Cerebrovascular Diseases最新文献

Introduction: General anesthesia (GA) with endotracheal intubation is standard during endovascular treatment (EVT) for acute ischemic stroke (AIS), but the optimal timing for post-procedural extubation remains unclear.

Methods: In this retrospective cohort study, we analyzed data from 372 patients who underwent EVT under GA at our center. Extubation failure was defined as re-intubation within 48 h of extubation. Continuous variable extubation timing was categorized using thresholds of 4, 6, 8, and 24 h for analysis. Poor outcome was defined as modified Rankin scale ≥3 at discharge and 90 days.

Results: Successful extubation was associated with favorable outcomes (p < 0.001). Among patients with successful extubation, delayed extubation beyond 24 h was associated with poor outcomes compared with extubation within 24 h (p < 0.001). The timing of extubation within the first 24 h showed distinct associations with outcomes. Extubation performed at 8-24 h was associated with poor outcomes both at 90 days (odds ratio [OR] 2.179, 95% confidence interval [CI] 1.124-4.223, p = 0.021) and at discharge (OR 2.015, 95% CI 1.065-3.811, p = 0.031) compared with extubation within 8 h. Comparisons of extubation at 4-24 h versus ≤4 h and 6-24 h versus ≤6 h showed no similar association.

Conclusion: Successful extubation was associated with favorable outcomes in AIS patients undergoing EVT under GA. Within the first 24 h, extubation ≤8 h was associated with better outcomes than extubation at 8-24 h. However, extubation at ≤4 h versus 4-24 h, or ≤6 h versus 6-24 h, was not associated with better outcomes.

Introduction: Efficient spatial layout of comprehensive stroke centers (CSCs) is crucial for the timely transport of stroke patients to hospitals for effective treatment following symptom onset. However, limited research has focused on the spatial allocation of CSCs. Therefore, this study aimed to evaluate the spatial distribution and accessibility of CSCs in Liaoning Province, China.

Methods: The closest facility analysis and location-allocation model were employed to examine spatial accessibility, urban-rural disparities, and 1-h coverage of the high-risk population under current and simulated CSC distribution scenarios.

Results: Key findings include the following: (1) CSC accessibility in Liaoning Province varies significantly, with better accessibility in major cities and poorer accessibility in mountainous and rural areas. (2) The existing 34 CSCs were mainly located in urban areas, and only 48.41% of townships and 60.63% of the high-risk population in Liaoning province can access them within 1 h. (3) In the optimization scenario, considering only candidate tertiary hospitals extended coverage to 75.63% of the high-risk populations. Integrating both candidate tertiary and secondary hospitals increased coverage in high-risk populations to 89.78%, effectively increasing the accessibility of CSCs, particularly in rural areas, and reducing the urban-rural accessibility gap.

Conclusion: These insights shed light on the spatial disparities of CSCs in Liaoning Province and provide a spatial blueprint for establishing a "1-h gold rescue circle." While improving geographic accessibility is a prerequisite, future policy should also prioritize the capacity building of candidate hospitals to ensure clinical efficacy.

Introduction: The benefits of long-term blood pressure (BP) lowering for the prevention of recurrent stroke and other serious cardiovascular (CV) events in patients who suffer an acute spontaneous intracerebral hemorrhage (ICH) is well established. However, there is uncertainty as to whether the treatment effect varies according to certain patient characteristics and across various CV and non-CV outcomes, and the timing of when the benefits manifest over time. We aim to pool individual participant data (IPD) from randomised controlled trials (RCTs) that included patients with a history of ICH to determine the efficacy of BP lowering for the secondary prevention of major CV events.

Methods and analysis: A systematic review was undertaken according to the Preferred Reporting Items for Systematic review and Meta-Analysis of Individual Participant Data (PRISMA-IPD) Statement. A search of multiple databases from inception to 25 January 2026 was conducted to identify RCTs of BP-lowering therapy for secondary prevention after ICH that enrolled at least 100 participants with ICH. We will undertake an IPD meta-analysis, with TRIDENT (Triple therapy prevention of Recurrent Intracerebral Disease EveNts Trial) serving as our anchor study, and three other major RCTs of BP lowering treatment for secondary prevention with a subgroup of at least 100 ICH patients: ESPRIT (Effects of Intensive Systolic Blood Pressure Lowering Treatment in Reducing Risk of Vascular Events) trial, PROGRESS (Perindopril Protection Against Recurrent Stroke Study), and RESPECT (Recurrent Stroke Prevention Clinical Outcome) Study. The primary CV outcome is the time to first recurrent stroke of any type. Secondary outcomes include major adverse cardiovascular events (MACE): non-fatal stroke, non-fatal myocardial infarction, or cardiovascular death; each component of MACE, stroke subtypes, and all-cause death. The safety outcome is any serious adverse event. All analyses will be performed on the intention-to-treat dataset from each trial using a one-stage approach. The effect of the intervention will be estimated as the cause-specific hazard ratio and 95% confidence intervals (CI) obtained from a Cox proportional hazard model, adjusting for age, sex, history of hypertension, and history of diabetes mellitus. A sensitivity analysis will treat death as a competing risk. The time to benefit of BP lowering will also be estimated according to specific absolute risk reduction thresholds.

Introduction: Endovascular treatment (EVT) is effective for acute ischemic strokes due to proximal large vessel occlusions. However, its efficacy and safety in distal medium vessel occlusions (DMVOs) are debated. We performed a systematic review and meta-analyses to compare EVT with best medical treatment (BMT) in treating primary DMVOs.

Methods: A search was performed on Embase, PubMed, and Cochrane up to April 2025. Efficacy outcomes included functional independence and excellent functional outcomes at 90 days. Safety outcomes were symptomatic intracranial hemorrhage (sICH) and 90-day mortality. Statistical analyses used Review Manager (RevMan) version 5.3.

Results: Three RCTs and 30 observational studies were included in this meta-analysis of 8,936 patients. Overall, 4,049 (50.72%) were included in EVT and 4,887 (49.28%) in BMT arm. Overall, BMT was comparable to EVT in terms of excellent functional outcome (mRS 0-1) (OR 1.06, 95% CI 0.89-1.25), functional independence (mRS 0-2) (OR 0.97, 95% CI 0.82-1.14), and 90-day mortality (OR 1.15, 95% CI: 0.91-1.46). Notably, there was a statistically significant increase in sICH rates with EVT (OR 1.54, p-value = 0.01). In studies with mild strokes (NIHSS <6), BMT was superior to EVT in achieving functional independence (OR 0.57, p = 0.05), while EVT was associated with significantly higher sICH rates (OR 6.35, p = 0.010).

Conclusion: BMT is equally efficacious and safer than EVT in DMVO ischemic strokes. Based on current evidence, EVT should be avoided for medium and distal vessel occlusions given significantly higher risk of intracranial hemorrhage. Outcomes with EVT are also worse in posterior circulation DMVOs and when EVT is performed >4 h from the last known normal time.

Introduction: Benefits of percutaneous patent foramen ovale (PFO) closure is demonstrated in PFO-associated stroke for secondary prevention, compared with medical treatment alone. Unfortunately, stroke recurrence can occur before PFO closure. However, no study has focused on the prevention of early cerebral ischemic recurrences that can occur before closure. The aim of our study was to compare the antithrombotic strategy implemented to prevent early cerebral ischemic recurrences before PFO closure.

Method: This is a retrospective, single-center cohort study of adult patients with ischemic stroke who underwent PFO closure at Louis Pradel Hospital in Lyon between January 3, 2020, and November 22, 2023. The primary outcome was the occurrence of an ischemic recurrence, stroke or transient ischemic attack TIA, before closure. Major bleeding represented the safety endpoint.

Results: In this retrospective cohort of 492 patients with an indication for PFO closure performed within 1 year following an ischemic stroke, 384 (78%) were under antiplatelet (APT) and 108 (22%) under anticoagulant (ACT). There were 15 early cerebral ischemic recurrences. All of these occurred under APT. Complete separation of the data prevented us to conclude with a logistic regression but suggested a significant link between APT and ischemic recurrence. No serious bleeding complication occurred.

Conclusion: Our retrospective cohort of PFO-associated stroke patients suggests that early ischemic recurrences are more frequent with APT than with ACT, with no increase in hemorrhagic risk. The antithrombotic strategy in this early time window (before PFO closure) had not been previously studied, and our results need a randomized trial for confirmation.

Introduction: Socioeconomic status (SES) is known to influence health outcomes. We investigated whether prehospital time metrics are associated with neighbourhood SES (nSES) in a cohort of patients with neurological symptoms suspect for stroke from two regions in the Netherlands.

Methods: We analysed data from two prospective cohort studies. As a proxy for nSES, we used a postcode-based composite score as developed by "Statistics Netherlands" (CBS), with a range from -1 to 1. The associations between nSES and time metrics were examined through linear regression. Logistic regression estimated the association with final stroke diagnoses and receiving reperfusion treatment. Models were fit using generalized estimating equations. All analyses were adjusted for age, sex, and original study.

Results: The cohort included 2,854 patients (1,485 [52.0%] male, median age 73 [IQR 61-81], median baseline NIHSS score 2 [IQR 0-6]). nSES was associated with onset-to-alarm time (aβ -0.26 [95% CI: -0.49 to -0.03], p = 0.03) and onset-to-door time (aβ -0.21 [95% CI: -0.36 to -0.05], p = 0.01), with a respective 23% and 19% increase per 1 point shift toward a more deprived nSES. However, nSES was not associated with alarm-to-door time (aβ -0.01 [95% CI: -0.07 to 0.05], p = 0.79), final stroke diagnosis (adjusted odds ratio [aOR] 0.91 [95% CI: 0.66-1.35]) or likelihood of receiving reperfusion therapy (aOR 1.16 [95% CI: 0.79-1.70]).

Conclusion: Living in a more socioeconomically deprived neighbourhood is associated with prehospital delays for patients presenting with neurological symptoms suspect for stroke. This highlights the importance of examining barriers to timely emergency medical service activation and formulating strategies to reduce socioeconomic disparities in stroke response.

Introduction: Stroke trials conducted in prehospital settings face inherent complexities in patient screening, timely intervention delivery, and outcome assessment. The INTEnsive ambulance-delivered blood pressure Reduction in hyper-acute stroke Trial (INTERACT4) investigated the effect of prehospital blood pressure (BP) lowering initiated within 2 h of symptom onset in suspected acute stroke across multiple sites in China. This process evaluation aimed to examine implementation outcomes and contextual mechanisms influencing delivery.

Methods: A mixed-methods approach with a convergent parallel design. Quantitative data on fidelity, dose, and reach were obtained from case report forms and monitoring logs, including protocol deviations and BP target achievement. Qualitative data on acceptability, appropriateness, and adoption were collected through semi-structured interviews with ambulance and hospital staff from eight sampled hospitals, and a focus group discussion with project implementers. Data were analyzed descriptively and thematically, guided by the Medical Research Council complex intervention framework for process evaluation and normalization process theory.

Results: A total of 34 participants (19 ambulance staff and 15 hospital doctors) across 8 sites were interviewed. Fidelity was generally acceptable, with nearly 90% of eligible patients receiving the first urapidil dose. Dose achievement was modest, with 31.7% of patients achieving the prehospital systolic BP target of <140 mm Hg. Qualitative findings provided further explanation. Staff regarded the intervention as meaningful, safe, and compatible with workflows, and reported increasing proficiency through training and quality control. System-level differences were evident: in centralized dispatch systems, very short transfer times and frequent handovers with rotating junior physicians contributed to protocol deviations. Conversely, hospital-based systems, with stable doctor-nurse teams and longer transfer times, facilitated better adherence.

Conclusions: BP lowering in the prehospital setting was feasible and acceptable, but fidelity varied by the ambulance model. Hospital-based systems achieved higher adherence, highlighting the role of system design and training in prehospital stroke interventions.

Introduction: The aim of the study was to examine early neurological deterioration (END) using different definitions according to the National Institutes of Health Stroke Scale (NIHSS) and Glasgow Coma Scale (GCS) scores for their ability to predict 90-day unfavorable functional outcomes in acute ischemic stroke (AIS) patients from the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED).

Methods: ENCHANTED was an international, multicenter, 2 × 2 quasi-factorial, prospective, randomized open-trial of low-dose versus standard-dose intravenous alteplase, and intensive versus guideline-recommended blood pressure lowering in thrombolysis-eligible patients with AIS. Mild, moderate, and significant END_NIHSS were defined as an increase in the NIHSS score of ≥1, ≥2, and ≥4 points, respectively. Mild and moderate-significant END_GCS were defined as a decrease in the GCS score of ≥1 and ≥2 points, respectively. In all cases, END also included death within 24 h. Any END was defined as an increase of ≥1 point in the NIHSS score, a decrease of ≥1 point in the GCS score, or death within 24 h. Receiver operating characteristic curve analyses were used to assess the predictive performance of different definitions of END for death or major disability (modified Rankin scale scores: 3-6) and all-cause mortality.

Results: Among the 4,434 AIS patients, END ranged from 7.9% to 23.0% depending on definition, with the highest frequency for "any END." The discriminative ability of any END was superior to mild END_NIHSS and mild END_GCS for predicting 90-day death or major disability (area under the curve [AUC] 0.666 vs. 0.638 and 0.616; p < 0.001) and all-cause mortality (AUC 0.722 vs. 0.692 and 0.720; p = 0.001). Compared to patients without any END, those with any END had higher odds of 90-day death or major disability (odds ratio [OR]: 7.04, 95% confidence interval [CI]: 5.87-8.44) and all-cause mortality (OR: 6.27, 95% CI: 4.87-8.07).

Conclusions: In thrombolysis-eligible AIS patients, a broad definition of END identifies more patients with underlying acute neurological deterioration and demonstrated the strongest discriminative ability for 90-day outcomes.

The article "Relation between Cerebral Small Vessel Function at 7T MRI and Small Vessel Disease Burden in a General Aging Population" [Cerebrovasc Dis. 2025; https://doi.org/10.1159/000549411] by Pham et al. was published with the wrong open access license. The correct license of the article is CC-BY.The original article has been corrected.