Risultati per: Circulation

Circulation, Volume 150, Issue 1, Page 1-3, July 2, 2024.

Circulation, Volume 149, Issue 24, Page 1921-1926, June 11, 2024.

Circulation, Volume 149, Issue 18, Page 1466-1468, April 30, 2024.

Circulation, Volume 149, Issue 18, Page 1461-1465, April 30, 2024.

Stroke, Ahead of Print. BACKGROUND:Moyamoya disease (MMD) is a progressive, occlusive disease of the internal carotid arteries and their proximal branches, with the subsequent development of an abnormal vascular network that is rupture-prone. Steno-occlusive changes in the posterior cerebral arteries (PCAs) may contribute to worsened outcomes in patients with MMD; however, there is little information on the incidence and natural history of posterior circulation MMD (PCMMD). We describe clinical PCMMD characteristics in a large cohort of patients with MMD.METHODS:We retrospectively reviewed patients with MMD treated between 1991 and 2019 at a large academic medical center. Demographics, perioperative outcomes, and radiological phenotypes were recorded for 770 patients. PCA disease was graded as either 0 (no disease), 1 (mild), 2 (moderate), or 3 (severe or occluded) based on cerebral angiography. Patients with angiographically confirmed MMD diagnosis with at least 6 months follow-up and completion of revascularization surgery were included; patients with intracranial atherosclerosis, intracranial dissection, vasculitis, and undefined inflammatory processes were excluded. The presence of stenosis/occlusion was graded radiographically to assess for disease progression and the prevalence of risk factors related to reduced progression-free survival.RESULTS:In all, 686 patients met the inclusion criteria, with PCA disease identified in 282 (41.1%) patients. Of those 282 patients with PCMMD, disease severity ranged from 99 (35.1%) with mild, 72 (25.5%) with moderate, and 111 (39.4%) with severe. The total number of postoperative complications was significantly associated with PCMMD severity (P=0.0067). Additionally, PCMMD severity correlated with worse postoperative modified Rankin Scale scores (P

Circulation, Volume 149, Issue 14, Page 1139-1144, April 2, 2024.

Stroke, Ahead of Print. BACKGROUND:Inflammatory type focal cerebral arteriopathy (FCA-i) in the anterior circulation (AC) is well characterized, and the focal cerebral arteriopathy severity score (FCASS) reflects the severity of the disease. We identified cases of FCA-i in the posterior circulation (PC) and adapted the FCASS to describe these cases.METHODS:In this comparative cohort study, patients from the Swiss NeuroPaediatric Stroke Registry with ischemic stroke due to FCA-i between January 2000 and December 2018 were analyzed. A comparison between PC and AC cases regarding pediatric National Institutes of Health Stroke Scale score and pediatric stroke outcome measure and FCASS was performed. We estimated infarct size by the modified pediatric Alberta Stroke Program Early Computed Tomography Score in children with AC stroke and the adapted Bernese posterior diffusion–weighted imaging score in the PC.RESULTS:Thirty-five children with a median age of 6.3 (interquartile range, 2.7–8.2 [95% CI, 0.9–15.6]; 20 male; 57.1%) years with FCA-i were identified. The total incidence rate was 0.15/100 000/year (95% CI, 0.11–0.21). Six had PC-FCA-i. Time to final FCASS was longer in the PC compared with AC; the evolution of FCASS did not differ. Initial pediatric National Institutes of Health Stroke Scale score was higher in children with FCA-i in the PC with a median of 10.0 (interquartile range, 5.75–21.0) compared with 4.5 (interquartile range, 2.0–8.0) in those with AC-FCA-i. Different from the anterior cases, PC infarct volume did not correlate with higher discharge, maximum, or final FCASS scores (Pearson correlation coefficient [r], 0.25, 0.35, and 0.54).CONCLUSIONS:FCA-i also affects the PC. These cases should be included in future investigations into FCA-i. Although it did not correlate with clinical outcomes in our cohort, the modified FCASS may well serve as a marker for the evolution of the arteriopathy in posterior FCA-i.

Circulation, Volume 149, Issue 9, Page 717-721, February 27, 2024.

Circulation, Volume 149, Issue 8, Page 627-632, February 20, 2024.

Stroke, Volume 55, Issue Suppl_1, Page ATP53-ATP53, February 1, 2024. Background and Purpose:Notoriously difficult to recognize, posterior circulation strokes (PCS) can be some of the most devastating. It is incumbent on the triage nurse to recognize these signs and symptoms. This project was developed to educate frontline ED staff on early identification of posterior strokes, decrease time to recognition, and improve outcomes.Methods:The community Primary Stroke Center (PSC) identified the need to improve recognition of PCS after a series of treatment-eligible patients were missed. A team was created including the directors of the PSC and associated Comprehensive Stroke Center (CSC), emergency room physicians, and nurses. A triage algorithm was created to capture as many strokes as possible without a glut of false positives. This included focal and non-focal signs of stroke. ANY sign of stroke should initiate the code stroke (CS) process provided that the presentation was within 24 hours of last known well, the presentation was sudden, and the symptoms were disabling to the patient. Once approved, the algorithm and education were provided to all patient-facing ED staff. Updates were added to huddle notes and a copy of the algorithm was made available at all triage areas. Data was collected retroactively for a total of 16 months, 8 months prior to the intervention and 8 months after.Results:- For all PCS the median time from arrival to initiation of CS improved from 9 minutes to 1 minute- For all PCS the median time from arrival to confirmation of stroke improved from 597 minutes to 249 minutes- Prior to intervention, only 60% of CS-eligible patients had a CS initiated, compared to 92% after- Ninety-day Rankin was from 0-2 in 86% of PCS patients prior to intervention compared to 100% afterConclusions:A clear triage process can maximize identification of PCS, increase capture of treatment-eligible patients, and decrease disability. A PSC with tele-stroke coverage and ongoing education improved identification of posterior circulation strokes and outcomes. Key takeaways for success include clear and concise code stroke algorithm, support from providers, and ongoing educational interventions. While this data is preliminary, we will continue to track and trend. Next steps should include education directed to EMS personnel in the field.

Stroke, Volume 55, Issue Suppl_1, Page A85-A85, February 1, 2024. Introduction:Endovascular thrombectomy (EVT) in posterior circulation tandem occlusions can be challenging and the current evidence is limited to retrospective case series with small sample sizes.Method:Consecutive patients from both PRESIST (ChiCTR2000033211) and BASILAR (ChiCTR1800014759) prospective registries between 2014 and 2022 were included with a total of 53 centers. Posterior circulation tandem occlusion was defined as stroke due to intracranial vertebral (V4), basilar, or posterior cerebral artery (PCA) occlusions, with tandem steno-occlusive lesion >70% of the extracranial vertebral artery and impaired distal flow or partial filling of the VA from collaterals. Outcomes included successful reperfusion defined as modified Thrombolysis in Cerebral Infarction (mTICI) of 2b-3, symptomatic intracerebral hemorrhage (sICH), favorable functional outcome defined as a modified Rankin Scale (mRS) score of 0-3, and mortality, at 90 day and 1-year.Results:After excluding 14 cases with failed access/penetration, a total of 249 patients (mean age of 63.9 years [SD 11.7], 208 [83.5%] male) were included. Basilar artery occlusions were recorded in 179 patients (71.9%) followed by V4 occlusions in 64 patients (25.7%) and PCA occlusions in 6 patients (2.4%). The median baseline NIHSS score was 23 (IQR 12-30) and median PC-ASPECTS was 9 (IQR 7-10). Intravenous thrombolysis was administered in 55 patients (22.1%) while general anesthesia was used in 94/248 patients (37.9%). The median time from onset to puncture time was 320 minutes (IQR 215-496), with a median procedure time of 130 minutes (IQR 89-170). A median number of passes was 1 (IQR 1-2) and successful reperfusion was achieved in 209/249 patients (83.9%). Favorable clinical outcome (90-day mRS 0-3) was achieved in 99/246 patients (40.2%), with mortality affecting 98/246 patients (39.8%). The 24 h post procedural sICH was found in 19/247 patients (7.7%). At 1-year, favorable clinical outcome (mRS 0-3) was achieved in 98/237 patients (41.4%), with mortality affecting 113/236 patients (47.9%).Conclusion:EVT seems to be a safe and effective approach for posterior circulation tandem occlusions. More comparative studies are needed to confirm these results.

Stroke, Volume 55, Issue Suppl_1, Page AWP248-AWP248, February 1, 2024. Introduction:Clinicians need simple and highly predictive prognostic scores to assist practical decision-making and family discussion. We aimed to develop and validate a simple prediction score applied at 24 hours to assist prognostication in patients with anterior circulation ischemic stroke due to large vessel occlusion.Methods:Using the HERMES collaboration dataset (n = 1764), patients in the endovascular therapy (EVT) arm were divided randomly into a derivation cohort (n = 430) and a validation cohort (n = 441). From a set of candidate predictors, forward selection using c-statistics was employed to select a model which was both parsimonious and highly predictive for modified Rankin Scale (mRS) ≤2 at 90 days. The score was validated in both the EVT validation cohort and in the control arm (n = 893) for mRS ≤2 and ≤3.Results:In the derivation cohort, two significant predictors of mRS ≤2 (National Institutes of Health Stroke Scale [NIHSS] score at 24 h and age [β-coefficient 0.34 and 0.06]) were selected. Incorporating other variables did not much improve model performance. Among models with different weights, we derived the HERMES score: age (years)/10 + NIHSS score at 24 h, based on model performance and simplicity. The HERMES score was highly predictive for mRS ≤2 in the derivation cohort, validation cohort-EVT, and control arm (c-statistics 0.907, 0.914, and 0.909, respectively). Evaluation of the score against mRS ≤3 as an alternative outcome yielded similar results (c-statistics 0.911, 0.903, and 0.885). Among 435 subjects (24.7%) with HERMES score ≥25, the observed probability was 3.1-3.4% for mRS ≤2 and 9.4-16.7% for mRS ≤3 in the derivation cohort, validation cohort-EVT, and control arm (Figure).Conclusions:The HERMES score is a simple validated score to predict outcomes in patients with anterior circulation large vessel occlusion ischemic stroke regardless of intervention. HERMES score should be helpful in prognostic discussion with families on day two.

Stroke, Volume 55, Issue Suppl_1, Page ATMP70-ATMP70, February 1, 2024. Objectives:The Distal Hyperintense Vessel (DHV) sign on FLAIR imaging is a radiographic marker of inadequate blood flow due to poor collateral flow distal to the stenotic artery. Previous studies suggest that the DHV sign was associated with early recurrent ischemic stroke in the anterior circulation secondary to intracranial atherosclerotic disease (ICAD). However, its significance in ischemic stroke in the posterior circulation is unknown. Here, we investigate the association of DHV sign in the basilar artery and outcomes at discharge in patients with posterior circulation stroke or TIA secondary to ICAD.Methods:We retrospectively reviewed patients with ischemic strokes or TIA attributed to ICAD of the basilar or vertebral arteries admitted to two comprehensive stroke centers affiliated with UTSW Medical Center from 2010 to 2022. Patients were included if they met VERiTAS criteria (≥50% vertebrobasilar stenosis). The DHV sign was defined as positive when the increased intensity in the basilar artery distal to stenosis was higher than the surrounding CSF signal. The DHV sign was evaluated by blinded vascular neurologists and neuro-radiologists. The primary outcome was mRS at discharge. The secondary outcome was the incidence of clinical deterioration during admission, defined as any worsened neurological exam with associated new infarct or infarct expansion in the posterior circulation.Results:A total of 135 patients were included in the study. A total of 33 (24%) patients had the presence of the DHV sign on admission MRI. Compared to patients without DHV sign, patients with DHV sign had higher NIHSS scores on admission (median 7 vs 2, p

Stroke, Volume 55, Issue Suppl_1, Page AWP180-AWP180, February 1, 2024. Introduction:Up to 50% of acute ischemic stroke (AIS) patients who undergo successful mechanical thrombectomy (MT) fail to achieve favorable outcomes (futile recanalization). In this study we aim to develop a machine learning (ML) model to predict futile recanalization (FR) in AIS patients who undergo MT.Methods:We used data from an ongoing large, multicenter database from 2013 to 2023. We included AIS patients treated with MT for ICA, M1, or M2 occlusion with successful recanalization (modified Thrombolysis in Cerebral Infarction [mTICI] score ≥ 2C) and procedure durations under 60 minutes. FR was defined as successful recanalization with 90-day modified Rankin Scale (mRS) 3-6. The dataset was divided into 75% for training and 25% for external validation. Using the Caret Package in R, multiple models were tested, and their performances were evaluated by the area under the curve (AUC) of receiver operating. Both baseline and pre-interventional characteristics were incorporated into the model. The selected model was then externally validated on a 25% validation dataset.Results:Among 2,546 qualified patients, FR occurred in 1,342 (52.7%). In univariate analysis, baseline characteristics were significantly different between FR and non-FR groups. The M5P model demonstrated the highest performance (AUC: 0.833; 95% CI: 0.7989-0.852; PPV: 0.8101) in comparison to other tested models such as logistic regression (AUC: 0.74), RF (AUC: 0.78), J48 (AUC: 0.78), SVM (AUC: 0.79), and GB (AUC: 0.79). The external validation of the model showed satisfactory results (AUC: 75.25; 95% CI: 70-80; PPV: 76.87).Conclusion:Utilizing clinical, pre-procedural, and imaging parameters, the M5P model can efficiently predict F) in AIS patients before attempting MT. This tool can assist neurointerventionalists in adequately choosing their MT candidates.

Stroke, Volume 55, Issue Suppl_1, Page AWP190-AWP190, February 1, 2024. Purpose:ASPECTS100mL) for reperfusion using endovascular thrombectomy (EVT). While specific, ASPECTS100mL while maintaining similar specificity to ASPECTS.Methods:Retrospective analysis included consecutive stroke patients arriving within 24 hours of onset, with intracranial ICA and/or M1 occlusion on CTA, and had concurrent CT perfusion. RAPID AI software estimated ICV using the rCBF0 but =50 but 100mL. Sensitivity and specificity of that CS threshold vs ASPECTS100mL (9.8%) with median of 136mL (105-172). Using ASPECTS