaging data, and its efficacy was evaluated using decision curve analysis and calibration curves. In addition, we have also built a free browser-based online calculator based on this model for HT prediction. RESULTS: The study identified atrial fibrillation and hypertension as significant risk factors for HT. Patients with HT showed more extensive initial ischemic damage and a smaller ischemic penumbra. Our novel predictive model, integrating clinical indicators with CT and CTP parameters, demonstrated superior predictive value compared to models based solely on clinical indicators. CONCLUSIONS: The research highlighted the intricate interplay of clinical and imaging parameters in HT post-thrombectomy. It established a multifaceted predictive model, enhancing the understanding and management of acute ischemic stroke. Future studies should focus on validating this model in broader cohorts, further investigating the causal relationships, and exploring the nuanced effects of these parameters on patient outcomes post-stroke.
Assuntos
AVC Isquêmico , Tomografia Computadorizada por Raios X , Humanos , Masculino , Feminino , Estudos Retrospectivos , Idoso , AVC Isquêmico/diagnóstico por imagem , Pessoa de Meia-Idade , Fatores de Risco , Valor Preditivo dos Testes , Prognóstico , Idoso de 80 Anos ou mais , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/etiologia , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico por imagem , TrombectomiaRESUMO
BACKGROUND AND OBJECTIVES: Acute ischemic stroke patients with a large vessel occlusion (LVO) who present to a primary stroke center (PSC) often require transfer to a comprehensive stroke center (CSC) for thrombectomy. Not much is known about specific characteristics at the PSC that are associated with infarct growth during transfer. Gaining more insight into these features could aid future trials with cytoprotective agents targeted at slowing infarct growth. We aimed to identify baseline clinical and imaging characteristics that are associated with fast infarct growth rate (IGR) during interhospital transfer. METHODS: We included patients from the CT Perfusion to Predict Response to Recanalization in Ischemic Stroke Project, a prospective multicenter study. Patients with an anterior circulation LVO who were transferred from a PSC to a CSC for consideration of thrombectomy were eligible if imaging criteria were fulfilled. A CT perfusion (CTP) needed to be obtained at the PSC followed by an MRI at the CSC, before consideration of thrombectomy. The interhospital IGR was defined as the difference between the infarct volumes on MRI and CTP, divided by the time between the scans. Multivariable logistic regression was used to determine characteristics associated with fast IGR (≥5 mL/h). RESULTS: A total of 183 patients with a median age of 74 years (interquartile range 61-82), of whom 99 (54%) were male and 82 (45%) were fast progressors, were included. At baseline, fast progressors had a higher NIH Stroke Scale score (median 16 vs 13), lower cerebral blood volume index (median 0.80 vs 0.89), more commonly poor collaterals on CT angiography (35% vs 13%), higher hypoperfusion intensity ratios (HIRs) (median 0.51 vs 0.34), and larger core volumes (median 11.80 mL vs 0.00 mL). In multivariable analysis, higher HIR (adjusted odds ratio [aOR] for every 0.10 increase 1.32 [95% CI 1.10-1.59]) and larger core volume (aOR for every 10 mL increase 1.54 [95% CI 1.20-2.11]) remained independently associated with fast IGR. DISCUSSION: Fast infarct growth during interhospital transfer of acute stroke patients is associated with imaging markers of poor collaterals on baseline imaging. These markers are promising targets for patient selection in cytoprotective trials aimed at reducing interhospital infarct growth.