Efficacy of Early Intensive Blood Pressure Management After Thrombectomy: Protocol for a Randomized Controlled Clinical Trial (IDENTIFY).

BACKGROUND: The optimal strategy for blood pressure management after thrombectomy remains unknown. The primary objective of The Early Intensive Blood Pressure Management after Endovascular Thrombectomy (IDENTIFY) study is to explore the efficacy and safety of early intensive blood pressure management strategies after thrombectomy compared with that of standard management. METHODS: The IDENTIFY study is a prospective, randomized, open-label, assessor-blinded multicenter clinical trial. Patients with acute anterior circulation ischaemic stroke who underwent endovascular thrombectomy within 6 h of stroke onset, achieved successful recanalization, and had two consecutive blood pressure readings > 130 mm Hg during the first 6 h after thrombectomy will be enrolled and centrally randomized into intensive or standard management groups in a 1:1 ratio. Continuous blood pressure monitoring will be initiated at the end of thrombectomy, and patients with high blood pressure during the transfer to the wards will also be enrolled. For patients in the intensive management group, the target blood pressure will be < 130 mm Hg, and the use of antihypertensive drugs will be discontinued if systolic blood pressure goes below 110 mm Hg. The target blood pressure for the standard management group will be < 180 mm Hg, and if systolic blood pressure decreases below 140 mm Hg, the use of antihypertensive drugs will be stepwise decreased until the systolic blood pressure reaches 140 mm Hg again or the infusion is discontinued. Patients will have their blood pressure reduced to the target range within 1 h from randomization and maintained until 24 h after thrombectomy with intravenous hypertensive drugs. A sample size of 600 was predicted. The primary outcome will be the rate of dependency (modified Rankin Scale scores 3-6) at 90 days. Secondary outcomes will include intracerebral hemorrhage (either symptomatic or asymptomatic) within 24 h and 7 days, malignant brain oedema, all-cause death, death and severe disability at 90 days, and quality of life at 90 days, which will be measured using the EuroQol-5 Dimensions-5 Level (EQ-5D-5L) and the 36-Item Short Form Health Survey (SF-36). Safety outcomes will include stroke recurrence within 24 h, early neurological deterioration, hypotension within 24 h, death within 7 days after endovascular thrombectomy, and all-cause acute kidney injury. Trial registration chictr.org.cn (identifier: ChiCTR2200057770). Registered March 17, 2022, http://www.chictr.org.cn/edit.aspx?pid=162575&htm=4.

Retinal microvasculature and cerebral hemodynamics in patients with internal carotid artery stenosis.

PURPOSE: To investigate the relationship between retinal microvasculature and cerebral hemodynamics in patients with internal carotid artery (ICA) stenosis. METHODS: Patients with unilateral moderate or severe ICA stenosis(≥50%) from West China hospital, Sichuan university were consecutively and prospectively recruited enrolled in the current study. En face angiograms of the superficial vascular complex (SVC), deep vascular complex (DVC), superficial vascular plexus (SVP), intermediate capillary plexus (ICP), and deep capillary plexus (DCP) were generated by automatic segmentation using swept-source optical coherence tomography angiography (SS-OCTA) to assess the retinal microvascular perfusion. The cerebral blood flow perfusion on bilateral middle cerebral artery territories measured at the basal ganglia level was assessed by brain computed tomography perfusion (CTP). CTP data were postprocessed to generate maps of different perfusion parameters including cerebral blood flow (CBF), cerebral blood volume (CBV), time to peak (TTP), mean transit time (MTT) and permeability surface(PS). Relative perfusion parameters (rPS, rCBF, etc.) were calculated as the ratio of the value on the contralateral side to that on the ipsilateral side. RESULTS: In the final analysis, 31 patients were included, of whom 11 patients had a moderate ICA stenosis (50-69%) and 20 with a severe ICA stenosis(≥70%). A total of 55 eyes were analyzed in the study, 27 eyes from the ipsilateral side (ie, side with stenosis) and 28 eyes from the contralateral side. In the patients with ICA stenosis, there was a strong correlation between the retinal microvascular perfusion of SVC with rCBV(B = 0.45, p = 0.03), rCBF(B = 0.26, p = 0.02) and rPS(B = 0.45, p < 0.001) after adjustment for age, sex and vascular risk factors. Similar correlations were also found between microvasculature in SVP and cerebral perfusion changes. There were no any significant associations of microvascular perfusion in both DVC and DCP with CTP parameters(all p > 0.05). CONCLUSIONS: Retinal perfusion changes in superficial vascular layer (SVC and SVP) were correlated with brain hemodynamic compromise in patients with unilateral moderate or severe ICA stenosis(≥50%). Given the limited size of our study, future studies with larger sample size are needed to confirm our findings.

Fabry disease presenting as bilateral medial medullary infarction with a "heart appearance" sign: a case report.

BACKGROUND: The etiologic determinants of cryptogenic stroke remain a diagnostic challenge in clinical practice. Fabry disease (FD) is one of the monogenic causes of stroke that may remain unrecognized as a potential contributing causative factor, because of its rarity and difficulty in diagnosis. We report a case with rare bilateral medial medullary infarction manifesting as "heart appearance" who was diagnosed with FD. CASE PRESENTATION: A 51-year-old Chinese man presented with acute dysarthria and mild tetraparesis. In the 24 h following admission, the patient rapidly developed progressive flaccid quadriplegia and tongue weakness, necessitating ventilator support. Immediate magnetic resonance imaging of the brain showed heart-shaped appearance of bilateral medial medullary infarction. The patient suffered two new subcortical infarcts 40 days after the first. Detailed Family history and physical examination indicated symptoms consistent with FD, which was confirmed by very low alpha galactosidase A levels and a missense mutation of the alpha-galactosidase A gene. CONCLUSIONS: We report what appears to be the first case of FD manifesting as bilateral medial medullary infarction. Our case suggests that clinicians should consider the possibility of FD in patients with cryptogenic stroke, especially when combined with infarction in the vertebrobasilar artery system, renal insufficiency, or cardiomyopathy. A detailed analysis of subtle historical clues and performing a complete physical examination on stroke patients would help promote earlier diagnosis of FD.

Influence of Carotid Artery Stenting on the Retina and Choroid.

Purpose: The effect of carotid artery stenting in patients with unilateral carotid artery stenosis on the retina and choroid was evaluated using swept-source optical coherence tomography angiography (SS-OCTA). Methods: SS-OCTA examination was conducted before stenting and 4 days and 3 months after stenting. The retinal nerve fiber layer, ganglion cell-inner plexiform layer (GCIPL), inner nuclear layer, superficial vascular complex (SVC), deep vascular complex (DVC), choroidal vascular volume (CVV), and choroidal vascular index were measured. Repeated-measures analysis of variance was performed to assess the impact of carotid artery stenting on optical coherence tomography angiography (OCTA) metrics. Results: At baseline, 303 eyes from 160 patients (61.82 ± 9.98 years; 85.29% males) were enrolled. SVC and DVC densities and CVV were lower in ipsilateral eyes (stenosed side) compared to contralateral eyes (all P < 0.05). Four days after stenting, a significant increase was seen in SVC density in ipsilateral eyes (P < 0.05) while a significant increase was seen in CVV in ipsilateral eyes and contralateral eyes (both P < 0.05). Three months after stenting (63 patients with 114 eyes), a significant decrease was seen in the GCIPL thickness of ipsilateral and contralateral eyes (all P < 0.001). Conclusions: Short term after carotid artery stenting, ipsilateral eyes showed a rapid and significant increase in SVC density and CVV. Translational Relevance: Optical coherence tomography (OCT)/OCTA measurements may have the potential to detect retinal and choroidal changes after stenting. Future research on the long-term effect of stenting on the retina and choroid will be guided by these findings.

The stress hyperglycemia ratio is associated with the development of cerebral edema and poor functional outcome in patients with acute cerebral infarction.

Background and purpose: Absolute hyperglycemia at admission has been shown to be associated with the development of cerebral edema (CED) after acute cerebral infarction. Stress hyperglycemia is a more objective reflection of hyperglycemic state than absolute hyperglycemia. However, studies on the associations between stress hyperglycemia and CED are limited. We aimed to explore the associations of stress hyperglycemia, measured by stress hyperglycemia ratio (SHR), with the development of CED and poor functional outcome of acute cerebral infarction. Methods: Patients with acute middle artery cerebral infarction admitted to the Department of Neurology, West China Hospital of Sichuan University, within 24 h of symptom onset from January 2017 to March 2021 were included. Stress hyperglycemia was assessed by the SHR: admission fasting plasma glucose (FPG)/hemoglobin A1c (HbA1c). The primary outcome was the degree of CED evaluated on brain image. The secondary outcomes were moderate-to-severe CED, poor functional outcome (modified Rankin Scale score > 2), and death at 90 days. The associations between the SHR and outcomes were assessed with multivariate logistic regression analyses. We further compared the predictive value of the SHR, admission random plasma glucose (RPG), and admission FPG for outcomes in the training dataset and validation dataset. Results: 638 patients were enrolled. Each 0.1-point increase in the SHR was independently associated with a 1.31-fold increased risk of a higher degree of CED [odds ratio (OR): 1.31 (95% confidence interval (CI): 1.20-1.42), P < 0.001]. The SHR was independently associated with moderate-to-severe CED [per 0.1-point increase: OR: 1.39 (95% CI: 1.24-1.57), P < 0.001], poor functional outcome [per 0.1-point increase: OR: 1.25 (95% CI: 1.12-1.40), P < 0.001], and death [per 0.1-point increase: OR: 1.13 (95% CI: 1.03-1.25), P < 0.05]. The predictive value of the SHR (as a continuous variable), exhibited by the area under the curve in receiver operating characteristic analysis, was higher than that of the RPG and FPG for moderate-to-severe CED and poor functional outcome (P < 0.05). Conclusion: The SHR is independently associated with the severity of CED, poor functional outcome, and death after acute cerebral infarction, and the SHR (as a continuous variable) has a better predictive value for moderate-to-severe CED and poor functional outcome than the RPG and FPG.

Retinal Thickness Correlates with Cerebral Hemodynamic Changes in Patients with Carotid Artery Stenosis.

Background: We aimed to assess the retinal structural and choroidal changes in carotid artery stenosis (CAS) patients and their association with cerebral hemodynamic changes. Asymptomatic and symptomatic patients with unilateral CAS were enrolled in our study. Material and methods: Swept-source optical coherence tomography (SS-OCT) was used to image the retinal nerve fiber layer (RNFL), ganglion cell-inner plexiform layer (GCIPL), while SS-OCT angiography (SS-OCTA) was used to image and measure the choroidal vascular volume (CVV) and choroidal vascular index (CVI). Computed Tomography Perfusion (CTP) was used to assess the cerebral perfusion parameters; relative perfusion (r) was calculated as the ratio of the value on the contralateral side to that on the ipsilateral side. Results: Compared with contralateral eyes, ipsilateral eyes showed significantly thinner RNFL (p < 0.001), GCIPL (p = 0.013) and CVV (p = 0.001). Relative cerebral blood volume (rCBV) showed a significant correlation with RNFL (p < 0.001), GCIPL (p < 0.001) and CVI (p = 0.027), while the relative permeability surface (rPS) correlated with RNFL (p < 0.001) and GCIPL (p < 0.001). Conclusions: Our report suggests that retinal and choroidal changes have the potential to detect hemodynamic changes in CAS patients and could predict the risk of stroke.

Association Between Systemic Immune-Inflammation Index and Symptomatic Intracranial Hemorrhage in Acute Ischemic Stroke Patients Undergoing Endovascular Treatment.

BACKGROUND/OBJECTIVE: Systemic immune-inflammation index (SII) is a novel inflammatory factor, which may be involved in the destruction of the blood-brain barrier (BBB) after acute ischemic stroke (AIS); however, the association between SII and symptomatic intracranial hemorrhage (sICH) in AIS patients undergoing endovascular treatment (EVT) remains unclear. METHODS: Patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO) who underwent EVT were consecutively enrolled. Blood samples were collected in the emergency room and SII was calculated by neutrophils × platelets/lymphocytes. Participants were categorized into tertiles according to admission SII. The main outcome was defined as the occurrence of sICH, following the European Cooperative Acute Stroke Study III (ECASS-III) criteria. RESULTS: A total of 379 AIS-LVO patients with EVT were enrolled (median age = 71 years, 52.5% males). The median baseline National Institutes of Health Stroke Scale (NIHSS) score was 15 (IQR, 12-18). The median of SII was 820.9 × 109/L (IQR, 473.1-1345.2). Forty-three (11.3%) patients developed sICH. SII was found to be independently associated with sICH after EVT (adjusted odd ratio (OR) = 1.005 (per 10 units increase); 95% confidence interval (CI): 1.002-1.008; p = 0.002). Compared to patients in the lowest SII tertile, patients in the highest tertile had a higher risk of sICH (adj-OR 3.379; 95% CI 1.302-8.768; p = 0.012). The risk of sICH increased with the increase of SII in a dose-dependent manner (p for trend = 0.004). There was no interaction between potential modifiers and SII on sICH. CONCLUSION: Admission SII is positively associated with sICH in AIS-LVO patients treated with EVT. These results need to be confirmed in future studies.

Choroidal Changes in Carotid Stenosis Patients After Stenting Detected by Swept-source Optical Coherence Tomography Angiography.

BACKGROUND: Carotid artery stenosis (CAS) patients show reduced blood flow in the ophthalmic artery. This study aimed to assess the changes in the choriocapillaris and choroidal thickness in patients with unilateral carotid artery stenosis after carotid stenting using swept-source optical coherence tomography (SS-OCT)/swept-source optical coherence tomography angiography (SSOCTA). METHODS: Fifty-three mild to moderate CAS patients and 40 controls were enrolled in this study. All participants underwent digital subtraction angiography (DSA) and SS-OCT/SS-OCTAA imaging before and 4 days after carotid artery stenting. SS-OCTA was used to image and measure the perfusion of the choriocapillaris (mm2), while SS-OCT was used to image and measure the choroidal thickness (µm). The stenosed side was described as the ipsilateral eye, while the other side was the contralateral eye. RESULTS: Choroidal thickness was significantly thinner (P = 0.024) in CAS when compared with controls. Ipsilateral eyes of CAS patients showed significantly thinner (P = 0.008) choroidal thickness when compared with contralateral eyes. Ipsilateral eyes of CAS patients showed thicker (P = 0.027) choroidal thickness after carotid artery stenting, while contralateral eyes showed thinner choroidal thickness (P = 0.039). CONCLUSION: Our report suggests that in vivo quantification of the choroid with the SS-OCT/SSOCTA may allow monitoring of CAS and enable the assessment of purported treatments.

Benefits of Endovascular Treatment in Late Window for Acute Ischemic Stroke Selected without CT Perfusion: A Real-World Study.

Objective: This study examined the functional outcomes and safety of endovascular treatment (EVT) in acute ischemic stroke (AIS) patients owing to large vessel occlusion of the anterior circulation, presented during a late-time window (6-24 hours after last seen well (LSW)) in a real-world practice. Methods: This was a retrospective analysis from a bi-center prospective cohort. According to the stroke treatment, patients with continuous Alberta Stroke Plan Early Aspect score (ASPECTS) ≥6 on non-contrast CT (NCCT) and moderate to good collateral state on CT angiography (CTA) were divided into EVT group and standard medical treatment (SMT) group. The primary outcome was the rate of functional independence (90-day mRS ≤2). Safety outcomes were the occurrence of symptomatic intracranial hemorrhage (sICH) and the 90-day mortality. Results: Among the 288 enrolled patients (53.5% male, median age 64 years), there were 167 patients in the EVT group and 121 in the SMT group. After multivariable adjustments for potential confounders, EVT was associated with functional independence (adjusted OR: 3.052; 95% confidence interval (CI): 1.553-5.997; p = 0.001). In the PSM cohort, 44.2% (42/95) of patients in the EVT group versus 18.9% (18/95) in the SMT group achieved functional independence (OR: 3.39, 95% CI: 1.763-6.517), and there was a significant difference favoring EVT over the SMT in the overall distribution of mRS (OR: 2.170, 95% CI: 1.302-3.618) at 90 days. The rate of sICH did not differ between the EVT and SMT groups (10.5% vs 8.4%, p = 0.804) nor did 90-day mortality (18.9% vs 22.1%, p = 0.719). No interaction was found in p-values with statistical significance in subgroup analysis. Conclusion: This real-world experience suggests that EVT for late-presenting stroke patients, based on small core on NCCT and moderate to good collaterals on CTA, is associated with better outcomes than SMT alone, with no increase in sICH and 90-day mortality rates.

Macular Microvasculature Is Associated With Total Cerebral Small Vessel Disease Burden in Recent Single Subcortical Infarction.

PURPOSE: To assess the retinal microvasculature, choriocapillaris, and choroidal thickness in recent single subcortical infarction (RSSI) patients compared with healthy controls. We also assessed the correlation between the macular microvascular changes and choroidal changes with their clinical implications in RSSI patients. METHODS: Forty-six RSSI patients and 39 healthy controls (HC) were enrolled in our study. Magnetic resonance imaging (MRI) was done for all RSSI patients, and a total cerebral small vessel disease (CSVD) score was assessed for all patients. Swept-source optical coherence tomography (SS-OCT) was used to image and assess the choroidal thickness and SS-OCT angiography (SS-OCTA) was used to image and assess the macular microvasculature and choriocapillaris in all participants. Clinical information was collected for all participants. RESULTS: RSSI patients showed significantly sparser inner retinal microvasculature (P = 0.003) when compared with healthy controls. RSSI patients showed significantly thinner choroidal thickness (P < 0.001) when compared with HC. No significant difference (P = 0.247) was seen when the choriocapillaris was compared between the two groups. CSVD burden (P = 0.014) and NIHSS score (P = 0.010) showed significant correlation with the inner retinal microvasculature of RSSI patients. The inner retinal microvasculature (P = 0.016) and choroidal thickness (P = 0.018) showed a significant correlation with the MoCA scores in RSSI patients. CONCLUSIONS: Our report suggests that retinal and choroidal imaging may serve as useful indicators to expand our understanding of RSSI and its clinical validity.