Excessive apoptosis of Rip1-deficient T cells leads to premature aging.

In mammals, the most remarkable T cell variations with aging are the shrinking of the naïve T cell pool and the enlargement of the memory T cell pool, which are partially caused by thymic involution. However, the mechanism underlying the relationship between T-cell changes and aging remains unclear. In this study, we find that T-cell-specific Rip1 KO mice show similar age-related T cell changes and exhibit signs of accelerated aging-like phenotypes, including inflammation, multiple age-related diseases, and a shorter lifespan. Mechanistically, Rip1-deficient T cells undergo excessive apoptosis and promote chronic inflammation. Consistent with this, blocking apoptosis by co-deletion of Fadd in Rip1-deficient T cells significantly rescues lymphopenia, the imbalance between naïve and memory T cells, and aging-like phenotypes, and prolongs life span in T-cell-specific Rip1 KO mice. These results suggest that the reduction and hyperactivation of T cells can have a significant impact on organismal health and lifespan, underscoring the importance of maintaining T cell homeostasis for healthy aging and prevention or treatment of age-related diseases.

ChemR23 signaling ameliorates brain injury via inhibiting NLRP3 inflammasome-mediated neuronal pyroptosis in ischemic stroke.

BACKGROUND: Inflammatory response has been recognized as a pivotal pathophysiological process during cerebral ischemia. ChemR23 signaling is involved in the pathophysiology of various inflammatory diseases. Nevertheless, the role of ChemR23 signaling in ischemic stroke remains largely unknown. METHODS: Permanent ischemic stroke mouse model was accomplished by middle cerebral artery occlusion (MCAO). Resolvin E1 (RvE1) or chemerin-9 (C-9), the agonists of ChemR23, were administered by intracerebroventricular (i.c.v) injection before MCAO induction. Then, analysis of neurobehavioral deficits and brain sampling were done at Day 1 after MCAO. The brain samples were further analyzed by histological staining, immunofluorescence, RNA sequencing, ELISA, transmission electron microscope, and western blots. Furthermore, oxygen-glucose deprivation (OGD) was employed in SH-SY5Y to mimic MCAO in vitro, and ChemR23 signaling pathway was further studied by overexpression of ChemR23 or administration of related agonists or antagonists. Analysis of cell death and related pathway markers were performed. RESULTS: ChemR23 expression was upregulated following MCAO. Under in vitro and in vivo ischemic conditions, ChemR23 deficiency or inhibition contributed to excessive NLRP3-mediated maturation and release of IL-1ß and IL-18, as well as enhanced cleavage of GSDMD-N and neuronal pyroptosis. These influences ultimately aggravated brain injury and neuronal damage. On the other hand, ChemR23 activation by RvE1 or C-9 mitigated the above pathophysiological abnormalities in vivo and in vitro, and overexpression of ChemR23 in SH-SY5Y cells also rescued OGD-induced neuronal pyroptosis. Blockade of NLRP3 mimics the protective effects of ChemR23 activation in vitro. CONCLUSION: Our data indicated that ChemR23 modulates NLRP3 inflammasome-mediated neuronal pyroptosis in ischemic stroke. Activation of ChemR23 may serve as a promising potential target for neuroprotection in cerebral ischemia.

Association between blood pressure variability and clinical outcomes after successful thrombectomy in acute basilar artery occlusion stroke patients: A multicenter cohort study.

BACKGROUND: Limited data are available on the appropriate choice of blood pressure management strategy for patients with acute basilar artery occlusion (BAO) treated with mechanical thrombectomy (MT). We evaluated the impact of blood pressure variability on clinical outcomes after MT in patients with acute BAO. METHODS: This multicenter cohort study included 108 patients with acute BAO who underwent successful emergency thrombectomy at two comprehensive stroke centers from 2016 to 2021. Blood pressure was measured hourly during the first 24 h after successful reperfusion. Blood pressure variability was calculated as mean arterial pressure (MAP) assessed by the standard deviation (SD). Multivariate logistic models were used to investigate the association between BPV, the primary outcome (futile recanalization, 90-day modified Rankin Scale score 3-6), and the secondary outcome (30-day mortality). Subgroup analysis was performed as a sensitivity test. RESULTS: Futile recanalization occurred in 60 (56 %) patients, while 26 (24 %) patients died within 30 days. In the fully adjusted model, MAP SD was associated with a higher risk of futile recanalization (OR adj=1.36, per 1 mmHg increase, 95 % CI: 1.09-1.69, P=0.006) and 30-day mortality (OR adj=1.56, per 1 mmHg increase, 95 % CI: 1.20-2.04, P=0.001). A significant interaction between MAP SD and the lack of hypertension history on futile recanalization (P<0.05) was observed. CONCLUSIONS: Among recanalized acute BAO ischemic patients, higher blood pressure variability during the first 24 h after MT was associated with worse outcomes. This association was stronger in patients without a history of hypertension.

Meta-analysis on clinical outcomes of suprapapillary versus transpapillary stent insertion in malignant biliary obstruction.

BACKGROUND/AIMS: Endoscopic biliary stenting is an essential treatment for malignant biliary obstruction (MBO). However, the optimal location for the placement of metal stents (MS) or plastic stents (PS) during the management of MBO, whether above (suprapapillary) or across (transpapillary) the sphincter of Oddi (SO), has not been thoroughly evaluated. This meta-analysis aims to compare the clinical outcomes associated with endoscopic retrograde cholangiopancreatography (ERCP)-guided biliary stents placed above and across the SO in patients with MBO. METHODS: A comprehensive search of electronic databases was carried out to identify studies published from inception to April 2022. The clinical outcomes examined including stent patency, stent occlusion, and overall adverse events (AEs) such as cholangitis, post-ERCP pancreatitis (PEP), cholecystitis, stent migration, and bleeding. The selection of a random-effects model or fixed-effects model was based on the presence of heterogeneity. RESULTS: A total of 12 articles involving 751 patients were analyzed. The findings showed that the suprapapillary approach had longer stent patency compared to the transpapillary approach (mean difference: 38.58; 95% confidence interval 16.02-61.14, P < 0.0001). Additionally, the suprapapillary approach was associated with a lower risk of stent occlusion and overall AEs (P = 0.04, P = 0.002, respectively), particularly in the incidence of PEP (P = 0.009). The incidence of cholangitis, cholecystitis, stent migration, and bleeding were similar between the suprapapillary and transpapillary approaches. The subgroup analyses indicated that suprapillary PS had a significant decrease in the incidence of stent occlusion and longer stent patency, while suprapillary MS had a significant decrease in the incidence of overall AEs and PEP than the transpapillary approach. CONCLUSION: Compared with the transpapillary approach, the suprapapillary stent had superiority in longer stent patency, lower rates of stent occlusion and overall AEs, and notably, a lower incidence of PEP. The incidence of cholangitis, cholecystitis, stent migration, and bleeding were similar between the suprapapillary and transpapillary approaches. Further large-scale randomized controlled studies are needed to confirm our findings. REGISTRATION NO: CRD42022336435.

Visualization of Thrombus Enhancement on Thin-Slab Maximum Intensity Projection of CT Angiography: An Imaging Sign for Predicting Stroke Source and Thrombus Compositions.

Background Thrombus enhancement (TE) in large vessel occlusion in patients with acute ischemic stroke can be visualized with thin-slab maximum intensity projection (TS-MIP) image reconstruction of CT angiograms. Purpose To evaluate whether TE on TS-MIP reconstructed CT angiograms can be used to predict thrombus composition and stroke source. Materials and Methods This retrospective study included consecutive patients with acute ischemic stroke who underwent thrombectomy in the anterior circulation between August 2016 and July 2019. Stroke types were classified according to the Trial of ORG 10172 in Acute Stroke Treatment. TE on TS-MIP reconstructed CT angiograms was evaluated by two readers. Various clinical and interventional parameters and histopathologic thrombi examination results were compared between the TE-positive and TE-negative groups. The associations between TE and thrombus compositions and stroke sources were analyzed by using multivariable linear and logistic regression models. Results A total of 148 patients (mean age, 71 years ± 11 [standard deviation]; 94 men) were included. TE was confirmed in 80% (119 of 148) of the patients. TE-positive thrombi contained a higher fibrin and platelet proportion (mean, 46% ± 16 vs 34% ± 13; P = .02) and fewer erythrocytes (mean, 33% ± 14 vs 48% ± 20, P = .002) than the TE-negative thrombi. The proportion of cardioembolic and cryptogenic strokes in the TE-positive and TE-negative groups was 92% (110 of 119) and 24% (seven of 29), respectively (P < .001). In adjusted analysis, the presence of TE (odds ratio, 155; 95% CI: 17, 1438; P < .001) was associated with a combination of cardioembolic and cryptogenic strokes. A multiple logistic regression model showed that TE (odds ratio, 23; 95% CI: 1.8, 288; P = .02) was significantly associated with cardioembolic stroke. Conclusion Thrombus enhancement on thin-slab maximum intensity projection of CT angiography can be used to predict cardioembolic and cryptogenic strokes and identify thrombi with a higher fibrin-to-platelet fraction and a lower erythrocyte proportion. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Kansagra and Goyal in this issue.

ADAMTS13 ameliorates inflammatory responses in experimental autoimmune encephalomyelitis.

BACKGROUND: ADAMTS13 (a disintegrin and metalloprotease with a thrombospondin type 1 motif, member 13) plays a vital role in preventing microvascular thrombosis and inflammation. Reduced ADAMTS13 levels in plasma have been detected in multiple sclerosis (MS) patients. In the present study, we have determined the role of ADAMTS13 in the disease progression of MS using a mouse model of experimental autoimmune encephalomyelitis (EAE). METHODS: Female C57BL/6 mice were immunized with MOG35-55 peptide and then treated with ADAMTS13 or vehicle in preventive and therapeutic settings. Mice were analyzed for clinical deficit, white matter demyelination and inflammatory cell infiltration. To explore the underlying mechanism, VWF expression and blood-spinal cord barriers (BSCB) were determined. RESULTS: Plasma ADAMTS13 activity was suppressed in EAE mice. ADAMTS13-treated EAE mice exhibited an ameliorated disease course, reduced demyelination, and decreased T lymphocyte, neutrophil and monocyte infiltration into the spinal cord. Consistently, ADAMTS13 treatment reduced VWF levels and inhibited BSCB breakdown in the spinal cords of EAE mice. However, leukocytes in the blood and spleen of EAE mice remained unaffected by ADAMTS13 administration. CONCLUSION: Our results demonstrate that ADAMTS13 treatment ameliorates inflammatory responses, demyelination and disease course in EAE mice. Therefore, our study suggests that ADAMTS13 may represent a potential therapeutic strategy for MS patients.

Aquaporin-4 deletion ameliorates hypoglycemia-induced BBB permeability by inhibiting inflammatory responses.

BACKGROUND: Severe hypoglycemia induces brain edema by upregulating aquaporin-4 (AQP4) expression and by degrading tight junctions. Acute severe hypoglycemia induces a proinflammatory environment that may contribute to a disruption in the epithelial barrier by decreasing tight junction protein expression. Interestingly, the altered AQP4 expression has been considered to play a critical role in neuroinflammation during acute brain injury. It has been shown that AQP4 deletion reduces brain inflammation in AQP4-null mice after intracerebral LPS injection. However, the effect of AQP4 deletion regarding protection against hypoglycemia-induced blood-brain barrier (BBB) breakdown is unknown. METHODS: An acute severe hypoglycemic stress model was established via injection of 4 unit/kg body weight of insulin. Evans blue (EB) staining and water measurement were used to assess BBB permeability. Western blot, reverse transcription polymerase chain reaction, and immunofluorescence were used to detect the expression of related proteins. The production of cytokines was assessed via enzyme-linked immunosorbent assay. RESULTS: Hypoglycemia-induced brain edema and BBB leakage were reduced in AQP4-/- mice. AQP4 deletion upregulated PPAR-γ and inhibited proinflammatory responses. Moreover, knockdown of aquaporin-4 by small interfering RNA in astrocytes co-cultured with endothelial cells effectively reduced transendothelial permeability and degradation of tight junctions. Treatment with PPAR-γ inhibitors showed that upregulation of PPAR-γ was responsible for the protective effect of AQP4 deletion under hypoglycemic conditions. CONCLUSIONS: Our data suggest that AQP4 deletion protects BBB integrity by reducing inflammatory responses due to the upregulation of PPAR-γ expression and attenuation of proinflammatory cytokine release. Reduction in AQP4 may be protective in acute severe hypoglycemia.

Identification of the Protective Role of DJ-1 in Hypoglycemic Astrocyte Injury Using Proteomics.

As a common complication of glycemic control in patients with diabetes, hypoglycemia often leads to brain dysfunction or damage. To identify new mechanisms underlying hypoglycemic brain injury, we determined the difference of protein expression profiles in brains between hypoglycemic rats and sham hypoglycemic controls by isobaric tags for relative and absolute quantitation (iTRAQ) analysis. Among the 89 deregulated proteins, DJ-1 protein (Park7) was verified to be upregulated following hypoglycemia insult in vivo and glucose deprivation in an astrocyte cell line (CTX-TNA2) cultured in vitro. Further studies indicated the pro-survival role of autophagy activation and impaired autophagy flux in CTX-TNA2 cells short of glucose. DJ-1 knockdown hindered the initiation of the autophagy process via the AMPK/mTOR pathway and aggravated cell death induced by glucose deficiency. Taken together, our results show that responsive overexpression of DJ-1 plays a protective role against hypoglycemic astrocyte injury partly mediated by the regulation of autophagy.

Protective effects of vascular endothelial growth factor in cultured brain endothelial cells against hypoglycemia.

Hypoglycemia is a common and serious problem among patients with type 1 diabetes receiving treatment with insulin. Clinical studies have demonstrated that hypoglycemic edema is involved in the initiation of hypoglycemic brain damage. However, the mechanisms of this edema are poorly understood. Vascular endothelial growth factor (VEGF), a potent regulator of blood vessel function, has been observed an important candidate hormone induced by hypoglycemia to protect neurons by restoring plasma glucose. Whether VEGF has a protective effect against hypoglycemia-induced damage in brain endothelial cells is still unknown. To investigate the effects of hypoglycemia on cerebral microvascular endothelial cells and assess the protective effect of exogenous VEGF on endothelial cells during hypoglycemia, confluent monolayers of the brain endothelial cell line bEnd.3 were treated with normal (5.5 mM glucose), hypoglycemic (0, 0.5, 1 mM glucose) medium or hypoglycemic medium in the presence of VEGF. The results clearly showed that hypoglycemia significantly downregulated the expression of claudin-5 in bEnd.3 cells, without affecting ZO-1 and occludin expression and distribution. Besides, transendothelial permeability significantly increased under hypoglycemic conditions compared to that under control conditions. Moreover, the hypoglycemic medium in presence of VEGF decreased endothelial permeability via the inhibition of claudin-5 degradation and improved hypoglycemia-induced cell toxicity. Furthermore, Glucose transporter-1 (Glut-1) and apoptosis regulator Bcl-2 expression were significantly upregulated. Taken together, hypoglycemia can significantly increase paraendocellular permeability by downregulating claudin-5 expression. We further showed that VEGF protected brain endothelial cells against hypoglycemia by enhancing glucose passage, reducing endothelial cell death, and ameliorating paraendocellular permeability.

Clinical Reasoning: A 30-Year-Old Woman Presenting With Rapidly Progressive Dementia and Extreme Hypoglycorrhachia.

A 30-year-old woman presented with rapidly progressive dementia 1 month after the coronavirus disease 2019 infection. Repeated CSF analysis showed extreme hypoglycorrhachia, while cultures, metagenomic next-generation sequencing, and cytopathology testing of CSF were negative. Laboratory investigations for possible etiologies revealed elevated blood ammonia and cancer antigen 125. Brain MRI demonstrated bilateral symmetric diffuse cortical lesions with mild hyperintensity on T1-weighted image and postcontrast enhancement. A more thorough history and specific examinations subsequently indicated an underlying etiology. This case provides an approach for evaluating young patients with rapidly progressive dementia, extreme hypoglycorrhachia, and diffuse CNS lesions, highlighting the importance of considering a broad differential diagnosis.

Impact of leukoaraiosis on the infarct growth rate and clinical outcome in acute large vessel occlusion stroke after endovascular thrombectomy.

INTRODUCTION: As a marker of chronic cerebral small vessel disease, leukoaraiosis (LA) was reported to impact the recruitment of collaterals in acute ischemic stroke (AIS). We intended to explore the impact of LA on the infarct growth rate (IGR) and clinical outcome by impaired collateral development in AIS patients with large vessel occlusion (LVO) who underwent endovascular thrombectomy (EVT). PATIENTS AND METHODS: Two hundred thirty-six AIS patients who underwent EVT were retrospectively reviewed. The severity of LA was graded using the Fazekas scale with non-contrast CT. IGR was calculated by the acute core volume on CT perfusion divided by the time from stroke onset to imaging. The collateral status after LVO was assessed using the ASITN/SIR collateral scale. The clinical outcomes after EVT were evaluated using a modified Rankin Scale (mRS). The Alberta stroke program early CT score (ASPECTS), the National Institutes of Health Stroke Scale (NIHSS) score at admission, and the modified treatment in cerebral infarction (mTICI) score after EVT were also included. Correlations between those factors were analyzed. RESULTS: Patients with severe LA had significantly larger core volume on CTP (p = 0.022) and lower collateral grade (p < 0.001). Faster IGR was significantly associated with higher LA severity (adjusted odds ratio [aOR]: 1.53; 95% CI: 1.02-2.33; p = 0.046), higher NIHSS (aOR: 1.04; 95% CI: 1.00-1.09; p = 0.032) and impaired collaterals (aOR: 2.26; 95% CI: 1.27-4.03; p = 0.005). In mediation analysis, collaterals explained 33% of the effect of LA on fast IGR. There was correlation between the severity of LA and mRS (p = 0.007). DISCUSSION AND CONCLUSION: The increasing severity of LA is associated with impaired collateral status and fast infarct growth. These findings suggest that LA may become a predictive imaging biomarker for the likelihood of progression of tissue injury and clinical outcome after EVT in acute large vessel occlusion stroke.

Core overestimation of CT perfusion in patients with cardiac insufficiency who had a stroke is mediated by impaired collaterals.

BACKGROUND: We hypothesized that left ventricular systolic dysfunction (LVSD) would lead to an ischemic core overestimation in patients with acute ischemic stroke (AIS), and impaired collateral status might partly mediate this effect. OBJECTIVE: A pixel-based analysis of CT perfusion (CTP) and follow-up CT was undertaken to investigate the optimum CTP thresholds for the ischemic core if overestimation was found. METHODS: A total of 208 consecutive patients with AIS with large vessel occlusion in the anterior circulation, who received initial CTP evaluation and successful reperfusion, were retrospectively analyzed and divided into an LVSD (left ventricular ejection fraction (LVEF) ratio <50%; n=40) and a normal cardiac function (LVEF≥50%; n=168) group. Ischemic core overestimation was considered when the CTP-derived core was larger than the final infarct volume. We investigated the relationship between cardiac function, probability for core overestimation, and collateral scores using mediation analysis. A pixel-based analysis was undertaken to define the optimum CTP thresholds for ischemic core. RESULTS: LVSD was independently associated with impaired collaterals (aOR=4.28, 95% CI 2.01 to 9.80, P<0.001) and core overestimation (aOR=2.52, 95% CI 1.07 to 5.72, P=0.030). In mediation analysis, the total effect on core overestimation is composed of the direct effect of LVSD (+17%, P=0.034) and the mediated indirect effect of collateral status (+6%, P=0.020). Collaterals explained 26% of the effect of LVSD on core overestimation. Compared with relative cerebral blood flow (rCBF) thresholds of <35%, <30%, and <20%, a rCBF <25% cut-off point had the highest correlation (r=0.91) and best agreement (mean difference 3.2±7.3 mL) with the final infarct volume to determine the CTP-derived ischemic core in patients with LVSD. CONCLUSIONS: LVSD increased the possibility of ischemic core overestimation on baseline CTP, partly due to impaired collateral status, and a stricter rCBF threshold should be considered.

Impact of high-sensitivity troponin elevation and dynamic changes on 90-day mortality in patients with acute ischemic stroke after mechanical thrombectomy: results from an observational cohort.

BACKGROUND: A study was undertaken to evaluate the impact of high-sensitivity cardiac troponin I (hs-cTnI) elevation and hs-cTnI dynamic changes on 90-day mortality in patients with acute ischemic stroke (AIS) treated with mechanical thrombectomy (MT). METHODS: Patients with AIS receiving MT were included in the study. Sixty hours after AIS onset, hs-cTnI levels were measured before and after MT to determine elevated and dynamic changes. Patients were stratified into either normal or hs-cTnI elevation groups according to the pre-MT hs-cTnI cut-off value of 0.03 ng/L. hs-cTnI dynamic changes were defined as an increase or decrease of more than 20% pre-MT and post-MT, and at least one hs-cTnI level >0.03 ng/L. Multivariate Cox regression models were used to investigate the association between hs-cTnI elevation, hs-cTnI dynamic changes, and 90-day mortality in patients with AIS after MT. RESULTS: A total of 423 patients with AIS after MT were included in our final analysis, of whom only 72 (17%) showed hs-cTnI elevation. Post-MT hs-cTnI retesting was performed in 354 patients, and 90 (25.4%) patients presented with hs-cTnI dynamic changes. 119 patients died within 90 days. After adjusting for potential confounding factors, the Cox regression model showed that patients with hs-cTnI dynamic changes, rather than hs-cTnI elevation, were associated with 90-day mortality (p<0.05). Compared with the hs-cTnI non-dynamic changes, these results showed that a statistical association was present between rising hs-cTnI dynamic changes and 90-day mortality (p>0.05). CONCLUSIONS: hs-cTnI dynamic changes, dominated by the rising pattern rather than hs-cTnI elevation, were independent factors associated with 90-day mortality in patients with AIS after MT, especially in elderly subjects.

Effects of predictive nursing intervention on cognitive impairment and neurological function in ischemic stroke patients.

BACKGROUND: Ischemic stroke is a clinical emergency caused by insufficient intracranial blood supply, which eventually leads to brain tissue necrosis and neurological impairment. Predictive nursing intervention has achieved impressive success in the nursing of multiple surgeries. However, the role of predictive nursing intervention in the care of patients with ischemic stroke remains unclear. METHODS: This study was a randomized controlled trial. Based on the inclusion and exclusion criteria, 126 patients were randomly assigned into two groups, namely the control group and the predictive nursing intervention group. Both groups were treated with thrombolytic therapy with alteplase. The patients in the control group were given routine nursing intervention and the predictive nursing intervention group received additional predictive care. Neurologic functions and cognitive impairment were evaluated by National Institutes of Health Stroke Scale (NIHSS), Fugl-Meyer assessment (FMA), Montreal cognitive assessment (MoCA), and mini-mental state examination (MMSE) scales, respectively. Door-to-Needle Times, venous thromboembolism (VTE)-related parameters, and complications were recorded. RESULTS: Predictive nursing intervention significantly shortened the Door-to-Needle Times and enhanced the peak/average femoral venous blood flow and femoral venous diameter. In addition, predictive nursing intervention improved the NIHSS, FMA, MMSE, and MoCA scores and remarkably reduced the recurrence of ischemic stroke, deep vein thrombosis and gingival bleeding. CONCLUSION: Predictive nursing intervention is beneficial to improve the effects of thrombolytic therapy in patients with ischemic stroke, which improves the neurological, cognitive and motor functions of patients, and reduces the occurrence of complications, suggesting an important clinical application value.

Thrombus enhancement sign on CT angiography is associated with the first pass effect of stent retrievers.

BACKGROUND: The thrombus enhancement sign (TES) is thought to be associated with the source of the stroke and thrombus composition. We investigated whether this imaging sign along with other thrombus characteristics could be used to predict the successful first pass effect (FPE) of mechanical thrombectomy. METHODS: 246 consecutive patients with acute ischemic stroke in the anterior circulation with large vessel occlusion who underwent thrombectomy with a stent retriever and clot collection were included. Patients were divided into FPE (modified Thrombolysis in Cerebral Infarction (mTICI) grade 2c or 3)/non-FPE (mTICI 0-2b) and modified FPE (mFPE) (mTICI 2b-3)/non-mFPE (mTICI 0-2a) groups based on flow restoration after the first pass. TES presence, thrombus density, thrombus length, clot burden score, and thrombus composition were compared. The association between FPE and imaging biomarkers, along with clinical and interventional parameters, was investigated by univariate and multivariate analysis. RESULTS: FPE was achieved in 85 (34.6%) patients. TES presence was significantly lower in the FPE group (64.7% vs 80.7% in the non-FPE group, p=0.008) and mFPE group (69.1% vs 81.0% in the non-mFPE group, p=0.039). Histopathological examination revealed that TES (+) thrombi contained a higher fibrin/platelet proportion (50.9% vs 46.9% in TES (-) thrombi, p=0.029) and fewer erythrocytes (43.3% vs 47.3% in TES (-) thrombi, p=0.030). Thrombus characteristics, namely shorter thrombus length (p=0.032), higher erythrocyte proportions (p=0.026), and less fibrin/platelets (p=0.014), were confirmed in patients with FPE. In multivariable analysis, TES was the only independent predictor of FPE failure (OR 0.51, 95% CI 0.28 to 0.94; p=0.031). CONCLUSIONS: TES was independently associated with first pass angiographic failure in patients treated with a stent retriever.

Thrombus Enhancement Sign May Differentiate Embolism From Arteriosclerosis-Related Large Vessel Occlusion.

BACKGROUND AND PURPOSE: To evaluate whether the thrombus enhancement sign (TES) can be used to differentiate embolic large vessel occlusion (LVO) from in situ intracranial atherosclerotic stenosis (ICAS)-related LVO in the anterior circulation of patients with acute ischemic stroke (AIS). METHODS: Patients with LVO in the anterior circulation who underwent both non-contrast computed tomography (CT) and CT angiography and mechanical thrombectomy were retrospectively enrolled. Both embolic LVO (embo-LVO) and in situ ICAS-related LVO (ICAS-LVO) were confirmed by two neurointerventional radiologists after reviewing the medical and imaging data. TES was assessed to predict embo-LVO or ICAS-LVO. The associations between occlusion type and TES, along with clinical and interventional parameters, were investigated using logistic regression analysis and a receiver operating characteristic curve. RESULTS: A total of 288 patients with AIS were included and divided into an embo-LVO group (n=235) and an ICAS-LVO group (n=53). TES was identified in 205 (71.2%) patients and was more frequently observed in those with embo-LVO, with a sensitivity of 83.8%, specificity of 84.9%, and area under the curve (AUC) of 0.844. Multivariate analysis showed that TES (odds ratio [OR], 22.2; 95% confidence interval [CI], 9.4-53.8; P<0.001) and atrial fibrillation (OR, 6.6; 95% CI, 2.8-15.8; P<0.001) were independent predictors of embolic occlusion. A predictive model that included both TES and atrial fibrillation yielded a higher diagnostic ability for embo-LVO, with an AUC of 0.899. CONCLUSION: TES is an imaging marker with high predictive value for identifying embo- and ICAS-LVO in AIS and provides guidance for endovascular reperfusion therapy.

No sex difference was found in the safety and efficacy of intravenous alteplase before endovascular therapy.

Background and purpose: Prior studies on sex disparities were post-hoc analyses, had limited treatment modalities, and had controversial findings. Our study aimed to examine whether sex difference modifies the effect of intravenous alteplase before endovascular therapy. Methods: We conducted a multicenter prospective cohort study of 850 eligible patients with acute ischemic stroke who underwent endovascular therapy. A propensity score was utilized as a covariate to achieve approximate randomization of alteplase pretreatment. The baseline characteristics of women and men were compared. Logistic regression with interaction terms, adjusted for potential confounders, was used to investigate the effect of sex on the prognosis of bridging therapy. Results: In comparison to men, women were older [78.00 (70.00-84.00) vs. 67 (61.00-74.00), P < 0.001], had more atrial fibrillation (61.4 vs. 35.2%, P < 0.001), had a lower ASPECTS [10.00 (8.00-10.00) vs. 10 (9.00-10.00), P = 0.0047], and had a higher NIHSS score [17.00 (14.00-20.00) vs. 16 (13.00-19.00), P = 0.005]. Women tended to receive less bridging therapy (26.3 vs. 33%, P = 0.043) and more retrieval attempts [2.00 (1.00-2.00) vs. 1 (1.00-2.00), P = 0.026]. There was no sex difference in functional independence at 90 days after bridging therapy (OR 0.968, 95% CI 0.575-1.63), whereas men benefited more after EVT alone (OR 0.654, 95% CI 0.456-0.937). There were no sex-treatment interactions observed regardless of the location of the occlusion. There were no significant sex differences in all safety outcomes. Conclusion: Our study could not confirm that sex modifies the treatment effect of intravenous alteplase before endovascular therapy. At the same time, we advocate for women to seek timely medical treatment.

Analyses on safety and efficacy of non-standard dose of r-tPA in intravenous thrombolysis-treated AIS patients.

Background: Intravenous 0.9 mg/kg recombinant tissue plasminogen activator (r-tPA) is one of the most effective treatments in acute ischemic stroke patients. Practically, the dose of r-tPA is still a topic that is constantly being discussed. Methods: For this observational study, data were obtained from 537 patients who received r-tPA thrombolysis at Shanghai Sixth People's Hospital stroke center over 5 years (2014-2019). Patients were divided into two groups: a non-standard dose group (0.6 mg/kg ≤ dose < 0.9 mg/kg) and a standard dose group (0.9 mg/kg). Different outcomes were observed: efficacy: 3 months mRS 0-1 (3m-mRS0-1); safety: symptomatic intracranial hemorrhage within 24 h (24h-sICH) and 3 months mortality (3m-death). We also observed the effect of r-tPA dose coefficient on outcomes in different age groups and baseline National Institute of Health stroke scale (NIHSS) score subgroups. Results: There were 265 patients who gave the standard dose treatment and 272 gave the nonstandard dose. There was no significant difference between the non-standard dose group and the standard dose group in 3m-mRS0-1, 3m-death, and 24h-sICH (p = 0.567, 0.327, and 0.415, respectively). The dose coefficient presents a significant negative correlation (p = 0.034, B = -4.290) with 3m-death in NIHSS < 16 sub-group. Door-to-needle time (DNT) is the most important independent outcome-influential factor (MIOIF) in the NIHSS ≥16 sub-group. The diabetes history and baseline NIHSS score were the MIOIF in the age ≥80-year sub-group. Conclusions: The non-standard dose group (0.6 mg/kg ≤ dose < 0.9 mg/kg) shows no difference in safety and effectiveness than the standard dose group (0.9 mg/kg) in our study. The standard dose should be considered first according to current evidence and Guidelines, but the non-standard dose (0.6 mg/kg ≤ dose < 0.9 mg/kg) might be an option in the actual diagnosis and treatment process considering the patient's clinical profile and financial condition.

Systemic Glycemic Variation Predicts Mortality of Acute Ischemic Stroke After Mechanical Thrombectomy: A Prospective Study Using Continuous Glucose Monitoring.

Objective: We investigated the association of glycemic variation with the clinical outcomes of large vessel occlusion (LVO) induced acute ischemic stroke (AIS) after mechanical thrombectomy (MT). Methods: We recruited consecutive ischemic patients with stroke. Glucose levels were assessed through continuous glucose monitoring in 70 patients with AIS who had undergone MT. Metrics including percentages of time of glucose levels above the range, the hypoglycemic range, and the time within the range, coefficient of variation, standard deviation (SD), mean of daily differences, mean amplitude of glycemic excursion, largest amplitude of glycemic excursion, high blood glucose index, and low blood glucose index. The outcomes of this observational study were in-hospital mortality, neurological improvement during hospitalization, functional independence, and mortality at follow-up (3 months). The associations of the blood glucose metrics with outcomes were analyzed. Results: The average period of glucose monitoring was 3.5 days, and serum glucose was recorded 728 times after MT for each person. The glycemic variation expressed in SDs was independently associated with in-hospital mortality [odds ratio (OR): 2.8, 95% confidence interval (CI): 1.276-6.145, p = 0.01] and the 3-month mortality (OR: 2.107, 95% CI: 1.013-4.382, p = 0.046) after adjusting for potential confounders. There was no association of glycemic variation with the 3-month clinical functional independence. Conclusions: Increased systemic glycemic variation was associated with higher odds of mortality of LVO-AIS after MT. Clinical Trial Registration: http://www.chictr.org.cn/showproj.aspx?proj=21016, identifier: ChiCTR-OOC-17012378.

Potential Factors Predicting Histopathologically Upgrade Discrepancies between Endoscopic Forceps Biopsy of the Colorectal Low-Grade Intraepithelial Neoplasia and Endoscopic Resection Specimens.

Background: It was gradually accepted that endoscopic fragment biopsy (EFB) diagnosis cannot accurately guarantee the absence of higher-grade neoplasms within the lesion of the digestive tract. There are no well-established predictors for histopathologically upgrade discrepancies between EFB diagnosing colorectal low-grade intraepithelial neoplasia (LGIN) and endoscopic resection (ER) specimens. Methods: A total of 918 colorectal LGINs was histopathologically diagnosed by EFB, including 162 cases with upgrade discrepancy and 756 concordant cases. We compared clinicopathological data of EFB and ER specimens between these two groups. Multivariate analysis was performed to identify predictors for this upgrade histopathology. Results: The predominant upgrade discrepancy of LGINs diagnosed by EFB was upgrades to high-grade dysplasia (114/918, 12.4%), followed by upgrades to intramucosal carcinoma (33/918, 3.6%), submucosal adenocarcinoma (10/918, 1.1%), and advanced adenocarcinoma (5/918, 0.5%). NSAID history (OR 4.83; 95% CI, 2.27-10.27; p < 0.001), insufficient EFB number (OR 2.99; 95% CI, 1.91-4.68; p < 0.001), maximum diameter ≥ 1.0 cm (OR 6.18; 95% CI, 1.32-28.99; p = 0.021), lobulated shape (OR 2.68; 95% CI, 1.65-4.36; p < 0.001), erythema (OR 2.42; 95% CI, 1.50-3.91; p < 0.001), erosion (OR 7.12; 95% CI, 3.91-12.94; p < 0.001), surface unevenness (OR 2.31; 95% CI, 1.33-4.01; p = 0.003), and distal location of the target adenoma (OR 3.29; 95% CI, 1.68-6.41; p < 0.001) were associated with the histologically upgrade discrepancies. Conclusion: NSAID history, insufficient EFB number, adenoma size and location, and abnormal macroscopic patterns are potential predictors for upgrade histopathology of LGINs diagnosed by EFBs. The standardization of EFB number and advanced imaging techniques could minimize the risk of neglecting the potential of this upgrade histopathology.