Risultati per: Circulation

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 ATP137-ATP137, February 1, 2023. Background:Prior studies have shown rescue intracranial angioplasty and/or stenting (PTAS) is safe and efficacious in acute large vessel occlusion (LVO) of the anterior circulation with underlying intracranial atherosclerotic disease (ICAD). We investigated the safety and efficacy of acute intracranial angioplasty and/or stenting in patients with posterior circulation intracranial atherosclerosis-related occlusion (ICAS-O).Methods:Through the utilization of a prospectively collected endovascular database at a comprehensive stroke center between January 2016- May 2022, variables such as demographics, co-morbid conditions, symptomatic intracerebral hemorrhage (ICH), the mortality rate at discharge, and recanalization rate and favorable clinical outcome, modified thrombolysis in cerebral infarction score (mTICI) and favorable clinical outcome (modified Rankin Scale (mRS), were examined. The outcomes between acute PTAS + MT in the anterior and posterior circulation were compared.Results:There were a total of 75 acute ischemic stroke (AIS) patients who underwent rescue PTAS, of which 15 (20.0 %) were posterior circulation ICAS-O group. Baseline characteristics were similar between the groups except for gender (6.7 % vs 45.0) and atrial fibrillation (21.7% vs 0.0%). There was no statistical difference in discharge NIH Stroke Scale (mean, 18 vs 23%, P = 0.860) or favorable outcome (modified Rankin Scale ≤ 2) at 90 days (46.7% vs 38.7 %, P = 0.477) between the posterior and anterior ICAS-O groups respectively. Symptomatic ICH rate tended to be higher in the anterior group (11.7 vs 6.7%, P = 0.495).Conclusions:Rescue angioplasty and/or stenting seem safe treatment options for posterior circulation ICAS-related LVO. Further larger multicenter prospective studies are required to corroborate the results of our study.

Stroke, Volume 54, Issue Suppl_1, Page ATP177-ATP177, February 1, 2023. Introduction:The determinants of fast and slow progressor phenotypes of infarct growth in anterior circulation large vessel occlusion (ACLVO) remain poorly understood. Previous studies have shown a potential link between baseline serum glucose and acute infarct growth. We assessed whether presenting serum glucose is independently associated with fast or slow progression of infarct growth in ACLVO stroke.Methods:Retrospective analysis of patients with acute stroke due to intracranial ICA or proximal MCA occlusion across two comprehensive stroke centers from 2014-2019. Baseline CTP or MRI were obtained within 24hours of stroke onset. Fast progressors (ischemic core > 70ml, 0-6 h) and slow progressors (

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 ATP2-ATP2, February 1, 2023. Introduction:Recent publications suggest a positive added effect of iv-thrombolysis (IVT) in patients that undergo endovascular treatment (EVT). It is hypothesized that thrombolytics might have a beneficial impact on microcirculation beyond recanalization. We aim to analyze the potential impact of IVT in patients who underwent a repeated CTP after interhospital transfer.Methods:We retrospectively screened 116 patients transferred to our comprehensive stroke center from a primary stroke center capable to perform CTP from June 2021 to August 2022. We collected clinical and radiological data of patients that underwent CTP at both centers, which were analyzed with Rapid software. A neurointerventionalist assessed the occlusion location in CTA.Results:Twenty-eight patients with anterior circulation occlusion underwent two multimodal studies, median time between CTPs was 168[142-190]min. Fifteen (53.6%) patients received IVT in the primary stroke center and 13(46.4%) received EVT. Reperfusion occurred in 3(10.7%) cases, migration to distal segments in 5(17.9%). Among the 20 patients without changes in the occlusion location, CTP volumes remained stable (Tmax >6s 61[41-141]ml vs 62[24-178], p=0.72; Tmax >10s 19[8-96] vs 13[0-105], p=0.55; CBF30 0[0-66] vs 0[0-65], p=0.99). CTP volumes tended to decrease with IVT, but a modest increase was observed in patients that did not receive IVT (Tmax >6s -17[-29,+8]ml vs +22[-8,+42], p=0.08; Tmax >10s -8[-16,+6] vs +6[0,+37], p=0.10; CBF10s (p=0.06) and CBF

Stroke, Volume 54, Issue Suppl_1, Page AWP102-AWP102, February 1, 2023. Introduction:Side-to-side relative reduction in end-diastolic velocity (EDV) of the common carotid artery (CCA) may discriminate ipsilateral anterior circulation large vessel occlusion (LVO), which will contribute faster patient triage for reperfusion therapy. We evaluated the discriminative accuracy of this simple sonographic index for anterior circulation LVO in acute stroke population, including intracerebral hemorrhage (ICH).Methods:Among patients with acute stroke admitted to our institute between 2016-2018, those who underwent both carotid ultrasonography and head MRA or CTA within 24 hours after last known normal time were reviewed. Relative EDV reduction was calculated as a ratio by dividing the CCA EDV lower side by the EDV higher side. Anterior circulation LVO was defined as occlusion of the internal carotid artery (ICA) or M1 segment of the middle cerebral artery on the lower EDV side. Discriminative performance of relative EDV reduction for anterior circulation LVO was assessed by receiver operating characteristics analysis.Results:A total of 688 patients (411 males; median age 77 years; 87 with anterior circulation LVO) were analyzed. When compared to no occlusion, value of relative EDV reduction was remarkably lower in ICA occlusion, followed by that in M1 occlusion (Figure). Area under the curve (AUC) of relative EDV reduction for ICA occlusion was 0.96 (95% confidence interval [CI] 0.94-0.99) with an appropriate cut-off value of 0.50 (sensitivity 94%, specificity 94%). When the discrimination target was set to anterior circulation LVO, the AUC was 0.78 (95% CI 0.72-0.85) with an appropriate cut-off value of 0.67 (sensitivity 69%, specificity 83%). At this cut-point, 51% of patients with M1 occlusion was classified as false negative.Conclusions:The discriminative performance of the relative CCA EDV reduction in acute stroke population was excellent for ICA occlusion and acceptable for anterior circulation LVO.

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 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.

Stroke, Volume 54, Issue Suppl_1, Page ATP133-ATP133, February 1, 2023. Background and Purpose:The efficacy of mechanical thrombectomy (MT) for posterior circulation large vessel occlusions has not been fully elucidated. We investigated the efficacy and safety of MT for posterior circulation stroke (PCS) compared with anterior circulation stroke (ACS).Methods:We analyzed 885 consecutive patients who underwent MT for acute ischemic stroke between January 2013 and December 2020 at six comprehensive stroke centers. The patients were divided into two groups; the PCS and ACS group. The procedural and clinical outcomes were compared between the groups.Results:A total of 767 patients (PCS group, 83; ACS group, 684), were analyzed. PCS patients were significantly younger (75 vs. 79, P = 0.008) and had a higher NIHSS score at baseline (23 vs 19, p=0.012) and longer door to puncture time (97 vs 73 min, p=0.009). The rate of male (67.0 vs 46.9% p

Stroke, Volume 54, Issue Suppl_1, Page AWMP79-AWMP79, February 1, 2023. Introduction:Intracranial atherosclerotic disease (ICAD) remains a major source of stroke worldwide, with high recurrence risk. Prior evaluation of posterior circulation ICAD patients enrolled in the prospective VERiTAS and MYRIAD studies revealed regional hypoperfusion, assessed by large vessel flow measurements using quantitative MRA (QMRA), predicts subsequent vertebrobasilar stroke risk. We examined whether a similar approach to regional flow assessment using QMRA predicted stroke risk in anterior circulation ICAD patients enrolled in MYRIAD.Methods:MYRIAD enrolled patients with recent TIA or stroke attributable to 50-99% stenosis of proximal intracranial artery; the primary outcome was ischemic stroke in the territory of the stenotic artery with 1 year of follow-up. Secondary outcomes included new in-territory infarcts on MRI at 6-8 weeks. Flow was measured in the major intracranial arteries at baseline using QMRA. We designated patients as low- or normal-flow status based on an algorithm assessing distal flow and collateral capacity using age-normalized MCA and hemispheric (aggregate of ipsilateral ACA, MCA, and PCA) flows. Different thresholds for flow status categorization were tested to determine the optimal algorithm for stroke risk prediction.Results:Of 73 enrolled subjects with symptomatic anterior circulation ICAD, 7 (9.6%) patients had recurrent stroke. Z-score thresholds for age-normalized flow ranging from -0.5 to -1.5 were examined. The optimal thresholds identified were as follows: -1 for the MCA and -0.75 for hemispheric flow. 24 (33%) patients were categorized as low-flow status based on these thresholds; recurrent stroke occurred in 21% of low-flow patients vs. 4% of normal-flow patients (OR 6.2 (95% CI 1.1-34.7, p=0.04). However, flow status was not predictive of recurrent infarct on imaging among 61 patients with 6-8 week MRI (32% in low-flow vs. 26% in normal-flow patients).Conclusions:Similar to the predictive value in the posterior circulation, distal flow status assessed through QMRA regional flow measurement appears to be predictive for recurrent clinical (but not imaging-based) stroke. Identification of high-risk patients has implications for future investigation of therapeutic interventions.

Circulation, Volume 147, Issue 5, Page 361-363, January 31, 2023.