Risultati per: Circulation

New England Journal of Medicine, Volume 392, Issue 13, Page 1288-1296, April 3, 2025.

Introduction
Vasopressor support is often preferred as an efficient and convenient way to raise the blood pressure during surgery and intensive care therapy. However, the optimal vasopressor for ensuring organ blood flow and tissue oxygen delivery during surgery remains undetermined. This study aims to assess the impact of norepinephrine versus phenylephrine on cerebral and non-cerebral organ perfusion and oxygenation during anaesthesia in neurosurgical patients with brain tumours. The study also explores the impact of the vasopressor agents on the distribution of cardiac output between various organs.

Methods and analysis
This is an investigator-initiated, double-blinded, randomised clinical trial including 32 patients scheduled for supratentorial brain tumour surgery. The patients are randomised to receive a phenylephrine or norepinephrine infusion during preoperative positron emission tomography (PET) examinations and the following neurosurgical procedure. PET measurements of blood flow and oxygen metabolism in the brain and other organs are performed on the awake subject during anaesthesia, following a 10% and 20% gradual increase in blood pressure from the baseline value. The primary endpoint is the between-group difference in cerebral blood flow. Secondary endpoints include detection of ischaemic brain lesions possibly associated with vasopressor treatment, changes in cerebral oxygen metabolism, non-cerebral organ blood flow and oxygen metabolism, cardiac output, regional cerebral oxygen saturation, autoregulation and distribution of cardiac output between organs.

Ethics and dissemination
This study was approved by the Danish National Medical Ethics Committee (20 May 2022; 2203674). Results will be disseminated via peer-reviewed publication and presentation at international conferences.

Trial registration number
EudraCT no: 2021-006168-26. ClinicalTrials.gov: NCT06083948.

Stroke, Ahead of Print. BACKGROUND:The optimal anesthetic approach for patients with acute ischemic stroke with large vessel occlusion but low National Institutes of Health Stroke Scale receiving mechanical thrombectomy remains unclear. We aimed to evaluate the association of anesthetic strategies with procedural and clinical outcomes, hypothesizing that conscious sedation/local anesthesia (CS/LA) may offer a more favorable risk-benefit ratio than general anesthesia (GA).METHODS:Multicenter cohort study screening all thrombectomy patients prospectively enrolled in GSR-ET (German Stroke Registry-Endovascular Treatment) across 25 centers between 2015 and 2021. Patients with an admission National Institutes of Health Stroke Scale score of

Circulation, Volume 151, Issue 12, Page 878-883, March 25, 2025.

Circulation, Volume 151, Issue 9, Page 644-648, March 4, 2025.

Circulation, Volume 151, Issue 8, Page 568-573, February 25, 2025.

In a randomized trial, use of intra-arterial tenecteplase following thrombectomy was not associated with an improved outcome.

Stroke, Volume 56, Issue Suppl_1, Page ATMP82-ATMP82, February 1, 2025. Introduction:Aspiration and stent retriever thrombectomy are the primary approaches for endovascular management of posterior circulation stroke. However, the optimal first-line choice of surgical technique remains unclear. This study aims to conduct a systematic review and meta-analysis comparing first-line aspiration with stent retriever thrombectomy in terms of recanalization rates, complications, and clinical outcomes.Methodology:This systematic review and meta-analysis followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Databases searched included PubMed, Embase, Web of Science, Cochrane, and ClinicalTrials.gov, focusing on studies comparing the efficacy and safety of first-line aspiration versus stent retriever thrombectomy for posterior circulation stroke. Data analysis was performed using RevMan version 5.4.1, with statistical significance set at p < 0.05.Result:A total of 21 studies, including 2,521 patients, were analyzed. First-line aspiration demonstrated a significant advantage in terms of successful recanalization (OR = 1.36; 95% CI: 1.04–1.76; p = 0.002) and complete recanalization (OR = 1.41; 95% CI: 0.91–2.20; p = 0.03), both favoring aspiration over the stent retriever technique. Additionally, first-line aspiration was associated with a significantly lower overall complication rate (OR = 0.58; 95% CI: 0.40–0.85; p = 0.005) and a shorter procedural time (SMD = -0.60; 95% CI: -0.81 to -0.40; p < 0.005). However, there were no statistically significant differences between the two techniques in the first pass effect (OR = 1.41; 95% CI: 0.95–2.09; p = 0.09), the need for rescue therapy (OR = 1.01; 95% CI: 0.71–1.44; p = 0.96), 90-day all-cause mortality (OR = 0.95; 95% CI: 0.71–1.27; p = 0.72), and 90-day favorable functional outcome (OR = 1.17; 95% CI: 0.97–1.41; p = 0.11).Conclusion:This meta-analysis suggests that first-line aspiration may offer advantages over stent retrievers for posterior circulation stroke, particularly in terms of recanalization success and procedural safety. However, no significant differences were observed in key clinical outcomes such as mortality and favorable recovery.

Stroke, Volume 56, Issue Suppl_1, Page A70-A70, February 1, 2025. Purpose:Fast progressors (FP) of infarct growth in anterior circulation occlusions at 0-6 hours from onset (early window) have been associated with reduced rates of favorable outcome post endovascular thrombectomy (EVT). FP can be identified by using CT perfusion (CTP) derived infarct core volume (ICV) to calculate infarct growth rate (IGR), but has disadvantages of added time/radiation and susceptibility to motion. CTP is often performed with CT angiography (CTA) but AHA/ASA guidelines do not require perfusion imaging in the early window for EVT decision making. Our aim was to determine if machine learning (ML) can identify FP with only clinical, laboratory, CT, and CTA variables, without using CTP data.Methods:We retrospectively included consecutive stroke patients arriving 0-6 hours from symptom onset with ICA and/or MCA occlusion on CTA and had concurrent CTP. RAPID AI generated maps of ICV and hypoperfusion volume with criteria of rCBF 6 seconds. IGR was calculated as ICV/onset-to-CT time. FP was defined as IGR ≥10 mL/hour. Eight ML algorithms for binary classification were used with 11 selected features including age, NIHSS, lab values, ASPECTS, clot burden score (CBS), and dichotomized collateral score (Tan method 0-1 vs 2-3). Data was randomly split 70:30 for training and testing. Synthetic Minority Oversampling Technique was used to balance the class distribution in the training set. 10-fold cross validation was assessed during training. The performance of the models during testing was compared using ROC AUC, precision (PPV), recall (sensitivity), and accuracy. Relative weights of features during testing were examined with Shapley Additive Explanations (SHAP).Results:147 patients were included with median (IQR) age 76 (67-85), onset-to-CT 2.5 hours (1.5-4), NIHSS 19 (12-24), ASPECTS 9 (8-10), CBS 7 (6-8), collateral score 1 (1-2), ICV 11 mL (0-34), hypoperfusion volume 104 mL (67-157), and IGR 3.4 mL/hour (0-12.3). 47 (32.0%) were labeled as FP with median IGR 24.0 mL/hour (13.3-40.0). 16 (34.0%) of these FP also had ICV >70 mL upon arrival. XGBoost was the best performing ML model with ROC AUC 0.90, precision 0.76, recall 0.93, and accuracy 0.89. SHAP analysis of this model ranked collateral score, time from onset, serum glucose level, systolic blood pressure, and ASPECTS as the top 5 most important features.Conclusion:ML can accurately identify FP in the early window without using CTP.

Stroke, Volume 56, Issue Suppl_1, Page A13-A13, February 1, 2025. Background:The effectiveness and safety of intravenous Tirofiban as an adjunct to endovascular therapy (EVT) in posterior circulation patients with tandem lesions (PCTL) remain uncertain.Methods:This study utilized individual patient data pooled from two multicenter observational studies: the BASILAR and the PERSIST registries. We included patients with acute ischemic stroke due to PCTLs who were treated with EVT. The patients were divided into two groups based on whether they received adjunctive intravenous Tirofiban therapy or not. The primary efficacy outcome was favorable functional outcome, defined as modified Rankin Scale (mRS) scores of 0-3 at one year. Secondary outcomes included safety assessments, such as rates of symptomatic intracerebral hemorrhage (sICH), early neurological deterioration (defined as a decline in National Institutes of Health Stroke Scale [NIHSS] score by ≥4 points within 72h), and all-cause mortality at one year. We also evaluated procedural outcomes, including successful reperfusion, defined as modified Thrombolysis in Cerebral Infarction (mTICI) grade 2b-3, and complete reperfusion, defined as mTICI 3.Results:Among 210 patients treated with EVT (126 Tirofiban, 84 Non-Tirofiban), successful reperfusion (mTICI 2b-3) was achieved in 109 (86.5%) Tirofiban patients versus 64 (76.2%) non-Tirofiban patients (Adjusted OR 1.75, 95%CI [0.76-4.03], P=0.19). Complete reperfusion (mTICI 3) was achieved in 74 (58.7%) Tirofiban patients versus 36 (42.9%) non-Tirofiban patients (Adjusted OR 2.08, 95%CI [1.04-4.14], P=0.04). Rates of sICH were 6 (4.8%) in the Tirofiban group versus 9 (10.7%) in the non-Tirofiban group (Adjusted OR 0.24, 95%CI [0.04-1.36], P=0.11). Early neurological deterioration occurred in 18 (14.3%) Tirofiban patients versus 32 (38.1%) non-Tirofiban patients (Adjusted OR 0.20, 95%CI [0.09-0.46], P

Stroke, Volume 56, Issue Suppl_1, Page ATP188-ATP188, February 1, 2025. Introduction:Pretreatment CT Perfusion (CTP) marker relative cerebral blood volume (rCBV)

Stroke, Volume 56, Issue Suppl_1, Page AWP88-AWP88, February 1, 2025. Background:The effect of renal dysfunction on early infarct growth rate (IGR) in anterior circulation large vessel occlusion (ACLVO) stroke is not well studied. This study aimed to explore the association between creatinine-based biomarkers of renal dysfunction, fast or slow progressor phenotypes of infarct growth in ACLVO stroke, and related clinical outcomes.Methods:This retrospective study examined patients with acute intracranial internal carotid artery or middle cerebral artery M1 occlusions admitted between 2014 and 2019. Patients were included if they received baseline MRI or CTP on presentation within 24 hours after stroke onset. Infarct growth rate (IGR) was determined by ischemic core volume divided by time from stroke onset to imaging and used to stratify fast progressors (IGR ≥10 mL/h) and slow progressors (IGR < 10 mL/h). Renal dysfunction was assessed based on serum creatinine and estimated glomerular filtration rate (eGFR) on presenting laboratories. Logistic regression models, adjusted for significant covariates, identified independent associations between renal dysfunction biomarkers, progressor status, and clinical outcomes based on modified Rankin Scale (mRS) at 90 days.Results:Among 230 patients with ACLVO, 29% were fast progressors, with median serum creatinine levels higher than slow progressors (1.1 vs. 0.9 mg/dL, p < 0.05) and lower median eGFR (66.2 vs. 69.0 mL/min/1.73m2, p < 0.05). Elevated creatinine (≥1.2 mg/dL) was independently associated with fast progressor status (adjusted OR 2.37, 95% CI 1.18-4.77), worse 90-day mRS (adjusted OR 1.88, 95% CI 1.01-3.51) and mortality (adjusted OR 2.57, 95% CI 1.14-5.79). Reduced eGFR (

Stroke, Volume 56, Issue Suppl_1, Page AWP167-AWP167, February 1, 2025. Background:Small studies have found that patients presenting with posterior circulation ischemic strokes are more likely than patients with anterior circulation strokes to suffer a missed or delayed diagnosis in the ED. We evaluated whether probable ED stroke misdiagnosis was more common among patients subsequently hospitalized with anterior versus posterior circulation acute ischemic strokes using a large, multistate cohort.Methods:We conducted a retrospective cohort study using administrative claims data from the Healthcare Cost and Utilization Project on all hospital admissions and ED visits across 11 states from 2016-2021. To identify patients with a probable ED misdiagnosis, we identified stroke patients with an ED visit for a neurological complaint resulting in discharge to home (treat-and-release visit) in the 7 days preceding hospitalization for ischemic stroke. We used validated International Classification of Disease, Tenth Revision, Clinical Modification codes to identify stroke patients with anterior or posterior circulation strokes. We used logistic regression to determine the odds of misdiagnosis depending on stroke location adjusting for demographics and vascular risk factors.Results:We identified 264,705 ischemic stroke patients with a documented territory of brain infarction; 191,689 (72%) had anterior circulation stroke, 63,697 (24%) had posterior circulation stroke, and 11,319 (4%) had stroke involving both territories. Based on preceding ED treat-and-release visits, 1,116 (0.58%) patients with anterior circulation stroke, 944 (1.48%) patients with posterior circulation stroke, and 82 (0.72%) with stroke involving both territories had a probable ED misdiagnosis. After adjusting for demographic and vascular risk factors, posterior circulation strokes had a higher odds of probable ED misdiagnosis relative to both anterior (adjusted OR, 2.44; 95% CI, 2.23-2.66) and mixed territory cases (adjusted OR, 2.03; 95% CI, 1.62-2.55).Conclusions:Patients with posterior circulation stroke are over two times as likely to have a probable misdiagnosis in the week preceding their hospital admission relative to patients with anterior circulation stroke. These data highlight a disease of high diagnostic uncertainty and an opportunity for stroke quality improvement.

Stroke, Volume 56, Issue Suppl_1, Page ATP246-ATP246, February 1, 2025. Introduction:Mechanical thrombectomy (MT) is a primary treatment for acute ischemic stroke due to large vessel occlusions. While effective, 20-40% of patients experience hemorrhagic transformation (HT), and around 50% fail to achieve favorable functional outcomes. Transcranial Doppler (TCD) is a non-invasive and cost-effective method for real-time monitoring of hemodynamic status following MT. However, the prognostic value of TCD parameters in predicting HT and poor functional outcome is unclear. We performed a systematic review and meta-analysis of 4 TCD parameters (mean flow velocity (MFV), MFV index, peak systolic velocity (PSV), and pulsatility index (PI) in patients with and without HT and favorable vs poor functional recovery (modified Rankin Scale (mRS) 0-2 vs 3-6).Methods:PubMed, Embase, and Scopus were searched on July 25, 2024 to identify observational studies in which TCD parameters were measured within 48 hours from successful MT (Thrombolysis in Cerebral Infarction 2b–3) of anterior circulation. Risk of bias assessment was performed using a standardized tool tailored for TCD studies. The standardized mean difference (Hedges’ g) with 95% CI and risk ratios (RRs) with 95% CI were calculated using random-effects models. The review was prospectively registered on PROSPERO (registration number CRD42024575381).Results:Eleven studies met inclusion criteria. No study had high risk of bias. MFV and MFV index were higher in patients with HT+ compared with HT- (Hedges’ g = 0.42 and 0.54, p = 0.015 and 0.005, respectively). Patients with MFV index ≥1.3 showed a higher risk of all HT (RR = 2.01, 95% CI = 1.27–3.17, p = 0.003), symptomatic HT (RR, 4.68; 95% CI,1.49–14.65, p=0.008), and poor functional recovery at 90 days (RR, 1.66; 95% CI,1.32–2.08, p

Stroke, Volume 56, Issue Suppl_1, Page ADP38-ADP38, February 1, 2025. Background:Endovascular therapy (EVT) has emerged as a first-line intervention for vertebrobasilar artery occlusion (VBAO) patients, supported by two recent landmark randomized controlled trials. However, EVT outcomes may vary based on patient age and collateral status. This study examines the interaction between age and collateral status on EVT outcomes in VBAO patients.Methods:We retrospectively analyzed VBAO patients who underwent EVT from a prospectively maintained database between January 2014 and January 2024. Patients were categorized into non-octogenarians (age

Objective
To investigate the potential classification of kinesiophobia in patients after cardiac surgery under extracorporeal circulation from a psychosocial perspective, and analyse the characteristic differences among different latent levels of patients.

Study design
This is a cross-sectional study of Chinese adults after cardiac surgery under extracorporeal circulation, aged 18 years and older, recruited from a tertiary hospital in North China.

Methods
This study uses latent profile analysis to identify potential classifications of kinesiophobia in questionnaires from 348 patients undergoing cardiac surgery under extracorporeal circulation. Multiple logistic regression analysis was used to evaluate the influencing factors at different latent classifications.

Results
The average performance of each indicator in Model 3 is best suited for analysis, Entropy=0.873 and bootstrap likelihood ratio test (p)