Intracranial atherosclerosis

Feasibility of emergent single-step intracranial self-expanding stent deployment using over-the-wire coronary balloons in intracranial atherosclerosis-related large vessel occlusion thrombectomy

BACKGROUND

The currently US Food and Drug Administration approved intracranial stent delivery system involves a multistep deployment process that requires the use of an exchange length microwire (ELW). In this study, we describe a single-step approach to deploy the Neuroform Atlas stent without the need for ELW or lesion re-access, using the MINI TREK II over-the-wire (OTW) semi-compliant coronary balloon.

METHODS

We performed a retrospective review of prospectively maintained mechanical thrombectomy databases from two comprehensive stroke centers. The study included consecutive large vessel occlusion (LVO) stroke patients who underwent single-step angioplasty with the MINI TREK II OTW balloon followed by deployment of the Neuroform Atlas intracranial stent, without the use of an ELW.

RESULTS

A total of 12 patients met the inclusion criteria. Among them, the median age was 67 years (IQR: 58-73) and 50% were female. Most patients had middle cerebral artery (MCA) M1 occlusion (75%). One-third of the patients received intravenous thrombolysis. All patients achieved successful reperfusion (modified Treatment in Cerebral Ischemia (mTICI) 2b/3) with a median of two passes. The median National Institutes of Health Stroke Scale (NIHSS) score decreased from 14 (IQR: 10-19) at baseline to 4 (IQR: 1-9) at discharge, and the median modified Rankin Scale (mRS) score was 1 (IQR: 1-4) at discharge and 3 (IQR: 2-4) at 90 days. None of the patients in this series experienced symptomatic intracranial hemorrhage, though two patients (16.7%) were dead at 90 days but there was no procedural-related mortality.

CONCLUSIONS

This preliminary experience demonstrates the technical feasibility and success of single-step deployment of the Neuroform Atlas stent following angioplasty with the MINI TREK II OTW balloon, without the need for an ELW or lesion re-access. Larger prospective studies with extended clinical follow-up are needed to validate these findings.

Hypertension in atherosclerotic cardiovascular disease: insights into epidemiology, management strategies, and outcomes

PURPOSE OF REVIEW

To provide a comprehensive review of hypertension among patients with atherosclerotic vascular disease. Although there is significant alignment in treatment goals and strategies, blood pressure targets and therapies differ among atherosclerosis in varying vascular territories. Hypertension is a prominent risk factor for the development and amplification of atherosclerosis, as well as the cause of significant downstream morbidity and mortality.

RECENT FINDINGS

Hypertension is the greatest contributor to population attributable cardiovascular risk. Hypertension accelerates the development of atherosclerotic cardiovascular disease (ASCVD), and treatment of hypertension is a central tenet to managing ASCVD. Patients with ASCVD often merit a multidisciplinary approach, require multiple specialists and medications, and may suffer from additional consequences of therapy due to multimorbidity. Significant arterial stenoses may lead to unintended consequences of antihypertensive therapy. Further, there have been recent advances in the interventional management of hypertension, including techniques like renal denervation.

SUMMARY

In recent years, there have been significant changes in management guidelines of hypertension and peripheral arterial disease, new evidence in coronary artery disease, and simultaneously there's been an evolution in interventional management of hypertension, such as renal denervation. We provide an update on hypertension treatment in atherosclerotic disease among different vascular beds.

Effect of atherogenic index of plasma and triglyceride-glucose index on early neurological deterioration of patients with large artery atherosclerotic ischemic stroke

BACKGROUND

Stroke due to large artery atherosclerosis (LAA-stroke) has a poor early prognosis despite appropriate medical treatment. Recently, various parameters reflecting pathological conditions such as insulin resistance or atherogenic dyslipidemia have been proposed using triglyceride (TG) and other biomarkers. In this study, we evaluated the association between TG andTG-related parameters and early neurological deterioration (END) in patients with acute LAA stroke.

METHODS

We evaluated consecutive patients with acute LAA-stroke between January 2010 and December 2020. TG-related parameters were calculated using the following formulas: the atherogenic index of plasma (AIP) = log10 (TG level/high-density lipoprotein level) and TG-glucose (TyG) index = Ln (TG level x glucose level/2). END was defined as an increase of ≥ 2 in the total National Institutes of Health Stroke Scale (NIHSS) score or ≥ 1 in the motor NIHSS score within the first 72 h of admission.

RESULTS

Six hundred and forty patients with acute LAA-stroke were evaluated. In multivariable analyses, AIP (adjusted odds ratio [aOR]: 1.93, 95% confidence interval: 1.32-2.82) was closely associated with END after adjustment for confounders. The TyG index (aOR: 2.22, 95% confidence interval: 1.51-3.27) also showed close association with END. The AIP and TyG index showed significant differences between the END and no END groups only in patients with LAA-stroke caused by intracranial atherosclerosis. In addition, AIP and TyG index were closely related to END only in patients with LAA-stroke caused by artery-to-artery embolism and branch atheromatous disease mechanisms.

CONCLUSIONS

We found that TG and TG-related parameters were associated with the occurrence of END in patients with acute LAA-stroke. This association appeared differently depending on the location or mechanism of the relevant vessel that caused LAA-stroke.

Association between basilar artery stenosis features, vertebral artery stenosis and perforator stroke after stenting

Background and PurposeWe investigated the relationship between basilar artery (BA) atherosclerotic stenosis features and vertebral artery (VA) stenosis and explored whether BA stenosis features are associated with perforator stroke after stenting.MethodsPatients with BA stenosis who underwent HRMRI and DSA were recruited. Patients were divided into proximal BA stenosis and middle-or-distal BA stenosis groups, and then subgroup analyses were performed based on whether they had VA stenosis. BA plaque features were evaluated by HRMRI. Artery stenosis was measured by DSA. The incidence of perforator stroke after BA stenting was recorded, and the potential association between BA stenosis features and perforator stroke was analyzed.ResultsOne hundred and seventy-four patients were consecutively enrolled. Patients with proximal BA stenosis had a higher proportion of severe stenosis than those with middle-or-distal BA stenosis (P = 0.027). In the subgroup analysis, this difference mainly existed in patients complicated with VA stenosis (P = 0.023). Patients with proximal BA stenosis had a higher proportion of strong plaque enhancement than those with middle-or-distal BA stenosis (P < 0.001), especially in those with vertebrobasilar junction (VBJ) stenosis (P < 0.001). Perforator stroke after BA stenting occurred in five patients, of whom four had lateral wall BA plaques, four had plaque enhancement and four had proximal BA stenosis.ConclusionPatients with proximal BA stenosis had a higher proportion of severe stenosis and strong plaque enhancement, particularly in patients complicated with VA stenosis and VBJ stenosis. Perforator stroke after BA stenting may be related to distribution, burden and characteristics of BA lesions.

Investigating the Potential Therapeutic Targeting of the JAK-STAT Pathway in Cerebrovascular Diseases: Opportunities and Challenges

Cerebrovascular disease (CVD) is a significant neurological condition resulting from pathological changes in the brain's blood supply and is currently the leading cause of death and disability worldwide. The progression of CVD is closely associated with endothelial damage, plaque formation, and thrombosis, driven by long-term alterations in vascular endothelial cells, smooth muscle cells, microglia, and other immune-inflammatory cells. Among the key molecular pathways involved, the Janus kinase/signal transducer and activator of transcription (JAK-STAT) signaling pathway plays a central role. Dysregulation of the JAK-STAT pathway is implicated in the pathogenesis of CVD by influencing the aforementioned cell types and associated pathological processes. Importantly, the role of the JAK-STAT pathway varies across different types of CVD and throughout different stages of disease progression (e.g., pre-morbid, acute, and chronic phases). This review examines the composition, activation, and regulation of the JAK-STAT pathway and summarizes recent findings on its involvement in CVD. We discuss the distinct roles of JAK-STAT signaling in various CVD conditions, the potential reasons for these differences, and explore the clinical translational prospects and technical challenges of targeting the JAK-STAT pathway for therapeutic intervention in CVD.

CTP-defined collaterals is a better predictor of intracranial atherosclerotic stenosis-related large-vessel occlusion than multiphase CTA-defined collaterals

The optimal neuroimaging modalities for differentiating intracranial atherosclerotic stenosis-related large vessel occlusion (ICAS-LVO) from embolism related LVO remain uncertain. This study aimed to address this question by directly comparing collateral circulation using either baseline CT perfusion (CTP) or multiphase CT angiogram (mCTA) to define collaterals. We retrospectively analyzed consecutive patients with acute large vessel occlusion from October 2021 to December 2023. All patients underwent CTP before endovascular therapy, and mCTA was reconstructed from CTP data. In-situ ICAS-LVO was confirmed by a neuro-interventional radiologist. Favorable collateral circulation was defined as a collateral index <0.4 on CTP or a collateral score ≥3 on mCTA. Of 377 patients, 72 (19%) had ICAS-LVO. Patients with only a collateral score ≥3 did not show significantly higher odds of ICAS-LVO (P = 0.681). In contrast, those with a collateral index <0.4 but not favorable mCTA collateral had higher odds of ICAS-LVO (OR2.69, 95%CI [1.07-7.01], P = 0.037). Subgroup analysis showed that a collateral grading scale ≥3 may not predict ICAS-LVO within 6 hours, whereas CTP's predictive performance remained consistently strong in both early and late windows. CTP defined favorable collaterals of collateral index <0.4 demonstrate greater predictive value for ICAS-LVO compared to mCTA, especially within an early time window.

Comparison of safety and efficacy of different endovascular treatments for symptomatic intracranial atherosclerotic stenosis: results from a single center

Background

Symptomatic intracranial atherosclerotic stenosis (sICAS) is one of the common causes of ischemic stroke. However, the treatment of sICAS has remained a challenge in the past with unfavorable findings. This study aimed to evaluate the effectiveness and safety of different endovascular treatment methods for sICAS.

Methods

The study involved 154 patients with sICAS who received endovascular treatment at Qingdao University Hospital between January 2021 and October 2023. Based on the characteristics of the lesions, three different types of treatments were performed: bare metal stent group (BMS group), drug-coated balloon group (DCB group), and drug-eluting stent group (DES group). The primary endpoints included the incidence of in-stent restenosis (ISR) in the 6-month, periprocedural complications, the rate of stroke recurrence in the area of the stented artery during the follow-up period, and modified Rankin score (mRS) at discharge, at 1-month, at 3-month, at 6-month of patients after stenting.

Results

The incidence of perioperative complications did not differ significantly between groups (11.3% in the BMS group, 8.0% in the DCB group, and 6.1% in the DES group, p = 0.776). All patients (154/154) had successful reperfusion after endovascular treatment. The incidence of stroke during follow-up was 4.5% (7/154), with 5 (7.0%) patients in the BMS group, 1 (2.0%) patient in the DCB group, and 1 (3.0%) patient in the DES group. The restenosis rate in the BMS group [35.2% (25/71)] tended to be higher than that in the DCB group [6.0% (3/50)] and DES group [9.1% (3/33)]. In multivariate logistic regression analysis, endovascular treatment strategy and vessel distribution were significant independent risk factors for ISR within 6 months (p < 0.05).

Conclusion

Adverse events and success rates following stent implantation are comparable across therapy groups in individuals with sICAS. When compared to BMS, DES, and DCB reduce the risk of ISR, with the advantages of the DCB appearing to be greater for some high-risk patients with ICAS.

Ethnicity as a Risk Factor for Early Neurological Deterioration: A Post Hoc Analysis of the Secondary Prevention of Small Subcortical Strokes Trial

OBJECTIVES

Nearly 25% of those with a small vessel stroke will develop early neurological deterioration (END). The objectives of this study were to identify clinical risk factors for small vessel stroke-related END and its associated impact on functional outcomes in an ethnically diverse data set.

METHODS

We performed a post hoc analysis of the "Secondary Prevention of Small Subcortical Strokes" trial. The primary outcome was END defined as progressive or stuttering stroke-related neurological symptoms. Standard descriptive and inferential statistical methods were used for analysis. Functional outcomes are reported by modified Rankin Scale score and analyzed by the Wilcoxon signed-rank test.

RESULTS

In all, 69 participants met the inclusion criteria; 21 (30%) had END. Of the cohort, Spanish, Hispanic, or Latino ethnicity (grouping per trial definition) most frequently developed END [11 (52.4%) vs 4 (8.3%), P < 0.001] with a higher adjusted likelihood of END (odds ratio: 14.1, 95% CI: 2.57-76.7, P = 0.002). Black or African-American race less commonly had END [3 (14.3%) vs 21 (43.8%), P = 0.03] but lost significance after adjustment (odds ratio: 1.46, 95% CI: 0.26-8.17, P = 0.67) due to powering. END was associated with a higher mean modified Rankin Scale (2.06 ± 0.94 vs 1.17 ± 0.79, P = 0.006) but did not differ in the shift analysis.

CONCLUSIONS

We found that Spanish, Hispanic, or Latino ethnicity was the most consistent risk factor for END though it was without meaningful functional outcome differences.

Association of Subclavian Steal Phenomenon with Prevalence of Contralateral Vertebral Artery Atherosclerotic Stenosis: A Hospital-Based Cohort Study

AIMS

It is uncertain if there is a connection between subclavian steal phenomenon (SSP) and atherosclerotic stenosis in the opposite vertebral artery (VA). We aimed to explore the association between SSP and the incidence of contralateral vertebral artery stenosis (VAS) in vivo.

METHODS

In this prospective registry study, we included patients diagnosed with ＞50% stenosis of proximal subclavian artery (SA) or innominate artery (INA) by digital subtraction angiography (DSA) from our comprehensive stroke center between 2011 and 2022. VAS and SSP was diagnosed by DSA in the resting state. Propensity score matching (PSM) was conducted among all participants and subgroups with a 1:1 ratio according to the presence of SSP. We further conducted sensitivity analysis by dividing all participants into subgroups according to the degree of stenosis and type of SSP. Binomial logistic regression analysis was applied to investigate the association of SSP with contralateral VAS.

RESULTS

A total of 774 patients were included in this study and 309 (39.9%) were found with SSP. After PSM, presence of SSP was associated with lower prevalence of contralateral VAS among all participants (OR 0.45; 95% CI 0.31-0.65; p＜0.001). In subgroup analysis, the association was respectively found within left subclavian (LSA) stenosis group (OR 0.43; 95% CI 0.29-0.65; P＜0.001) and right subclavian artery (RSA) / INA stenosis group (OR 0.36; 95% CI 0.19-0.69; P=0.002).

CONCLUSIONS

SSP is associated with lower prevalence of contralateral VAS.

Clinical implications of haemodynamics in symptomatic intracranial atherosclerotic stenosis by computational fluid dynamics modelling: a systematic review

BACKGROUND

Recently, computational fluid dynamics (CFD) has been used to simulate blood flow of symptomatic intracranial atherosclerotic stenosis (sICAS) and investigate the clinical implications of its haemodynamic features, which were systematically reviewed in this study.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology statements, we searched PubMed and Embase up to March 2024 and screened for articles reporting clinical implications of haemodynamic parameters in sICAS derived from CFD models.

RESULTS

19 articles met the inclusion criteria, all studies recruiting patients from China. Most studies used CT angiography (CTA) as the source image for vessel segmentation, and generic boundary conditions, rigid vessel wall and Newtonian fluid assumptions for CFD modelling, in patients with 50%-99% sICAS. Pressure and wall shear stress (WSS) were quantified in almost all studies, and the translesional changes in pressure and WSS were usually quantified with a poststenotic to prestenotic pressure ratio (PR) and stenotic-throat to prestenotic WSS ratio (WSSR). Lower PR was associated with more severe stenosis, better leptomeningeal collaterals, prolonged perfusion time and internal borderzone infarcts. Higher WSSR and other WSS measures were associated with positive vessel wall remodelling, regression of luminal stenosis and artery-to-artery embolism. Lower PR and higher WSSR were both associated with the presence and severity of cerebral small vessel disease. Moreover, translesional PR and WSSR were promising predictors for stroke recurrence in medically treated patients with sICAS and outcomes after acute reperfusion therapy, which also provided indicators to assess the effects of stenting treatment on focal haemodynamics.

CONCLUSIONS

CFD is a promising tool in investigating the pathophysiology of ICAS and in risk stratification of patients with sICAS. Future studies are warranted for standardisation of the modelling methods and validation of the simulation results in sICAS, for its wider applications in clinical research and practice.

Hypertension may associate with cerebral small vessel disease and infarcts through the pathway of intracranial atherosclerosis

Hypertension, a major modifiable risk factor for cardiovascular diseases, is linked to late-life neurocognitive disorders such as vascular dementia and Alzheimer's disease (AD). This study explores the associations between hypertension, intracranial atherosclerotic disease (ICAD), cerebral small vessel disease (cSVD), and Alzheimer's disease neuropathologic change (ADNC) in a large community-based autopsy study. This cross-sectional study used data from the Biobank for Aging Studies of the University of São Paulo Medical School. Sociodemographic and clinical information was gathered from a reliable next-of-kin informant. Neurofibrillary tangles, neuritic plaques, lacunar infarcts, hyaline arteriolosclerosis, and cerebral amyloid angiopathy were evaluated. Causal mediation analyses with natural effect models were performed to examine indirect associations of hypertension with cerebrovascular pathologies and ADNC through morphometric measurements of intracranial artery lumen obstruction. Hypertensive participants (n = 354) presented a higher rate of stenosed arteries (obstruction ≥ 50 %), critically stenosed arteries (obstruction ≥ 70 %), and more severe ICAD, shown by higher maximum and mean obstruction indexes compared to nonhypertensive participants (n = 166). These measurements of atherosclerosis were associated with neurofibrillary tangles and cSVD lesions. Hypertension was indirectly associated with hyaline arteriolosclerosis and lacunar infarcts through the pathway of ICAD. Presenting hypertension indirectly increased the odds of displaying hyaline arteriolosclerosis by 26 % (95 % CI: 1.08, 1.45, p = 0.002) and lacunar infarcts by 17 % (95 % CI: 1.01, 1.35, p = 0.029). Cognitive and APOE ε4 carrier status did not alter the investigated associations. In this community sample, hypertension was indirectly associated with cSVD through ICAD.

Age-Related Association Between Circulating Inflammatory Indicators and Plaque Enhancement on High-Resolution Magnetic Resonance Imaging in Patients with Intracranial Atherosclerotic Stenosis

Background

Plaque enhancement is a non-specific marker of local inflammatory response, which may offer additional insights together with circulating inflammatory markers. Few studies have analyzed the association between intracranial atherosclerotic stenosis (ICAS) plaque enhancement and circulating inflammatory markers. Given the age-related variability in the progression of ICAS, this study aims to explore the association between the two across different age groups.

Methods

This retrospective study recruited 120 patients with ICAS-related ischemic events who had undergone high-resolution magnetic resonance imaging. Plaque enhancement index at the most stenosed site of the culprit vessel was calculated. Levels of circulating inflammatory indicators, including high-sensitivity C-reactive protein (hsCRP), lymphocyte-to-white blood cell ratio (LWR), systemic immune inflammation index (SII), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and neutrophil-to-lymphocyte ratio (NLR), were detected. General linear regression models were established to analyze the association between ICAS plaque enhancement index and circulating inflammatory indicators.

Results

In this study, hsCRP, but not other circulating inflammatory indicators, had a significant positive association with ICAS plaque enhancement index (β=0.219, 95% CI [0.036, 0.349], P=0.02). After multivariate adjustment, there was still a marginal correlation between hsCRP and the enhancement index (β=0.220, 95% CI [0.025, 0.362], P=0.05). The association was particularly significant in patients <60 years rather than those ≥60 years. For participants <60 years, hsCRP had the highest contribution to plaque enhancement interpretation.

Conclusion

ICAS plaque enhancement index was positively associated with hsCRP, particularly in participants aged <60 years. This may be helpful for understanding the significance of the enhancement index in clinical practice.

Drug-eluting stents versus bare-metal stents for intracranial atherosclerotic stenosis: a systematic review and meta-analysis

BACKGROUND

In-stent restenosis (ISR) is the primary cause of stroke recurrence after intracranial stenting. Drug-eluting stents (DES) have recently shown great potential for reducing restenosis. This systematic review aimed to evaluate the efficacy and safety of DES compared with bare-metal stents (BMS) for intracranial atherosclerotic stenosis (ICAS).

METHODS

We systematically searched the MEDLINE (Ovid), Cochrane Central Register of Controlled Trials, Embase (Ovid) and Web of Science databases for studies published from inception through 10 October 2023, comparing DES with BMS for the treatment of symptomatic severe ICAS. We included randomised controlled trials and cohort studies that compared DES and BMS in adult patients with ICAS. The primary outcomes were stroke or death within 30 days and ISR within 1 year. Secondary outcomes included procedure-related adverse events, technical success, functional evaluation findings, restenosis degree and other safety endpoints within 1 year. Subgroup analyses were conducted across different study types.

RESULTS

A total of 510 participants fulfilling all eligibility criteria were enrolled in four studies. DES had a similar rate of any stroke or death within 1 month (3 studies, 476 participants: risk ratio (RR): 1.00; 95% CI: 0.46 to 1.11; p=1.00; I2=31%) to that of the BMS group and had a significantly lower rate of ISR within 1 year (4 studies, 429 participants: RR: 0.23; 95% CI: 0.13 to 0.41; p<0.001; I2=0%). Moreover, a lower rate of stroke recurrence within 1 year was reported (3 studies, 436 participants: RR: 0.46; 95% CI: 0.24 to 0.88; p=0.02; I2=52%) in the DES group.

CONCLUSION

This review demonstrates that the application of DES for intracranial stenting is safe and can significantly reduce the rates of ISR and recurrent ischaemic events. Further research is required to validate these results.

PROSPERO REGISTRATION NUMBER

CRD42022338178.

Roles of Nontraditional Lipid Parameters for Predicting Restenosis in Patients with Intracranial Atherosclerotic Stenosis After Endovascular Treatment

PURPOSE

Nontraditional lipid parameters are associated with intracranial atherosclerotic stenosis (ICAS) progression. This study aimed to investigate the association of nontraditional lipid parameters with the risk of restenosis in patients with ICAS after endovascular treatment (EVT).

METHODS

This study retrospectively enrolled consecutive patients with symptomatic ICAS after successful EVT followed by at least 3 months of angiography. Participants were divided into restenosis or non-restenosis groups based on the angiographic follow-up results. The nontraditional lipid parameters were calculated from conventional lipid parameters. The COX regression models and restricted cubic splines (RCS) were used to explore the association between nontraditional lipid parameters and restenosis.

RESULTS

This study recruited 222 cases with 224 lesions eligible for our study, of which 56 (25%) had restenosis. Compared with the non-restenosis group, patients in the restenosis group had higher levels of the atherogenic index of plasma (AIP) (0.211, interquartile range, IQR, 0.065-0.404 vs. 0.083, IQR, -0.052-0.265, P = 0.001), remnant cholesterol (RC) (0.55, IQR, 0.33-0.77 vs. 0.30, IQR, 0.18-0.49, P < 0.001) and Castelli's index‑I (CRI-I) (4.13, IQR, 3.39-5.34 vs. 3.74, IQR, 2.94-4.81, P = 0.030). In the multivariable COX regression analysis, a 0.1 unit increase of AIP was an independent risk factor for restenosis (hazard ratio, HR = 1.20, 95% confidence interval, CI 1.05-1.35, P = 0.005) whereas such an association was not observed for RC (HR = 1.01, 95% CI 0.90-1.15, P = 0.835). The restricted cubic spline (RCS) plot revealed a linear relationship between AIP and restenosis (P for nonlinear = 0.835) but a nonlinear relationship for RC (P for nonlinear = 0.012). Patients were stratified according to tertiles (T) of AIP and RC and the risk of restenosis increased in T3 compared to T1 (HR = 3.21, 95% CI 1.35-7.62, P = 0.008 and HR = 2.99, 95% CI 1.11-8.03, P = 0.030, respectively). Furthermore, this association remained stable within each LDL‑C level subgroup.

CONCLUSION

The AIP and RC were positively and independently associated with restenosis in patients with ICAS after EVT.

European Stroke Organisation and European Society for Minimally Invasive Neurological Therapy guideline on acute management of basilar artery occlusion

The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology. Although BAO accounts for only 1%-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five ESMINT) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements. First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (albeit in small numbers) in IVT trials. Non-randomised studies of IVT-only cohorts showed high proportion of favourable outcomes. Expert Consensus suggests using IVT up to 24 h unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared to BMT alone within 6 and 6-24 h from last seen well. In both time windows, we observed a different effect of treatment depending on (a) the region where the patients were treated (Europe vs. Asia), (b) on the proportion of IVT in the BMT arm, and (c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with NIHSS below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT + BMT over BMT alone (i.e. based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT + BMT over BMT alone in proximal and middle locations of BAO compared to distal location. While recommendations for patients without extensive early ischaemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischaemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 h after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).

Impact of Covert Brain Infarction Following Coronary Angiography on Coronary Artery Bypass Surgery Outcomes

OBJECTIVE

To determine the association between preoperative covert brain infarction following coronary angiography (CAG) and major adverse cardiac and cerebrovascular events (MACCEs) after coronary artery bypass grafting (CABG).

DESIGN

A cohort study was conducted between January 2006 and December 2019, with the follow-up period concluding at either 5 years after surgery, the date of death, or April 27, 2023.

SETTING

A single tertiary center in Korea.

PARTICIPANTS

Patients who underwent preoperative CAG and subsequent brain magnetic resonance imaging (MRI) before elective CABG.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the incidence of MACCEs within 30 days of CABG. MACCEs included operative death (all-cause death within 30 days of surgery or before discharge), myocardial infarction, mechanical circulatory support, circulatory arrest, and stroke. Secondary outcomes included each component of MACCEs and all-cause mortality at 5 years after surgery. Of the 2,476 study patients (median [interquartile range] age: 65 [58-71] years; 24.7% were female), 212 (8.6%) had covert cerebral infarction on brain MRI after CAG but before CABG, and 353 (14.3%) patients experienced MACCEs after CABG. After performing 1:4 propensity-score matching, 1,057 patients were included in the final outcome analysis (212 with covert brain infarction and 845 without). The incidence of MACCEs within 30 days was not significantly different between patients with covert brain infarction and those without (15.1% [32/212] v 15.6% [132/845]; risk difference: -0.5, 95% confidence interval: -5.6 to 4.4; risk ratio: 0.97, 95% confidence interval: 0.66 to 1.32, p = 0.85). There were also no significant differences in each component of MACCEs within 30 days. There was no significant difference between the two groups regarding all-cause mortality at 5 years (18.7% v 17.0%, respectively, p for stratified log-rank test = 0.33).

CONCLUSIONS

Among patients undergoing elective CABG, there was no significant association between covert brain infarction following CAG and the occurrence of MACCEs within 30 days or long-term mortality after CABG.

First-in-human trial of a self-expandable, temporary dilation system for intracranial atherosclerotic disease in patients presenting with acute ischemic stroke

BACKGROUND

Intracranial atherosclerotic disease (ICAD) significantly contributes to ischemic stroke, especially among Asian populations. Large vessel occlusion (LVO) due to underlying ICAD accounts for 15-35% of acute ischemic stroke cases requiring endovascular therapy. However, the successful recanalization rate of ICAD-related LVO remains lower. The TG dilator is a self-expandable device, temporarily dilating ICAD-related blocked blood vessels.

OBJECTIVE

To demonstrate TG dilator safety and efficacy for ICAD-related acute ischemic stroke.

METHODS

This was a single-arm, open-label, non-randomized, prospective, multicenter, and investigator-initiated trial that involved patients undergoing TG dilator application for acute ischemic stroke caused by ICAD-related LVO or severe stenosis.

RESULTS

We enrolled 10 patients in this trial between November 2022 and April 2023. The median (IQR) age was 68 (59.3-75.3) years. Before using the dilator, seven patients received stent retriever treatment. All 10 patients were prescribed a loading dose of aspirin with prasugrel. The median application time was 10 (10-12) min. At the end of the procedure, we achieved significant recanalization immediately in all patients. The stenosis/occlusion decreased from 100% (100-100) to 68% (56.3-75.3). No patient experienced recurrent ischemic stroke or reocclusion within 90 days. We achieved a modified Rankin scale score of 0-2 in 8 patients by day 90. We detected no cases of intracranial hemorrhage, equipment failure, distal embolism, vasospasm, dissection, or perforation requiring intervention.

CONCLUSIONS

Acute revascularization using the TG dilator on patients with ICAD-related LVO or severe stenosis did not cause any significant adverse event, and consistently improved blood flow at 90 days.

Trendelenburg position for acute anterior circulation ischaemic stroke with large artery atherosclerosis aetiology (HOPES 3): rationale and design

RATIONALE

The effect of the head position as a non-pharmacological therapy on acute ischaemic stroke (AIS) remains inconclusive. Our recent Head dOwn-Position for acutE moderate ischaemic Stroke with large artery atherosclerosis (HOPES 2) suggested the safety, feasibility and potential benefit of the head-down position (HDP) in AIS.

AIM

To investigate the benefit of HDP in acute moderate ischaemic stroke patients with large artery atherosclerosis (LAA).

SAMPLE SIZE ESTIMATES

Based on a two-sided 0.05 level of significance, 600 patients are expected to yield the superiority hypothesis with 80% power, stratified by age, sex, history of diabetes, baseline systolic blood pressure, location of index vessel, National Institutes of Health Stroke Scale Score at randomisation, onset to randomisation time, progression to moderate neurological deficit due to early neurological deterioration and degree of responsible vessel stenosis.

DESIGN

Head dOwn-Position for acutE moderate ischaemic Stroke with large artery atherosclerosis(HOPES 3) is a prospective, randomised, open-label, blinded endpoint and multicentre study. Eligible patients who had an ischaemic stroke will be randomly assigned (1:1) into the HDP group receiving -20° Trendelenburg plus standard medical care in compliance with national guidelines, or control group only receiving standard medical care in compliance with national guidelines.

OUTCOME

The primary outcome is favourable functional outcome, defined as modified Rankin Scale 0-2 at 90 days. Safety outcomes are HDP-related adverse events. All outcomes will have blinded assessment and will be analysed on the intention-to-treat basis.

CONCLUSIONS

The results of HOPES 3 will provide evidence for the effect of HDP in acute moderate ischaemic stroke patients with LAA within 24 hours of onset or in patients with progression from mild neurological deficit within 24 hours.

TRIAL REGISTRATION NUMBER

NCT06010641.

Efficacy and safety of drug-eluting stents versus bare-metal stents in symptomatic intracranial and vertebral artery stenosis: a meta-analysis

Objectives

This study aims to present the first comprehensive meta-analysis assessing the effectiveness and safety of drug-eluting stents (DES) versus bare-metal stents (BMS) in treating intracranial and vertebral artery stenosis.

Methods

A comprehensive examination was undertaken to compare the effectiveness and safety of DES and BMS in individuals experiencing symptomatic stenosis in the intracranial and vertebral arteries through an in-depth analysis of clinical research. We conducted an extensive search across multiple databases including PubMed, Embase, Web of Science, and the Cochrane Library up to September 2024. The emphasis of our investigation was on various outcomes including rates of in-stent restenosis, symptomatic occurrences of in-stent restenosis, incidence of stroke, procedural success, mortality rates, complications associated with the procedure, and any adverse events.

Results

Our analysis included 12 studies with a total of 1,243 patients (562 in the DES group and 681 in the BMS group). The findings demonstrated a significantly lower rate of in-stent restenosis in the DES group for both intracranial [odds ratio (OR): 0.23; 95% confidence interval (CI): 0.13 to 0.41; p < 0.00001] and vertebral artery stenosis (OR: 0.38; 95% CI: 0.20 to 0.72; p = 0.003) compared to the BMS group. Additionally, the DES group showed a significantly reduced rate of postoperative strokes in vertebral artery stenosis cases (OR: 0.38; 95% CI: 0.16 to 0.90; p = 0.03), with no significant differences noted in the intracranial artery stenosis comparison (OR: 0.63; 95% CI: 0.20 to 1.95; p = 0.42). The study also revealed no significant disparities in symptomatic in-stent restenosis, procedural success, mortality, adverse effects, and perioperative complications between the two groups across the conditions studied.

Conclusion

The comparison indicates that DES significantly reduces the risk of in-stent restenosis and postoperative strokes in patients with vertebral artery stenosis, compared to BMS. For both intracranial and vertebral artery stenosis, DES and BMS exhibit comparable safety profiles.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=439967.

The Association Between the Fibrinogen-to-Albumin Ratio and Intracranial Arterial Stenosis in Patients With Acute Ischemic Stroke

The association between the fibrinogen-to-albumin ratio (FAR) and intracranial arterial stenosis (ICAS) in patients with acute ischemic stroke (AIS) has not yet been reported. In this large-scale investigation, 7894 AIS patients with ICAS-evaluation imaging data from the Third China National Stroke Registry were included. ICAS was defined as >50% stenosis of the intracranial arteries. We dichotomized the degree of ICAS into stenosis and occlusion. The number of ICAS lesions was the total number of intracranial stenotic arteries. Fibrinogen and albumin levels were assessed in the central laboratory of Beijing Tiantan Hospital. Univariate and multivariate analyses with logistic regression were used to determine the association between the FAR quartiles and ICAS. A total of 3900 (49.66%) patients had ICAS. Compared with those of the lowest FAR quartile, the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of the highest FAR quartile were 1.26 (1.10-1.44), 1.15 (.99-1.33), and 1.19 (1.01-1.39) for ICAS, symptomatic ICAS, and asymptomatic ICAS, respectively. An elevated FAR was also associated with occlusion (adjusted OR: 1.28, 95% CI: 1.10-1.49) and lesion number ≥2 (adjusted OR: 1.25, 95% CI: 1.07-1.45).

Rare RNF213 variants is related to early-onset intracranial atherosclerosis: A Chinese community-based study

BACKGROUND

The relationship between rare variants in Ring finger protein 213 (RNF213) and intracranial atherosclerosis (ICAS) remained unelucidated. Using whole-exome sequencing (WES) and high-resolution magnetic resonance imaging (HR-MRI), this study aimed at investigating the association between rare RNF213 variants and ICAS within a Chinese community-dwelling population.

METHODS

The present study included 821 participants from Shunyi cohort. Genetic data of rare RNF213 variants were acquired by WES and were categorized by functional domains. Intracranial and extracranial atherosclerosis were assessed by brain HR-MRI and carotid ultrasound, respectively. Logistic regression and generalized linear regression were applied to evaluate the effects of rare RNF213 variants on atherosclerosis. Stratification by age were conducted with 50 years old set as the cutoff value.

RESULTS

Ninety-five participants were identified as carriers of rare RNF213 variants. Carotid plaques were observed in 367 (44.7 %) participants, while ICAS was identified in 306 (37.3 %). Rare variants of RNF213 was not associated with ECAS. Employing HR-MRI, both the presence of rare variants (β = 0.150, P = 0.025) and numerical count of variants (β = 0.182, P = 0.003) were significantly correlated with ICAS within the group of age ≤50 years. Both variant existence (β = 0.154, P = 0.014) and variant count (β = 0.188, P = 0.003) were significantly associated with plaques in middle cerebral arteries within younger subgroup, rather than basilar arteries. Furthermore, a significant association was observed between variants that located outside the N-arm domain and ICAS in the younger subgroup (OR = 2.522, P = 0.030). Statistical results remained robust after adjusted for age, gender, and cardiovascular risk factors.

CONCLUSIONS

Rare variants of RNF213 is associated with age-related ICAS in general Chinese population, highlighting the potential role of RNF213 as a genetic contributor to early-onset ICAS.

Simulation analysis of different types of balloon dilatation catheters for the treatment of intracranial arterial stenosis

The application of balloon dilation catheters in the management of intracranial arterial stenosis has been gradually increasing. However, studies on the feasibility and effectiveness of different types of balloons remain relatively scarce. In this study, catheter models of three different materials were designed to simulate balloon crimping,splitting, and dilatation processes. A compliant balloon produces large deformations with poor dilatation and a stress concentration phenomenon. During dilatation, the shear stress generated in the intima and lesion area by the semi-compliant balloon was smaller than that generated by the non-compliant balloon. These results demonstrate the feasibility of using semi-compatible balloons.

Angioplasty and/or stenting following successful mechanical thrombectomy for intracranial atherosclerosis-related emergent large vessel occlusive stroke (ASSET): protocol of a multicentre randomised trial

RATIONALE

The management of residual stenosis after mechanical thrombectomy in patients with intracranial atherosclerotic stenosis-related emerge large vessel occlusive (ICAS-LVO) stroke is still unclear question in clinical practice.

AIM

To demonstrate the design of a clinical trial on emergency balloon angioplasty and/or stenting (BAS) combined with standard medical treatment (SMT) for residual stenosis of ICAS-LVO stroke patients with successful recanalisation.

DESIGN

ASSET is a multicentre, prospective, randomised, open-label, blinded end-point, controlled clinical trial designed (PROBE) by investigators. This trial evaluates the effectiveness and the safety of emergency BAS in combination with SMT compared with SMT alone in ICAS-LVO stroke patients with successful recanalisation (defined as expanded treatment in cerebral ischaemia grade of 2b50-3 and maintained for more than 20 min) and residual stenosis (defined as ≥50%) up to 24 hours after the onset of symptoms or the last known well.

OUTCOME

The primary outcome assessed at 90 (±7) days after randomisation is the incidence of ischaemic stroke in the responsible vessel. Symptomatic intracranial haemorrhage within 24 (±3) hours is the primary safety outcome.

DISCUSSION

The ASSET trial is designed to provide strong evidence on the effectiveness and safety of emergency BAS to treat residual stenosis after successful recanalisation in patients with ICAS-LVO stroke.

TRIAL REGISTRATION NUMBER

ChiCTR2300079069.

Burden of intracranial artery calcification in white patients with ischemic stroke

INTRODUCTION

The diagnostic workup of stroke doesn't identify an underlying cause in two-fifths of ischemic strokes. Intracranial arteriosclerosis is acknowledged as a cause of stroke in Asian and Black populations, but is underappreciated as such in whites. We explored the burden of Intracranial Artery Calcification (IAC), a marker of intracranial arteriosclerosis, as a potential cause of stroke among white patients with recent ischemic stroke or TIA.

PATIENTS AND METHODS

Between December 2005 and October 2010, 943 patients (mean age 63.8 (SD ± 14.0) years, 47.9% female) were recruited, of whom 561 had ischemic stroke and 382 a TIA. CT-angiography was conducted according to stroke analysis protocols. The burden of IAC was quantified on these images, whereafter we assessed the presence of IAC per TOAST etiology underlying the stroke and assessed associations between IAC burden, symptom severity, and short-term functional outcome.

RESULTS

IAC was present in 62.4% of patients. Furthermore, IAC was seen in 84.8% of atherosclerotic strokes, and also in the majority of strokes with an undetermined etiology (58.5%). Additionally, patients with larger IAC burden presented with heavier symptoms (adjusted OR 1.56 (95% CI [1.06-2.29]), but there was no difference in short-term functional outcome (1.14 [0.80-1.61]).

CONCLUSION

IAC is seen in the majority of white ischemic stroke patients, aligning with findings from patient studies in other ethnicities. Furthermore, over half of patients with a stroke of undetermined etiology presented with IAC. Assessing IAC burden may help identify the cause in ischemic stroke of undetermined etiology, and could offer important prognostic information.

Residual inflammatory risk predicts long-term outcomes following stenting for symptomatic intracranial atherosclerotic stenosis

BACKGROUND AND PURPOSE

Residual inflammatory risk (RIR) can predict the unfavourable outcomes in patients with minor ischaemic stroke. However, the impact of preprocedural RIR on long-term outcomes in patients with symptomatic intracranial atherosclerotic stenosis (sICAS) who underwent stenting remains understudied.

METHODS

This retrospective, single-centre cohort study evaluated consecutive patients with severe sICAS who underwent intracranial stenting. Patients were categorised into four groups based on preprocedural high-sensitivity C-reactive protein (hs-CRP) and low-density lipoprotein cholesterol (LDL-C): residual cholesterol inflammatory risk (RCIR, hs-CRP ≥3 mg/L and LDL-C ≥2.6 mmol/L), RIR (hs-CRP ≥3 mg/L and LDL-C <2.6 mmol/L), residual cholesterol risk (RCR, hs-CRP <3 mg/L and LDL-C ≥2.6 mmol/L) and no residual risk (NRR, hs-CRP <3 mg/L and LDL-C <2.6 mmol/L). The long-term clinical outcomes included recurrent ischaemic stroke and death. The long-term imaging outcomes consisted of in-stent restenosis (ISR) and symptomatic ISR (sISR) after stenting.

RESULTS

In this study, 952 patients were included, with 751 (78.9%) being male. Forty-six cases were categorised into the RCIR group, 211 into the RIR group, 107 into the RCR group and 588 into the NRR group. Patients with RCIR (adjusted HR 6.163; 95% CI 2.603 to 14.589; p<0.001) and RIR (adjusted HR 2.205; 95% CI 1.294 to 3.757; p=0.004) had higher risks of recurrent ischaemic stroke than those with NRR during the 54 months of median follow-up time. Patients with RCIR (adjusted HR 3.604; 95% CI 1.431 to 9.072; p=0.007) were more likely to occur ISR, and patients in the RIR group showed a significant increase in the risk of sISR (adjusted HR 2.402; 95% CI 1.078 to 5.351; p=0.032) compared with those in the NRR group with a median follow-up time of 11.9 months.

CONCLUSIONS

In patients with sICAS, preprocedural RIR may predict long-term recurrent ischaemic stroke, ISR and sISR following intracranial stenting.

European Stroke Organisation (ESO) and European Society for Minimally Invasive Neurological Therapy (ESMINT) guideline on acute management of basilar artery occlusion

The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology.Although BAO accounts for only 1-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five representing the European Society of Minimally Invasive Neurological Therapy (ESMINT)) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements.First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (although in small numbers) in IVT trials. Non-randomized studies of IVT-only cohorts showed a high proportion of favorable outcomes. Expert Consensus suggests using IVT up to 24 hours unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared with BMT alone within 6 and 6-24 hours from last seen well. In both time windows, we observed a different effect of treatment depending on a) the region where the patients were treated (Europe vs Asia), b) on the proportion of IVT in the BMT arm, and c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with a National Institutes of Health Stroke Scale (NIHSS) score below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT+BMT over BMT alone (this is based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS score below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT+BMT over BMT alone in proximal and middle locations of BAO compared with distal location. While recommendations for patients without extensive early ischemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 hours after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).

Hypercholesterolemia and the Increased Risk of Vascular Dementia: a Cholesterol Perspective

PURPOSE OF REVIEW

Vascular dementia (VaD) is the second most prevalent type of dementia after Alzheimer's disease.Hypercholesterolemia may increase the risk of dementia, but the association between cholesterol and cognitive function is very complex. From the perspective of peripheral and brain cholesterol, we review the relationship between hypercholesterolemia and increased risk of VaD and how the use of lipid-lowering therapies affects cognition.

RECENT FINDINGS

Epidemiologic studies show since 1980, non-HDL-C levels of individuals has increased rapidly in Asian countries.The study has suggested that vascular risk factors increase the risk of VaD, such as disordered lipid metabolism. Dyslipidemia has been found to interact with chronic cerebral hypoperfusion to promote inflammation resulting in cognitive dysfunction in the brain.Hypercholesterolemia may be a risk factor for VaD. Inflammation could potentially serve as a link between hypercholesterolemia and VaD. Additionally, the potential impact of lipid-lowering therapy on cognitive function is also worth considering. Finding strategies to prevent and treat VaD is critical given the aging of the population to lessen the load on society. Currently, controlling underlying vascular risk factors is considered one of the most effective methods of preventing VaD. Understanding the relationship between abnormal cholesterol levels and VaD, as well as discovering potential serum biomarkers, is important for the early prevention and treatment of VaD.

Bioinspired Self-Adhesive Multifunctional Lubricated Coating for Biomedical Implant Applications

In the realm of clinical applications, the concern surrounding biomedical device-related infections (BDI) is paramount. To mitigate the risk associated with BDI, enhancing surface characteristics such as lubrication and antibacterial efficacy is considered as a strategic approach. This study delineated the synthesis of a multifunctional copolymer, embodying self-adhesive, lubricating, and antibacterial properties, achieved through free radical polymerization and a carbodiimide coupling reaction. The copolymer was adeptly modified on the surface of stainless steel 316L (SS316L) substrates by employing a facile dip-coating technique. Comprehensive characterizations were performed by using an array of analytical techniques including Fourier transform infrared spectroscopy, X-ray photoelectron spectroscopy, optical interferometry, scanning electron microscopy, and atomic force microscopy. Nanoscale tribological assessments revealed a notable reduction in the value of the friction coefficient of the copolymer-coated SS316L substrates compared to bare SS316L samples. The coating demonstrated exceptional resistance to protein adsorption, as evidenced in protein contamination models employing bovine serum albumin and fibrinogen. The bactericidal efficacy of the copolymer-modified surfaces was significantly improved against pathogenic strains such as Staphylococcus aureus and Escherichia coli. Additionally, in vitro evaluations of blood compatibility and cellular compatibility underscored the remarkable anticoagulant performance and biocompatibility. Collectively, these findings indicated that the developed copolymer coating represented a promising candidate, with its facile modification approach, for augmenting lubrication and antifouling properties in the field of biomedical implant applications.

Hemodynamic Impairment of Blood Pressure and Stroke Mechanisms in Symptomatic Intracranial Atherosclerotic Stenosis

BACKGROUND

Hemodynamic impairment of blood pressure may play a crucial role in determining the mechanisms of stroke in symptomatic intracranial atherosclerotic stenosis). We aimed to elucidate this issue and assess the impacts of modifications to blood pressure on hemodynamic impairment.

METHODS

From the Third China National Stroke Registry III, computed fluid dynamics modeling was performed using the Newton-Krylov-Schwarz method in 339 patients with symptomatic intracranial atherosclerotic stenosis during 2015 to 2018. The major exposures were translesional systolic blood pressure (SBP) drop and poststenotic mean arterial pressure (MAP), and the major study outcomes were cortex-involved infarcts and borderzone-involved infarcts, respectively. Multivariate logistic regression models and the bootstrap resampling method were utilized, adjusting for demographics and medical histories.

RESULTS

In all, 184 (54.3%) cortex-involved infarcts and 70 (20.6%) borderzone-involved infarcts were identified. In multivariate logistic model, the upper quartile of SBP drop correlated with increased cortex-involved infarcts (odds ratio, 1.92 [95% CI, 1.03-3.57]; bootstrap analysis odds ratio, 2.07 [95% CI, 1.09-3.93]), and the lower quartile of poststenotic MAP may correlate with increased borderzone-involved infarcts (odds ratio, 2.07 [95% CI, 0.95-4.51]; bootstrap analysis odds ratio, 2.38 [95% CI, 1.04-5.45]). Restricted cubic spline analysis revealed a consistent upward trajectory of the relationship between translesional SBP drop and cortex-involved infarcts, while a downward trajectory between poststenotic MAP and borderzone-involved infarcts. SBP drop correlated with poststenotic MAP negatively (rs=-0.765; P<0.001). In generating hemodynamic impairment, simulating blood pressure modifications suggested that ensuring adequate blood pressure to maintain sufficient poststenotic MAP appears preferable to the reverse approach, due to the prolonged plateau period in the association between the translesional SBP drop and cortex-involved infarcts and the relatively short plateau period characterizing the correlation between poststenotic MAP and borderzone-involved infarcts.

CONCLUSIONS

This research elucidates the role of hemodynamic impairment of blood pressure in symptomatic intracranial atherosclerotic stenosis-related stroke mechanisms, underscoring the necessity to conduct hemodynamic assessments when managing blood pressure in symptomatic intracranial atherosclerotic stenosis.

Colchicine in patients with acute ischaemic stroke or transient ischaemic attack (CHANCE-3): multicentre, double blind, randomised, placebo controlled trial

OBJECTIVES

To assess the efficacy and safety of colchicine versus placebo on reducing the risk of subsequent stroke after high risk non-cardioembolic ischaemic stroke or transient ischaemic attack within the first three months of symptom onset (CHANCE-3).

DESIGN

Multicentre, double blind, randomised, placebo controlled trial.

SETTING

244 hospitals in China between 11 August 2022 and 13 April 2023.

PARTICIPANTS

8343 patients aged 40 years of age or older with a minor-to-moderate ischaemic stroke or transient ischaemic attack and a high sensitivity C-reactive protein ≥2 mg/L were enrolled.

INTERVENTIONS

Patients were randomly assigned 1:1 within 24 h of symptom onset to receive colchicine (0.5 mg twice daily on days 1-3, followed by 0.5 mg daily thereafter) or placebo for 90 days.

MAIN OUTCOME MEASURES

The primary efficacy outcome was any new stroke within 90 days after randomisation. The primary safety outcome was any serious adverse event during the treatment period. All efficacy and safety analyses were by intention to treat.

RESULTS

4176 patients were assigned to the colchicine group and 4167 were assigned to the placebo group. Stroke occurred within 90 days in 264 patients (6.3%) in the colchicine group and 270 patients (6.5%) in the placebo group (hazard ratio 0.98 (95% confidence interval 0.83 to 1.16); P=0.79). Any serious adverse event was observed in 91 (2.2%) patients in the colchicine group and 88 (2.1%) in the placebo group (P=0.83).

CONCLUSIONS

The study did not provide evidence that low-dose colchicine could reduce the risk of subsequent stroke within 90 days as compared with placebo among patients with acute non-cardioembolic minor-to-moderate ischaemic stroke or transient ischaemic attack and a high sensitivity C-reactive protein ≥2 mg/L.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05439356.

Predicting postoperative delirium after percutaneous transluminal angioplasty and stenting in patients with intracranial atherosclerotic stenosis

OBJECTIVE

Known as a major surgical complication, postoperative delirium (POD) has not been well studied in patients with intracranial atherosclerotic stenosis (ICAS). This study aimed to investigate the correlation between perioperative clinical characteristics and the occurrence of POD.

METHODS

Patients' demographic characteristics and perioperative testing data were collected. Binary logistic regression was conducted for assessing related risk factors. A nomogram was developed to predict the occurrence of POD after percutaneous transluminal angioplasty and stenting (PTAS) in patients with ICAS.

RESULTS

The occurrence of POD in this study was 30.67%. Among all the clinical and laboratory characteristics in patients, age (OR = 1.234, 95%CI = 1.004-1.517, p = 0.046), gender (OR = 5.676, 95%CI = 1.028-31.334, p = 0.046), preoperative MMSE scores (OR = 2.298, 95%CI = 1.005-5.259, p = 0.049), the degree of stenosis (OR = 6.294, 95%CI = 1.043-37.974, p = 0.045), operating time (OR = 1.088, 95%CI = 1.023-1.157, p = 0.006), and HbA1c levels (OR = 2.226, 95%CI = 1.199-4.130, p = 0.011) were the independent risk factors.

CONCLUSION

Male patients with advanced-age, lower preoperative MMSE scores, severe stenosis, longer operating time, and higher HbA1c levels are closely related to POD after PTAS. Fully perioperative assessments may play an important role in predicting the occurrence of POD.

Cerebrovascular disease in patients with antiphospholipid antibody syndrome: a transcranial Doppler and magnetic resonance imaging study

Objective

Transcranial Doppler (TCD) and brain MRI may be useful in evaluating patients with APS, helping to stratify the risk of cerebrovascular ischaemic events in this population. This study aimed to assess the frequency of brain MRI abnormalities in patients with primary antiphospholipid syndrome, secondary antiphospholipid syndrome and SLE and correlate to TCD findings.

Methods

The study, conducted over four years at two autoimmune disease referral centres, included 22 primary antiphospholipid syndrome patients, 24 secondary antiphospholipid syndrome patients, 27 SLE patients without APS and 21 healthy controls. All participants underwent TCD to assess cerebral haemodynamics, detect microembolic signals and evaluate right-to-left shunts, followed by brain MRI and magnetic resonance angiography. MRI scans were reviewed for acute microembolism, localized cortical infarctions, border infarctions, lacunar infarctions, ischaemic lesions, white matter hyperintensity, micro and macro haemorrhages and arterial stenosis ≥50% of the cervical carotid artery, by two neuroradiologists blinded to the clinical data.

Results

Brain MRI findings were similar between the groups, except for lacunar infarction, more frequent in patients with secondary antiphospholipid syndrome (P = 0.022). Patients with intracranial stenosis detected by TCD had a higher frequency of territorial infarction (40% vs 7.5%, P = 0.02), lacunar (40% vs 11.3%, P = 0.075) and border zone infarcts (20% vs 1.9%, P = 0.034).

Conclusions

Patients with intracranial stenosis presented a higher frequency of territorial, lacunar and border zone infarcts, suggesting that evaluating the intracranial vasculature should not be neglected in patients with APS and stroke.

Hypertension, Neurodegeneration, and Cognitive Decline

Elevated blood pressure is a well-established risk factor for age-related cognitive decline. Long linked to cognitive impairment on vascular bases, increasing evidence suggests a potential association of hypertension with the neurodegenerative pathology underlying Alzheimer disease. Hypertension is well known to disrupt the structural and functional integrity of the cerebral vasculature. However, the mechanisms by which these alterations lead to brain damage, enhance Alzheimer pathology, and promote cognitive impairment remain to be established. Furthermore, critical questions concerning whether lowering blood pressure by antihypertensive medications prevents cognitive impairment have not been answered. Recent developments in neurovascular biology, brain imaging, and epidemiology, as well as new clinical trials, have provided insights into these critical issues. In particular, clinical and basic findings on the link between neurovascular dysfunction and the pathobiology of neurodegeneration have shed new light on the overlap between vascular and Alzheimer pathology. In this review, we will examine the progress made in the relationship between hypertension and cognitive impairment and, after a critical evaluation of the evidence, attempt to identify remaining knowledge gaps and future research directions that may advance our understanding of one of the leading health challenges of our time.

Self-expanding versus balloon expandable stent for intracranial arterial stenosis: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

There are limited data regarding the comparison of balloon expandable stents (BES) and self-expanding stents (SES) for the treatment of intracranial arterial stenosis.

METHODS

We conducted a systematic review to identify studies that compared SES and BES in patients with symptomatic intracranial arterial stenosis. Data were extracted from relevant studies found through a search of PubMed, Scopus, and Web of Science until from January 1, 2010 to September 28, 2023. Statistical pooling with random-effects meta-analysis was undertaken to compare the rates/severity of postprocedure stenosis, technical success, 30-day stroke and/or death, cumulative clinical endpoints, and restenosis rates.

RESULTS

A total of 20 studies were included. The standardized mean difference (SMD) for postprocedure stenosis (%) was significantly lower (SMD: -0.52, 95% confidence interval [CI]: -0.79 to -0.24, p < .001, 10 studies involving 1515 patients) with BES. The odds for 30-day stroke and/or death were significantly lower (odds ratio [OR] 0.68, 95% CI: 0.50-0.94, p = .019, 15 studies involving 2431 patients), and cumulative clinical endpoints on follow-up were nonsignificantly lower (OR 0.64, 95% CI: 0.30-1.37, p = .250, 10 studies involving 947 patients) with BES. The odds for restenosis during follow-up were significantly lower (OR 0.50, 95% CI: 0.31-0.80, p = .004, 13 studies involving 1115 patients) with BES.

CONCLUSIONS

Compared with SES, BES were associated with lower rates of postprocedure 30-day stroke and/or death with lower rates of restenosis during follow up and the treatment of symptomatic intracranial arterial stenosis.

Outcome of Mechanical Thrombectomy for Acute Basilar Artery Occlusion in Patients with Intracranial Atherosclerotic Disease

INTRODUCTION

Intracranial atherosclerotic disease (ICAD) has been identified as a major cause of acute basilar artery occlusion (BAO).This study compared the characteristics and treatment outcomes in acute BAO patients with and without ICAD.

METHODS

A prospective cohort study was conducted at 115 People's Hospital, Ho Chi Minh city, Vietnam from August 2021 to June 2023. Patients with acute BAO who underwent endovascular treatment within 24 h from symptom onset were included (thrombectomy alone or bridging with intravenous alteplase). The baseline characteristics and outcomes were analyzed and compared between patients with and without ICAD. Good functional outcome was defined as mRS ≤3 at 90 days.

RESULTS

Among the 208 patients enrolled, 112 (53.8%) patients were categorized in the ICAD group, and 96 (46.2%) in the non-ICAD group. Occlusion in the proximal segment of the basilar artery was more common in patients with ICAD (55.4% vs. 21.9%, p < 0.001), whereas the distal segment was the most common location in the non-ICAD group (58.3% vs. 10.7%, p < 0.001). Patients in the ICAD group were more likely to undergo treatment in the late window, with a higher mean onset-to-treatment time compared to the non-ICAD group (11.6 vs. 9.5 h, p = 0.01). In multivariable logistic regression analysis, distal segment BAO was negatively associated with ICAD (aOR 0.13, 95% CI: 0.05-0.32, p < 0.001), while dyslipidemia showed a positive association (aOR 2.44, 95% CI: 1.15-5.17, p = 0.02). There was a higher rate for rescue stenting in the ICAD compared to non-ICAD group (15.2% vs. 0%, p < 0.001). However, no significant differences were found between the two groups in terms of good outcome (45.5% vs. 44.8%, p = 0.91), symptomatic hemorrhage rates (4.5% vs. 8.3%, p = 0.25), and mortality (42% vs. 50%, p = 0.25).

CONCLUSION

ICAD was a common etiology in patients with BAO. The location segment of BAO and dyslipidemia were associated with ICAD in patients with BAO. There was no difference in 90-day outcomes between BAO patients with and without ICAD undergoing endovascular therapy.

Analysis of risk factors related to the progression rate of hemifacial spasm

Introduction

Although there have been many researches on the etiology and risk factors with the onset of hemifacial spasm, researches on the risk factors related to progression rate are limited. This study aims to analyze the risk factors related to the progression rate of hemifacial spasm.

Methods

The study enrolled 142 patients who underwent microvascular decompression for hemifacial spasm. Based on the duration and severity of symptoms, patients were classified into rapid progression group and slow progression group. To analyze risk factors, univariate and multivariate logistic regression analyses were conducted. Of 142 patients with hemifacial spasm, 90(63.3%) were classified as rapid progression group, 52(36.7%) were classified as slow progression group.

Results

In the univariate analysis, there were significant statistical differences between the two groups in terms of age of onset (P = 0.021), facial nerve angle (P < 0.01), hypertension (P = 0.01), presence of APOE ε4 expression (P < 0.01) and different degrees of brainstem compression in the Root Entry Zone (P < 0.01). In the multivariable analyses, there were significant statistical differences between the two groups in terms of age of symptom onset (P < 0.01 OR = 6.591), APOE ε4 (P < 0.01 OR = 5.691), brainstem compression (P = 0.006 OR = 5.620), and facial nerve angle (P < 0.01 OR = 5.758). Furthermore, we found no significant correlation between the severity of facial spasms and the progression rate of the disease (t = 2.47, P = 0.12>0.05).

Conclusion

According to our study, patients with facial nerve angle ≤ 96.5°, severer compression of the brainstem by offending vessels, an onset age > 45 years and positive expression of APOE ε4, may experience faster progression of hemifacial spasm.

Preparation of biocompatibility coating on magnesium alloy surface by sodium alginate and carboxymethyl chitosan hydrogel

Magnesium alloy is an excellent material for biodegradable cerebrovascular stents. However, the rapid degradation rate of magnesium alloy will make stent unstable. To improve the biocompatibility of magnesium alloy, in this study, biodegradable sodium alginate and carboxymethyl chitosan (SA/CMCS) was used to coat onto hydrothermally treated the surface of magnesium alloy by a dipping coating method. The results show that the SA/CMCS coating facilitates the growth, proliferation, and migration of endothelial cells and promotes neovascularization. Moreover, the SA/CMCS coating suppresses macrophage activation while promoting their transformation into M2 type macrophages. Overall, the SA/CMCS coating demonstrates positive effects on the safety and biocompatibility of magnesium alloy after implantation, and provide a promising therapy for the treatment of intracranial atherosclerotic stenosis in the future.

A bibliometric analysis of the 100 most-cited clinical articles in the research of intracranial artery stenosis and intracranial atherosclerosis

Background

Intracranial arterial stenosis (ICAS), caused by intracranial atherosclerosis, is one of the major causes of ischemic stroke. This study identified the top 100 most-cited publications on ICAS through a bibliometric analysis.

Methods

Two independent authors conducted a search in the Web of Science database for clinical articles on ICAS published between 1993 and 2022. The top 100 most-cited articles were then extracted. For each article, the analysis covered the title, author, country of origin/affiliation, journal, total number of citations, number of citations per year, and type of study.

Results

The top 100 most-cited papers in the ICAS were authored by 565 authors from 12 countries and published in 29 journals. In terms of the 5-year trend, the largest number of papers were published between 2003 and 2007 (n = 31). The median number of citations for the 100 papers was 161 (range 109-1,115). The journal with the highest proportion of the 100 most published articles was Stroke, accounting for 41% of articles and 37% of the citations. According to country of origin, the United States of America accounted for the largest number of articles, followed by China, Japan, and South Korea, with these four countries together accounting for 81% of the total number of articles and 88% of the citations. Trends in the past five years included the use of terms such as acute ischemic stroke and mechanical thrombectomy.

Conclusion

The findings of this study provide novel insight into this field and will facilitate future research endeavors.

In Vivo Imaging of γ-Glutamyl Transferase in Cardiovascular Diseases with a Photoacoustic Probe

In this work, a photoacoustic (PA) probe, HDS-GGT, was developed for the in vivo imaging of cardiovascular diseases by monitoring the γ-glutamyl transferase (GGT) dynamics. HDS-GGT exhibited a stable PA signal with auxiliary absorbance and NIRF variation after the trigger by GGT. In all three modalities of absorbance, NIRF, and PA, HDS-GGT could quantitatively reflect the GGT level. In PA modality, HDS-GGT indicated the practical advantages including high sensitivity, high stability, and high specificity. In living oxidized low-density lipoprotein-induced RAW264.7 cells, HDS-GGT indicated proper capability for imaging the plaques by visualizing the GGT dynamics. Moreover, during imaging in living model mice, HDS-GGT was achieved to distinguish the plaques from healthy blood vessels via a multiview PA presentation. HDS-GGT could also suggest the severity of plaques in the extracted aorta from the model mice, which was consistent with the histological staining results. The information herein might be useful for future investigations on cardiovascular diseases.

Imaging of intracranial arterial disease: a comparison between MRI and unenhanced CT

Background and purpose

Arterial calcifications on unenhanced CT scans and vessel wall lesions on MRI are often used interchangeably to portray intracranial arterial disease. However, the extent of pathology depicted with each technique is unclear. We investigated the presence and distribution of these two imaging findings in patients with a history of cerebrovascular disease.

Materials and methods

We analyzed CT and MRI data from 78 patients admitted for stroke or TIA at our institution. Vessel wall lesions were assessed on 7 T MRI sequences, while arterial calcifications were assessed on CT scans. The number of vessel wall lesions, severity of intracranial internal carotid artery (iICA) calcifications, and overall presence and distribution of the two imaging findings were visually assessed in the intracranial arteries.

Results

At least one vessel wall lesion or arterial calcification was assessed in 69 (88%) patients. Only the iICA and vertebral arteries (VA) showed a substantial number of both calcifications and vessel wall lesions. The other vessels showed almost exclusively vessel wall lesions. The number of vessel wall lesions was associated with the severity of iICA calcification (p = 0.013).

Conclusions

The number of vessel wall lesions increases with the severity of iICA calcifications. Nonetheless, the distribution of vessel wall lesions on MRI and arterial calcifications on CT shows remarkable differences. These findings support the need for a combined approach to examine intracranial arterial disease.

Examining Atherosclerosis Patterns in the Circle of Willis: A Case Study of Duplicated Anterior Communicating Artery

The anterior communicating artery (ACoA) plays a pivotal role in maintaining cerebral hemodynamics, as its diameter is a major determinant of blood collateralization through the circle of Willis following internal carotid artery occlusion. While variations of this artery are not uncommon, data on their clinicopathologic relevance are limited. In this report, we present our observation from a fresh cadaver of a male individual who had succumbed to cardiac causes. The circle of Willis displayed a duplicated ACoA with atherosclerosis that predominantly affected the posterior horn while sparing the anterior horn. The anterior horn was characterized by its shorter length and larger diameter compared to the posterior horn. The paper focuses on elucidating the microsurgical anatomy of this particular ACoA variant and exploring potential mechanisms that may underlie the pattern of atherosclerotic distribution within the circle of Willis. Based on this report, while further evidence is needed for confirmation, it is plausible that the existence of a duplicated ACoA may offer a protective mechanism, ensuring uninterrupted collateral circulation in the event of a blockage in one of the horns. Further analysis of the ACoA and its pattern of involvement in intracranial atherosclerosis is warranted, as the atherosclerotic patterns in this region hold clinical and pathological significance.

The prevalence and prognosis of asymptomatic intracranial atherosclerosis in a community-based population: Results based on high-resolution magnetic resonance imaging

BACKGROUND AND PURPOSE

Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke in China, but the prevalence and prognosis of asymptomatic ICAD detected using high-resolution magnetic resonance imaging (HR-MRI) is largely unknown. The aim of this study was to investigate the prevalence and prognosis in order to guide neurologists in interpreting ICAD detected on HR-MRI.

METHODS

We included stroke-free participants from a community-based prospective cohort (Shunyi study participants) who underwent HR-MRI between July 2014 and April 2016. The participants were divided into two groups: those with or without ICAD (ICAD+ and ICAD- , respectively). ICAD included intracranial artery stenosis and non-stenotic plaque. The primary outcome was ischemic stroke. Cox proportional hazard models were used to evaluate the association between ICAD and event outcomes.

RESULTS

A total of 1060 stroke-free participants evaluated by HR-MRI were included from the Shunyi study. The median age at HR-MRI was 56 years and 64.7% were female. The ICAD prevalence was 36.3% (n = 385). The ICAD+ group was older and had more cerebrovascular risk factors. The rates of ischemic stroke in the ICAD- and ICAD+ groups were 1.3% (n = 9) and 5.2% (n = 20), respectively, with a median follow-up time of 54 months. ICAD was associated with an increased risk of ischemic stroke in the unadjusted and adjusted Cox models, with hazard ratios of 4.12 (95% confidence interval [CI] 1.87-9.05) and 2.50 (95% CI 1.05-5.94), respectively. The greatest risk of an event outcome was observed in participants with ≥70% stenosis or occlusion. The features of high-risk plaques were also identified.

CONCLUSIONS

We found that ICAD detected using HR-MRI increases the long-term risk of a first-ever ischemic stroke in a stroke-free population, suggesting that the current primary prevention protocol of stroke awaits further optimization.

Vascular Health Promotion Project and Vascular Medicine in China-CCVM2004-2023

Cardiovascular disease(CVD) has become a major disease burden affecting people's health in China. Blood vessels are very important for human health and are the "sentinel" for the development of many cardiovascular and cerebrovascular diseases. The key to effectively preventing fatal, disabling heart, brain and peripheral vascular events lies in controlling traditional and non-traditional risk factors for vascular health from the source, and early assessment and intervention of early vascular lesions. Since 2004, China government promoted the early detection technology of vascular lesions and vascular medicine, and proposed the Beijing Vascular Health Stratification (BVHS) to provide suggestions for the examination, evaluation and management of risk factors, and to provide new ideas for lifelong maintenance of vascular health. This review mainly introduces the establishment and development of the clinical discipline of "vascular medicine" in the past 20 years in China, introduces the indicators for detecting vascular function and structure and the predictive value of vascular events, and carries out intelligent and digital management of vascular health throughout the life cycle of individualized prevention, treatment and rehabilitation for people with different parts or degrees of lesions, effectively reducing the occurrence and development of cardiovascular and cerebrovascular diseases, and the prospect of new technology in maintaining vascular health.

Intimal predominant calcification is associated with plaque instability in the vertebrobasilar artery by vessel wall magnetic resonance imaging and computed tomography

BACKGROUND AND AIMS

It remains unknown about the relationship between vertebrobasilar artery (VBA) calcification and plaque instability. We aimed to investigate the characteristics of VBA calcification using vessel wall magnetic resonance imaging (MRI) and computed tomography (CT) and its association with acute cerebral infarction (ACI).

METHODS

Nine hundred and thirty patients with VBA stenosis who underwent vessel wall MRI and CT examinations were evaluated retrospectively. Calcification morphology was classified as either intimal or non-intimal predominant using a CT-pathology-validated grading method. Qualitative and quantitative plaque MRI variables and calcification characteristics were compared between culprit and non-culprit lesions. The association between VBA calcification and the occurrence of culprit lesions was investigated using multivariate logistic regression.

RESULTS

A total of 150 patients with ACI and 142 patients without ACI were eligible for subsequent analyses, respectively. In the qualitative analysis, T1 hyperintensity (p < 0.001) and intimal predominant calcification (p = 0.021) were more frequently observed in the culprit than non-culprit lesions. In the quantitative analyses, culprit lesions had a larger stenosis degree, plaque length, normal wall index, contrast enhancement ratio, lower calcification density and smaller calcification volume than non-culprit lesions (p all < 0.05). Intimal predominant calcification (odds ratio [OR], 2.51; 95 % confident interval [CI], 1.31-4.82, p = 0.006) and calcification density (OR, 0.53; 95 % CI, 0.35-0.78, p = 0.001) were independently associated with the presence of ACI after adjusting for clinical risk factors and plaque variables.

CONCLUSIONS

Intimal predominant calcification in vertebrobasilar atherosclerosis is associated with the likelihood of having caused acute cerebral infarction. The morphology and density of VBA calcification may provide insight into stroke risk stratification in the posterior circulation.

Neuropathologic evaluation of cerebrovascular disease in patients with rheumatoid arthritis

OBJECTIVES

Active RA has been associated with an increased risk of both cardiovascular and peripheral vascular disease. We aimed to compare cerebrovascular changes in patients with and without RA, both with and without a neuropathologic diagnosis of neurodegenerative disease.

METHODS

Patients with RA (n = 32) who died and underwent autopsy between 1994 and 2021 were matched to non-RA controls (n = 32) on age, sex and level of neurodegenerative proteinopathy. Routine neuropathologic examination was performed at the time of autopsy. Cerebrovascular disease severity was evaluated using modified Kalaria and Strozyk scales. Clinical dementia diagnoses were manually collected from patients' medical records.

RESULTS

Prior to death, 15 (47%) RA patients and 14 (44%) controls were diagnosed with dementia; 9 patients in each group (60% and 64%, respectively) had Alzheimer's disease. The prevalence of cerebral amyloid angiopathy, microinfarcts, infarcts or strokes was found to be similar between groups. Patients with RA were more likely to have more severe vascular changes in the basal ganglia by Kalaria scale (P = 0.04), but not in other brain areas. There were no significant differences in the presence of large infarcts, lacunar infarcts or leukoencephalopathy by Strozyk scale. Among patients with RA and no clinical diagnosis of dementia, the majority had mild-moderate cerebrovascular abnormalities, and a subset of patients had Alzheimer's disease neuropathologic changes.

CONCLUSION

In this small series of autopsies, patients with and without RA had largely similar cerebrovascular pathology when controlling for neurodegenerative proteinopathies, although patients with RA exhibited more pronounced cerebrovascular disease in the basal ganglia.

Investigation into the vascular contributors to dementia and the associated treatments

As the average lifespan has increased, memory disorders have become a more pressing public health concern. However, dementia in the elderly population is often neglected in light of other health priorities. Therefore, expanding the knowledge surrounding the pathology of dementia will allow more informed decision-making regarding treatment within elderly and older adult populations. An important emerging avenue in dementia research is understanding the vascular contributors to dementia. This review summarizes potential causes of vascular cognitive impairment like stroke, microinfarction, hypertension, atherosclerosis, blood-brain-barrier dysfunction, and cerebral amyloid angiopathy. Also, this review address treatments that target these vascular impairments that also show promising results in reducing patient's risk for and experience of dementia.

Differences in distribution and features of carotid and middle cerebral artery plaque in patients with pial infarction and perforating artery infarction: A 3D vessel wall imaging study

PURPOSE

Atherosclerotic plaques of carotid artery (CA) and middle cerebral artery (MCA) are important causes of acute ischemic stroke (AIS). This study was designed to jointly assess the plaque distribution and features of CA and MCA in AIS patients with pial infarction (PI) and perforating artery infarction (PAI), and to investigate the associations between plaque characteristics and ischemic infarction patterns.

METHODS

Imaging data of sixty-five patients from a cross-sectional study were reviewed. All the patients had acute infarction in the MCA territory on diffusion weighted imaging (DWI) and underwent CA and MCA vessel wall imaging (VWI). The CA and MCA plaque presence and high-risk features on the ipsilateral side of infarction were analyzed. The brain infarction lesions were divided into PI group vs. non-PI group, and PAI group vs. non-PAI group. Different plaque distribution types and plaque features were compared in each two groups, and their associations were investigated using binary logistic regression.

RESULTS

Sixty-five patients (mean age, 54.6 ± 10.1 years; 61 men) were included. The CA high-risk plaque (OR: 5.683 [1.409-22.929], P = 0.015) and MCA plaque presence (OR: 3.949 [1.397-11.162], P = 0.010) were significantly associated with PI. MCA plaques that involved the orifice of the perforating arteries were significantly associated with PAI (OR: 15.167 [1.851-124.257], P = 0.011).

CONCLUSION

CA and MCA plaques show distinct distribution and high-risk features in patients with PI and PAI. Combined intracranial and extracranial arteries imaging should be considered for the evaluation of the symptomatic ischemic patients.

Hemodynamics combined with inflammatory indicators exploring relationships between ischemic stroke and symptomatic middle cerebral artery atherosclerotic stenosis

BACKGROUND AND PURPOSE

Intracranial atherosclerotic stenosis (ICAS) is a major cause of ischemic stroke, and high-resolution vessel wall imaging (HR-VWI) can be used to assess the plaque characteristics of ICAS. This study combined HR-VWI, hemodynamics, and peripheral blood inflammatory indicators to investigate the role of these factors in symptomatic intracranial atherosclerotic stenosis (sICAS) and their inter-relationships.

METHODS

Patients diagnosed with atherosclerotic middle cerebral artery stenosis were recruited retrospectively from June 2018 to July 2022. Plaque enhancement was qualitatively and quantitatively analyzed, and the degree of plaque enhancement was graded according to the plaque-to-pituitary stalk contrast ratio (CR). Computational fluid dynamics models were constructed, and then hemodynamic parameters, including wall shear stress (WSS) and pressure ratio (PR), were measured and recorded. Univariate and multivariable analyses were performed to identify factors that can predict sICAS. In addition, the correlation analysis between the plaque characteristics on HR-VWI, hemodynamic parameters, and peripheral blood inflammatory indicators was performed to investigate the interrelationships between these factors.

RESULTS

Thirty-two patients were included. A higher proportion of plaque enhancement, maximum WSS, and WSS ratio (WSSR) were significantly associated with sICAS. The multiple logistic regression analysis showed that only the WSSR was an independent risk factor for sICAS. The correlation analysis revealed that both the CR and plaque burden showed linear positive correlation with the WSSR (R = 0.411, P = 0.022; R = 0.474, P = 0.007, respectively), and showed linear negative correlation with the lymphocyte to monocyte ratio (R = 0.382, P = 0.031; R = 0.716, P < 0.001, respectively).

CONCLUSIONS

The plaque enhancement and WSSR were significantly associated with sICAS, WSSR was an independent risk factor for sICAS. Plaque enhancement and plaque burden showed linear correlation with the WSSR and lymphocyte-to-monocyte ratio (LMR). Hemodynamics and inflammation combined to promote plaque progression.

A Knowledge Map of the Relationship between Diabetes and Stroke: A Bibliometric Analysis Study

INTRODUCTION

The correlation between diabetes and stroke has been studied extensively in epidemiological research. Here, we used bibliometric software to visualize and analyze the literature related to diabetic stroke to provide an overview of the current state of research, hotspots, and future trends in the field.

METHODS

Based on the Web of Science Core Collection (WoSCC) database, we collected studies related to diabetic stroke from 2007 to December 2022. We used CiteSpace (version 6.1.R5), VOSviewer, and Scimago Graphica to create knowledge maps and conduct visual analyses on authors, countries, institutions, cited references, and keywords, and Origin for statistical analysis.

RESULTS

We included a total of 5,171 papers on diabetic stroke from the WoSCC database. Overall, there was a steady increase in the number of publications, with a high number of emerging scientists. The USA was the most productive and influential country, which dominated national collaborations. The most common subject category was "neurology." In total, 12 major clusters were generated from the cited references. Keyword analysis showed that keywords related to poststroke injury and treatment are those with the highest burst intensity and latest burst time.

CONCLUSIONS

Individual disease treatment remains a hot topic, and how to balance acute stroke treatment and glycemic control is currently a difficult clinical problem. At the same time, the mechanism of their interaction and the prevention and treatment of related causative factors remain a hot topic of current and future research.

The correlation between medial pattern of intracranial arterial calcification and white matter hyperintensities

BACKGROUND AND AIMS

Despite reported correlations between intracranial arterial calcification (IAC) and white matter hyperintensities (WMH), little is known about the relationship between IAC pattern and WMH. By differentiating intimal and medial IAC, we aimed to investigate the relationship between IAC pattern and WMH.

METHODS

Consecutive acute stroke patients were included. IAC pattern was categorized as intimal or medial on plain brain CT. The number of cerebral arteries involved by IAC for each patient was recorded. IAC severity was defined as focal or diffuse. On brain MRI, the burden of WMH was visually graded and classified as absent mild, moderate and severe. Multiple logistic regression was performed to examine the relationship between IAC and WMH.

RESULTS

Among 265 patients, intimal IAC was detected in 54.7% patients and medial IAC in 48.5% patients. Diffuse IAC was present in 27.9% patients, all of which were medial. WMH was found in 75.5% patients, including 39.6% patients with mild WMH, 26.0% with moderate WMH, and 9.8% with severe WMH. The severity of medial IAC was correlated with WMH occurrence (p < 0.001). Chi-square linear trend suggested the number of arteries involved by medial IAC (p < 0.001) and the severity of medial IAC (p < 0.001) were correlated with WMH burden. Multiple ordinal logistic regression demonstrated a positive correlation of WMH burden with the number of arteries involved by medial IAC (p < 0.001) and the severity of medial IAC (p < 0.001).

CONCLUSIONS

Medial IAC was correlated with WMH. The dose-effect relationship between medial IAC and WMH suggests underlying shared mechanisms of intracranial large artery disease and small vessel disease.