Risultati per: Circulation

Circulation, Volume 148, Issue 10, Page 848-851, September 5, 2023.

Stroke, Ahead of Print. BACKGROUND:Endovascular treatment (EVT) for acute ischemic stroke (AIS) patients presenting with National Institutes of Health Stroke Scale score of 0 to 5 is common in clinical practice but has not yet been proven safe and effective. Our objective is to assess whether EVT on top of best medical treatment (BMT) in AIS patients with large-vessel occlusion of the anterior circulation presenting with mild symptoms is beneficial compared with BMT.METHODS:We searched MEDLINE, SCOPUS, and reference lists of retrieved articles published until December 28, 2022. A systematic literature search was conducted to identify clinical trials or observational cohort studies evaluating patients with AIS due to anterior circulation large-vessel occlusion and admission National Institutes of Health Stroke Scale score ≤5 treated with EVT versus BMT alone. The primary outcome was excellent functional outcome (modified Rankin Scale score 0–1) at 3 months. The protocol had been registered before data collection (PROSPERO).RESULTS:Eleven observational eligible studies were included in the meta-analysis, comprising a total of 2019 AIS patients with National Institutes of Health Stroke Scale score ≤5 treated with EVT versus 3171 patients treated with BMT. EVT was not associated with excellent functional outcome (risk ratio, 1.10 [95% CI, 0.93–1.31]). When stratified for different study design (per-protocol versus intention-to-treat), there were no significant subgroup differences. EVT was not associated with good functional outcome (modified Rankin Scale score 0–2; risk ratio, 1.01 [95% CI, 0.89–1.16]) or reduced disability at 3 months (common odds ratio, 0.92 [95% CI, 0.60–1.41]). Symptomatic intracranial hemorrhage was more common in the patients receiving EVT (risk ratio, 3.53 [95% CI, 2.35–5.31]). No correlation was found between EVT and mortality at 3 months (risk ratio, 1.34 [95% CI, 0.83–2.18]). The same overall associations were confirmed in the sensitivity analysis of studies that performed propensity score matching.CONCLUSIONS:EVT appears equivalent to BMT for patients with anterior circulation large-vessel occlusion AIS with low baseline National Institutes of Health Stroke Scale, despite the increased risk for symptomatic intracranial hemorrhage.Registration:URL:https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42022334417.

Circulation, Volume 148, Issue 5, Page 430-435, August 1, 2023.

Circulation, Volume 148, Issue 2, Page 162-166, July 11, 2023.

Circulation, Volume 148, Issue 1, Page 1-3, July 4, 2023.

Circulation, Volume 147, Issue 22, Page 1705-1710, May 30, 2023.

Circulation, Volume 147, Issue 17, Page 1304-1308, April 25, 2023.

Circulation, Volume 147, Issue 15, Page 1183-1185, April 11, 2023.

Circulation, Volume 147, Issue 13, Page 1039-1044, March 28, 2023.

Circulation, Volume 147, Issue 12, Page 977-981, March 21, 2023.

Stroke, Volume 54, Issue 3, Page 743-750, March 1, 2023. Background:The benefit of distinguishing between disabling versus nondisabling deficit in mild acute ischemic stroke due to endovascular thrombectomy-targetable vessel occlusion (EVT-tVO; including anterior circulation large and medium-vessel occlusion) is unknown. We compared safety and efficacy of acute reperfusion treatments in disabling versus nondisabling mild EVT-tVO.Methods:From the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Register, we included consecutive acute ischemic stroke patients (2015–2021) treated within 4.5 hours, with full NIHSS items availability and score ≤5, evidence of intracranial internal carotid artery, M1, A1-2, or M2-3 occlusion. After propensity score matching, we compared efficacy (3-month modified Rankin Scale score of 0–1, modified Rankin Scale score of 0–2, and early neurological improvement) and safety (nonhemorrhagic early neurological deterioration, any intracerebral or subarachnoid hemorrhage, symptomatic intracranial hemorrhage, and death at 3-month) outcomes in disabling versus nondisabling patients—adopting an available definition.Results:We included 1459 patients. Propensity score matched analysis of disabling versus nondisabling EVT-tVO (n=336 per group) found no significant differences in efficacy (modified Rankin Scale score 0–1: 67.4% versus 71.5%,P=0.336; modified Rankin Scale score 0–2: 77.1% versus 77.6%,P=0.895; early neurological improvement: 38.3% versus 44.4%,P=0.132) and safety (nonhemorrhagic early neurological deterioration: 8.5% versus 8.0%,P=0.830; any intracerebral hemorrhage or subarachnoid hemorrhage: 12.5% versus 13.3%,P=0.792; symptomatic intracranial hemorrhage: 2.6% versus 3.4%,P=0.598; and 3-month death: 9.8% versus 9.2%,P=0.844) outcomes.Conclusions:We found similar safety and efficacy outcomes after acute reperfusion treatment in disabling versus nondisabling mild EVT-tVO; our findings suggest to adopt similar acute treatment approaches in the 2 groups. Randomized data are needed to clarify the best reperfusion treatment in mild EVT-tVO.

Circulation, Volume 147, Issue 9, Page 768-773, February 28, 2023.

Stroke, Ahead of Print. BACKGROUND:It is unclear whether infarct location affects stroke recurrence after index ischemic stroke. We aimed to compare the risk of stroke recurrence and the responses to dual antiplatelets with ticagrelor-aspirin versus clopidogrel-aspirin between patients with posterior circulation infarct (PCI) and those with anterior circulation infarct (ACI) after minor stroke or transient ischemic attack.METHODS:Data were obtained from the double-blind CHANCE-2 trial (Ticagrelor or Clopidogrel With Aspirin in High-Risk Patients With Acute Nondisabling Cerebrovascular Events II), which was conducted across 202 centers in China from September 2019 to March 2021. Patients with positive diffusion-weighted imaging were included and classified into PCI and ACI groups according to the hyperintense lesions on diffusion-weighted imaging. The primary efficacy and safety outcomes were a new stroke and severe or moderate bleeding within 90 days, respectively.RESULTS:A total of 4168 patients were included in this substudy, with 1427 PCI and 2741 ACI. During the 90-day follow-up, the risk of stroke recurrence in patients with PCI was similar to that with ACI (7.4% versus 8.3%; adjusted hazard ratio, 1.01 [95% CI, 0.79–1.29];P=0.94). In comparison with clopidogrel-aspirin, ticagrelor-aspirin significantly reduced the risk of stroke recurrence in both the PCI (hazard ratio, 0.59 [95% CI, 0.40–0.89];P=0.01) and ACI groups (hazard ratio, 0.65 [95% CI, 0.50–0.85];P=0.002). There was no treatment-by-infarct location interaction (Pvalue for interaction, 0.92). The risk of severe or moderate bleeding was similar between PCI and ACI patients (P=0.19). However, the risk of any bleeding increased on ticagrelor-aspirin than clopidogrel-aspirin treatment in PCI and ACI patients (P=0.02 and 0.002, respectively).CONCLUSIONS:Our study demonstrated that stroke recurrence was similar between PCI and ACI in patients with minor stroke or transient ischemic attack. Additionally, ticagrelor-aspirin was superior to clopidogrel-aspirin in reducing the risk of stroke within 90 days in both PCI and ACI patients.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT04078737.

Stroke, Volume 54, Issue Suppl_1, Page AWMP84-AWMP84, February 1, 2023. Introduction:We compared the morphology of intracranial atherosclerotic plaques in the anterior versus posterior circulation, using three-dimensional rotational angiography (3DRA).Methods:We prospectively recruited adult patients with acute ischemic stroke or transient ischemic attack attributed to high-grade (60-99%), atherosclerotic intracranial stenosis as confirmed by 3DRA. We assessed the plaque morphology in 3DRA, including the percentage of luminal stenosis, smooth/irregular/ulcerative plaque surface contour, plaque thickness, length, eccentricity, upstream plaque shoulder angulation, longitudinal distribution of the maximal stenosis, and adjoining branch atheromatous disease (BAD). We compared characteristics of patients with middle cerebral artery-M1 (MCA-M1) and basilar artery (BA) plaques, and the plaque morphology in the two subgroups.Results:Overall, 164 and 17 patients respectively with MCA-M1 and BA plaques were analyzed, with similar age (medians 60 versus 62 years), sex (male 64.6 versus 52.9%) and history of common vascular risk factors. The percentage of luminal stenosis (medians 77 versus 81%), proportion of smooth/irregular/ulcerative plaque surface contour, upstream plaque shoulder angulation (32.1 versus 25.8 °), longitudinal distribution of the maximal stenosis, and presence of adjoining BAD (56.7 versus 64.7%) were similar between MCA-M1 and BA plaques. However, BA plaques were thicker (1.5 versus 1.3mm; p=0.03) and longer (16.4 versus 8.4mm; p

Stroke, Volume 54, Issue Suppl_1, Page AWMP74-AWMP74, February 1, 2023. Background:Intracranial arterial stenosis (ICAS) can cause stroke by different mechanisms: perforator disease, artery to artery embolism, and impaired flow. There is limited data exists on the utility of perfusion imaging in patients with ICAS. We aim to determine associations between perfusion delay volume and 90-day recurrence in patients with anterior circulation ICAS.Methods:This is a two-center study of symptomatic anterior circulation ICAS involving the left M1 or ICA who underwent perfusion imaging (MRP or CTP). The primary predictor was hypoperfusion mismatch volume HPV (T max delay volume – core volume) using Tmax >4 sec or Tmax >6 sec thresholds. The outcome was recurrent cerebrovascular events (RCVE) defined as new or worsening neurological symptoms due to confirmed or suspected new infarct or infarct extension. We used Youden’s index to define the optimal cut-point of Tmax4 and Tmax6 mismatch for predicting recurrent stroke. We fit time-to-event models for RCVE with HPV at dichotomized cut-points, both as a univariate analysis and after adjusting for co-variates.Results:50 patients met the inclusion criteria and 30% had RCVE. The median T max 4 HPV in mL was higher in patients with vs. without RCVE (121 vs. 19, p < 0.001) and the median T max 6 HPV in mL was higher in patients with vs. without RCVE (33 vs. 0, p = 0.004). We found an association between Tmax > 4 sec hypoperfusion volume (AUC 0.79, p =0.012) and max >6 sec hypoperfusion volume (AUC 0.75, p = 0.008) with RCVE. For Tmax 4 the cut-point was at 94 mL and for Tmax6 the cut-point was at 10 mL. Recurrent stroke was higher in those with vs. without Tmax >4 sec ≥94 mL delay (66.7% vs. 14.3%, (p6 sec≥10 mL delay (68.8% vs. 11.8%, p4 sec HPV ≥ 94 mL was 5.0 (95% CI 1.5-16.4) and that of Tmax >6 sec HPV > 8 ml was 11.3 (95% CI 3.7-116.8).Conclusion:In this two-center study, hypoperfusion delay volume is associated with early recurrence in patients with symptomatic ICAS. Studies are needed to validate our findings and to test endovascular reperfusion in the subset of patients with symptomatic ICAS and perfusion delay.

Stroke, Volume 54, Issue Suppl_1, Page A138-A138, February 1, 2023. Introduction:Data on predictors of early stroke recurrence in patients with symptomatic intracranial atherosclerotic disease (sICAD) is limited. We hypothesized that hypoperfusion delay predicts stroke recurrence within 90-days.Methods:We retrospectively collected all patients hospitalized with anterior circulation sICAD over 3 years (April 2019-April 2022) at a comprehensive stroke center. We collected demographics, clinical risk factors, radiological variables, and treatment strategies. Patients with an indication for anticoagulation such as atrial fibrillation and those with intracranial stenting or angioplasty were excluded. The outcome (verified by two independent reviewers) was recurrent stroke within 90 days in the affected artery. We assessed factors associated with stroke recurrence. We measured the effect of hypoperfusion delay volume on stroke recurrence using Cox-regression models.Results:Out of 131 sICAD hospitalizations during the study period, 66 involved the middle cerebral artery (MCA) M1 segment or intracranial internal carotid artery (ICA) and 44 patients met the inclusion criteria. The mean age was 71 years and 41% were women; 75% were treated with best medical management (dual antiplatelet therapy/high intensity statin therapy); and 75% had baseline perfusion imaging performed. Over 90 days, 11/44 (25%) patients had recurrent stroke. Factors associated with recurrence stroke were no best medical management (15.2% vs. 54.5%, p = 0.02), hypoperfusion Tmax >4 sec mismatch volume (p = 0.003), and hypoperfusion delay Tmax >6 sec mismatch volume (p=0.01). Using Youden’s cutoff for Tmax >4 sec mismatch (13 mL) and for Tmax >6 sec mismatch (5 mL), the risk of recurrent stroke at 90 days in separate models was higher in patients with Tmax >4 sec delay mismatch volume > 13 mL (HR 11.98 95% CI 1.48-96.96 p=0.02) and Tmax >6 sec mismatch volume > 5 mL (HR 4.37 95% CI 1.02-18.82, p=0.048). Effect size of the associations did not meaningfully change after adjusting for best medical management.Conclusion:Hypoperfusion delay is associated with an increased recurrent stroke risk within 90 days in patients with sICAD, despite best medical management. Validation by large prospective studies is warranted.