Safety and Outcome of Admission to Step-Down Level of Care in Patients with Low-Risk Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-analysis.

Spontaneous intracerebral hemorrhage (ICH) is the most devastating type of stroke, and it is associated with high morbidity and mortality. Patients with a spontaneous ICH are routinely admitted to an intensive care unit (ICU). However, an ICU is a valuable and limited resource, and not all patients may require this level of care. The authors conducted a systematic review and meta-analysis evaluating the safety and outcome of admission to a step-down level of care or stroke unit (SU) compared to intensive care in adult patients with low-risk spontaneous ICH. PubMed, Embase, and the Cochrane Library were searched for randomized clinical trials and observational cohort studies. The Mantel-Haenszel method or inverse variance, as applicable, was applied to calculate an overall effect estimate for each outcome by combining the specific risk ratio (RR) or standardized mean difference. Risk of bias was analyzed using the Newcastle-Ottawa Scale. The protocol was registered in PROSPERO (CRD42023481915). The primary outcome examined was in-hospital mortality. Secondary outcomes were unfavorable short-term outcome, length of hospital stay, and (re)admission to the ICU. Five retrospective cohort studies involving 1347 patients were included in the qualitative analysis. Two of the studies had severity-matched groups. The definition of low-risk ICH was heterogeneous among the studies. Admission to an SU was associated with a similar rate of mortality compared to admission to an ICU (1.4% vs. 0.6%; RR 1.66; 95% confidence interval [CI] 0.24-11.41; P = 0.61), a similar rate of unfavorable short-term outcome (14.6% vs. 19.2%; RR 0.77; 95% CI 0.43-1.36; P = 0.36), and a significantly shorter mean length of stay (standardized mean difference - 0.87 days; 95% CI - 1.15 to - 0.60; P < 0.01). Risk of bias was low to moderate for each outcome. The available literature suggests that a select subgroup of patients with ICH may be safely admitted to the SU without affecting short-term outcome, potentially saving in-hospital resources and reducing length of stay. Further studies are needed to identify specific and reliable characteristics of this subgroup of patients.

Stroke Risk before and after Central Retinal Artery Occlusion: A Population-based Analysis.

PURPOSE: To determine the risk of stroke, transient ischemic attack (TIA), and transient monocular vision loss (TMVL) before and after a central retinal artery occlusion (CRAO). DESIGN: Population-based, retrospective case series. PARTICIPANTS: Patients diagnosed with a CRAO in Olmsted County, Minnesota, from 1976 to 2016. METHODS: Patients living in Olmsted County with a diagnosis code of CRAO from 1976 to 2016 were reviewed. New CRAOs were confirmed, and stroke, TIA, and TMVL events in the 15 days before and after CRAO were recorded. MAIN OUTCOME MEASURES: Incidence of stroke, TIA, and TMVL events in the 15 days before and after CRAO. RESULTS: Eighty-nine patients with a CRAO were identified, providing an annual incidence of 2.58/100 000 (95% confidence interval [CI], 2.04-3.11). Median age at the time of CRAO was 76 years (range, 46-100 years); 56.2% were male, and 89.9% of the cohort was White. In the 15 days before and after CRAO, there were 2 ischemic strokes (2.2%), 1 hemorrhagic stroke (1.1%), 2 TIAs (2.2%), and 9 TMVL events (10.1%). Starting in 1999, 15 of 45 patients underwent magnetic resonance imaging within 2 months of CRAO. One patient (6.7%) had evidence of asymptomatic diffusion restriction, and 9 patients (60%) had a remote infarct. CONCLUSIONS: This population-based study demonstrated that the risk of symptomatic ischemic stroke is 2.2% in the 15 days before and after a CRAO, which is slightly lower than most studies from tertiary centers. These data should be considered as practice recommendations are developed regarding the urgency of neurovascular workup in patients with acute CRAO.

Evaluation and treatment of headache associated with moyamoya disease - a narrative review.

BACKGROUND: Headache in patients with moyamoya disease is an under-addressed topic in the medical literature. Delay in the diagnosis of moyamoya disease or inappropriate treatment of headache could lead to devastating cerebrovascular outcome. With the evolving understanding of moyamoya disease, migraine pathophysiology, and various migraine-specific medications that have become available, it is crucial to provide an updated overview on this topic. METHODS: We searched PubMed for keywords including moyamoya disease, moyamoya syndrome, headache in moyamoya, surgical revascularization, surgical bypass, migraine and moyamoya, and calcitonin gene-related peptide (CGRP). We summarized the literature and provide a comprehensive review of the headache presentation, possible mechanisms, the impact of various surgical revascularizations on headache in patients with moyamoya disease, and the medical management of headache incorporating novel migraine-specific treatments.Results and conclusion: The most common headache phenotype is migraine; tension-type headache, hemiplegic migraine, and cluster headache have also been reported. Most patients experience improvement of headache after surgical revascularization, though some patients report worsening, or new-onset headache after surgery. Given the complexity of moyamoya disease, careful consideration of different types of medical therapy for headache is necessary to improve the quality of life while not increasing the risk of adverse cerebrovascular events. More prospective studies are warranted to better understand and manage headache in patients with moyamoya disease.

Vessel wall imaging features of Moyamoya disease in a North American population: patterns of negative remodelling, contrast enhancement, wall thickening, and stenosis.

BACKGROUND: This study characterized vessel wall imaging (VWI) features of Moyamoya disease (MMD) in a predominantly adult population at a North American center. METHODS: Consecutive patients with VWI were included. Twelve arterial segments were analyzed for wall thickening, degree and pattern of contrast enhancement, and remodeling. RESULTS: Overall, 286 segments were evaluated in 24 patients (mean age = 36.0 years [range = 1-58]). Of 172 affected segments, 163 (95%) demonstrated negative remodeling. Complete vessel wall obliteration was most frequent in the proximal M1 (17/48, 35%). Affected segments enhanced in 72/172 (42%) (n = 15 for grade II; n = 54 for concentric and n = 18 for eccentric); 20 of 24 (83%) patients had at least one enhancing segment. Both enhancing and non-enhancing segments were present in 19/20 (95%) patients. Vessel wall enhancement was most common in the proximal segments and correlated to the degree of stenosis (p < 0.001), and outer wall diameter (p < 0.001), but not disease duration (p = 0.922) or Suzuki score (p = 0.477). Wall thickening was present in 82/172 (48%) affected segments and was associated with contrast enhancement (p < 0.001), degree of stenosis (p < 0.001), and smaller outer wall diameter (p = 0.004). CONCLUSION: This study presents VWI findings in North American patients with MMD. Negative remodeling was the most common finding. Most patients had both enhancing and non-enhancing abnormal segments. Vessel wall enhancement was most common in proximal segments, variable in pattern or degree and was correlated to the degree of stenosis and smaller outer wall diameter.

The Frequency of Carotid Intraplaque Hemorrhage on Vessel Wall Imaging in Patients With Retinal Artery Occlusion: A Cross-Sectional Prevalence Study.

BACKGROUND: Intraplaque hemorrhage (IPH) in a carotid artery plaque viewed on vessel wall imaging has been shown to be associated with ischemic stroke. Whether such an association between carotid IPH and retinal artery occlusion (RAO) exists remains unknown. METHODS: This was a cross-sectional prevalence study. Medical and imaging records of all patients who underwent neck MRA with plaque imaging sequences at our institution from 2015 to 2020 were retrospectively reviewed. Fourteen patients with confirmed RAO and plaque imaging performed within 6 weeks of presentation were included. A group of 211 patients without a prior ischemic event (RAO, stroke, etc.) with plaque imaging were used as controls. A single artery from control patients was randomly selected. The prevalence of IPH and degree of ipsilateral carotid stenosis were compared between RAO and control patients. Multiple regression analysis was performed to determine independent associations between variables and RAO. RESULTS: Five patients (35.7%) with RAO had imaging evidence of ipsilateral IPH in contrast to 7 of 211 (3.3%) patients in the control group (odds ratio [OR]: 16.2, 95% confidence interval [95% CI]: 4.3-61.1, P = 0.0002). Of the 5 patients with RAO and ipsilateral IPH, only one (20.0%) was found to ipsilateral carotid stenosis greater than 70%. Carotid IPH was the only variable that was independently associated with RAO (OR: 12.6, 95% CI = 2.2-73.6, P = 0.005). CONCLUSIONS: Carotid IPH is independently associated with RAO. The use of plaque imaging in the evaluation of patients with acute RAO is therefore supported.

Stroke Rate, Subtype, and Cardiovascular Risk Factors in Nonarteritic Anterior Ischemic Optic Neuropathy: A Population-Based Study.

BACKGROUND: Nonarteritic anterior ischemic optic neuropathy (NAION) is a common cause of acute optic neuropathy in adults and is associated with vascular risk factors. Owing to the overlapping risk factor profiles between NAION and cerebral stroke, previous studies have produced conflicting results with regard to NAION as an independent risk factor for stroke. METHODS: A retrospective chart review was conducted using the Rochester Epidemiology Project database to identify all cases of NAION occurring among Olmsted County, Minnesota residents from January 1, 1990, through December 31, 2016. Stroke events were characterized using clinical and radiologic data. Comparison was made to an age- and sex-matched control group with similar vascular risk factors. RESULTS: One-hundred four patients with NAION and 104 control subjects were analyzed. Median age at diagnosis was 65 years (range, 40-90 years). Thirteen patients (13%) with NAION and 10 controls (10%) had symptomatic strokes after the age of 40 years. Among patients with NAION, 6 (46%) suffered a stroke before the diagnosis of NAION, 5 (39%) at least 5 months after the NAION diagnosis, and 2 patients (15%) suffered strokes both before and after the NAION. The cumulative probability of symptomatic strokes for patients with NAION was not significantly different than for controls (hazard ratio = 1.50, 95% confidence interval: 0.66-3.42; P = 0.34). There were no cardioembolic strokes within 1 month of the NAION diagnosis. The mechanism of symptomatic strokes did not differ between the 2 groups. CONCLUSIONS: NAION does not confer an increased risk of symptomatic stroke beyond the risk posed by age and existing vascular risk factors.

High prevalence of pro-thrombotic conditions in adult patients with moyamoya disease and moyamoya syndrome: a single center study.

BACKGROUND: Moyamoya Disease (MMD) and moyamoya Syndrome (MMS) have been reported to be associated with pro-thrombotic states in some patients. To date, however, such reports have been limited to case reports or small case series. We sought to determine the prevalence of pro-thrombotic states among a large cohort of both MMD and MMS patients. METHODS: We retrospectively reviewed the medical records of all adult patients who were diagnosed with MMD or MMS from our institution. In addition to basic demographic and clinical data, the presence of certain pro-thrombotic conditions was noted. The presence of such conditions was determined based on review of clinical diagnoses and laboratory reports. The length of follow-up and the presence of interval ischemic events were obtained. RESULTS: Out of a total of 180 patients diagnosed with MMD or MMS, 33 were found to have a concomitant pro-thrombotic condition (18.3%). Of 147 patients with MMD, 23 were found to have a pro-thrombotic condition (15.6%). There were 10 out of 33 total patients (30.3%) in the MMS cohort that had a concomitant pro-thrombotic condition. There were no differences in specific pro-thrombotic conditions between MMD and MMS cohorts. There were no differences in future ischemic events between moyamoya patients with pro-thrombotic tendencies compared to those without (13.3% versus 23.7%, respectively, P = 0.32), and this was also true for patients who underwent revascularization procedures (22.6% versus 29.4%, P = 0.76). There was also no difference in prevalence of revascularization graft occlusion between moyamoya patients with pro-thrombotic tendencies and those without at follow-up (1.2% versus 5.9%, P = 0.31). CONCLUSIONS: It is likely that both MMD and MMS are associated with or predispose to pro-thrombotic conditions in adult patients, although the clinical and surgical significance is uncertain. Further study is needed in order to further elucidate and characterize this potential association.

Contemporary and emerging magnetic resonance imaging methods for evaluation of moyamoya disease.

Numerous recent technological advances offer the potential to substantially enhance the MRI evaluation of moyamoya disease (MMD). These include high-resolution volumetric imaging, high-resolution vessel wall characterization, improved cerebral angiographic and perfusion techniques, high-field imaging, fast scanning methods, and artificial intelligence. This review discusses the current state-of-the-art MRI applications in these realms, emphasizing key imaging findings, clinical utility, and areas that will benefit from further investigation. Although these techniques may apply to imaging of a wide array of neurovascular or other neurological conditions, consideration of their application to MMD is useful given the comprehensive multidimensional MRI assessment used to evaluate MMD. These MRI techniques span from basic cross-sectional to advanced functional sequences, both qualitative and quantitative.The aim of this review was to provide a comprehensive summary and analysis of current key relevant literature of advanced MRI techniques for the evaluation of MMD with image-rich case examples. These imaging methods can aid clinical characterization, help direct treatment, assist in the evaluation of treatment response, and potentially improve the understanding of the pathophysiology of MMD.

Rethinking Prehospital Stroke Notification: Assessing Utility of Emergency Medical Services Impression and Cincinnati Prehospital Stroke Scale.

BACKGROUND AND PURPOSE: Although prehospital stroke notification has improved stroke treatment, incorporation of these systems into existing infrastructure has resulted in new challenges. The goal of our study was to design an effective prehospital notification system that allows for early and accurate identification of patients presenting with acute stroke. METHODS: We conducted a retrospective single-center cohort study of patients presenting with suspicion of acute stroke from 2014 to 2015. Data recorded included patient demographics, time of symptom onset, Cincinnati Prehospital Stroke Scale (CPSS) score, Glasgow Coma Scale score, National Institutes of Health Stroke Scale (NIHSS) score, emergency medical services (EMS) impression, acute stroke pager activation, acute intervention, and discharge diagnosis. Univariate logistic regression was performed with discharge diagnosis of stroke as the end point. RESULTS: A total of 130 patients were included in the analysis; 96 patients were discharged with a diagnosis of stroke or transient ischemic attack. Both NIHSS and the presence of face, arm and speech abnormalities on CPSS were significantly higher in patients with stroke (P < .05). EMS correctly recognized stroke in 77.1% of cases but falsely identified stroke in 85.3% of negative cases. CPSS identified 75% of acute stroke cases, but specificity was poor at only 20.6%. All patients receiving intervention had acute stroke pager activation in Emergency Department. CONCLUSIONS: Prehospital stroke notification systems utilizing EMS impressions and stroke screening tools are sensitive but lack appropriate specificity required for modern acute stroke systems of care. Better solutions must be explored so that prehospital notification can keep pace with advances in acute stroke treatment.

Factors Associated with the Need for Intensive Care Unit Admission Following Supratentorial Intracerebral Hemorrhage: The Triage ICH Model.

BACKGROUND: Providing the correct level of care for patients with intracerebral hemorrhage (ICH) is crucial, but the level of care needed at initial presentation may not be clear. This study evaluated factors associated with admission to intensive care unit (ICU) level of care. METHODS: This is an observational study of all adult patients admitted to our institution with non-traumatic supratentorial ICH presenting within 72 h of symptom onset between 2009-2012 (derivation cohort) and 2005-2008 (validation cohort). Factors associated with neuroscience ICU admission were identified via logistic regression analysis, from which a triage model was derived, refined, and retrospectively validated. RESULTS: For the derivation cohort, 229 patients were included, of whom 70 patients (31 %) required ICU care. Predictors of neuroscience ICU admission were: younger age [odds ratio (OR) 0.94, 95 % CI 0.91-0.97; p = 0.0004], lower Full Outline of UnResponsiveness (FOUR) score (0.39, 0.28-0.54; p < 0.0001) or Glasgow Coma Scale (GCS) score (0.55, 0.45-0.67; p < 0.0001), and larger ICH volume (1.04, 1.03-1.06; p < 0.0001). The model was further refined with clinician input and the addition of intraventricular hemorrhage (IVH). GCS was chosen for the model rather than the FOUR score as it is more widely used. The proposed triage ICH model utilizes three variables: ICH volume ≥30 cc, GCS score <13, and IVH. The triage ICH model predicted the need for ICU admission with a sensitivity of 94.3 % in the derivation cohort [area under the curve (AUC) = 0.88; p < 0.001] and 97.8 % (AUC = 0.88) in the validation cohort. CONCLUSIONS: Presented are the derivation, refinement, and validation of the triage ICH model. This model requires prospective validation, but may be a useful tool to aid clinicians in determining the appropriate level of care at the time of initial presentation for a patient with a supratentorial ICH.

Seizures Following Ischemic Stroke: Frequency of Occurrence and Impact on Outcome in a Long-Term Population-Based Study.

BACKGROUND AND PURPOSE: Seizures are a known complication of ischemic stroke (IS). This study assesses the long-term incidence and characteristics of poststroke seizures in a well-defined population. METHODS: Using the Rochester Epidemiology Project medical records-linkage system, we identified all incident cases of IS among Rochester, Minnesota, residents from 1990 to 1994 and followed the patients in the comprehensive medical record through March 2014. All patients with poststroke seizures were identified, and data regarding incident IS, seizures, and status at last follow-up were analyzed. RESULTS: We identified 489 patients with first IS. Mean follow-up was 6.5 (standard deviation 6.3) years. New onset seizures occurred in 35 patients (7.2%). Patients with poststroke seizure did not differ from those without in terms of IS etiologic subtype (P = .44) or IS risk factors (P > .05). Early seizures (within 14 days of index stroke) developed in 14 patients (40%), the majority within the first 24 hours (n = 9, 64.3%). The median time of seizure onset for the remaining 21 patients was 13.8 months. Functional outcome, as measured by modified Rankin Scale (mRS), was worse following development of poststroke seizures (mean mRS score 2.9 after IS, 3.3 following index seizure; P = .005), and mortality was higher as well, even after adjusting for IS etiologic subtype (HR 1.52, 95% confidence interval 1.07-2.16, P = .02). CONCLUSION: Development of poststroke seizures is an infrequent but significant complication of IS, portending a worse short-term functional outcome and a higher long-term mortality rate. Seizure occurrence did not differ based on IS etiologic subtype or stroke risk factors.

Influence of antithrombotics on the etiology of intracerebral hemorrhage.

BACKGROUND: To determine the influence of antithrombotic use on the etiology of primary intracerebral hemorrhage (ICH). METHODS: We conducted a retrospective review of consecutive patients admitted with primary ICH from 2009 to 2012. Data recorded included age, history of hypertension, and use of antithrombotic medications. Imaging was reviewed to determine hemorrhage location and the presence and the location of any microhemorrhages. Etiologies were classified using a predetermined algorithm, which was based on existing literature. RESULTS: In total, 292 patients were included. Median age was 74 years (range, 18-101), and 52% were male (n = 151). Hemorrhage etiology was hypertension in 50.6% (n = 148), indeterminate in 29.5% (n = 86), and cerebral amyloid angiopathy (CAA) in 19.9% (n = 58). Most patients were on antithrombotics (61.3%, n = 179). Nearly half of the patients (49%) were 75 years of age or older, and the most common etiology in this group was hypertension (n = 77, 53%). There was a nonsignificant trend toward older age and CAA-ICH (median age, 77 years; interquartile range [IQR], 70-82 years) compared with other causes (median age, 74 years; IQR, 61-82 years; P = .07). There was no difference between CAA-ICH and other-cause ICH with respect to proportion of patients on antithrombotics in general (67% versus 60%; P = .367) or anticoagulants in particular (24% versus 25%; P = 1.000). CONCLUSIONS: The most common ICH etiology in this study was hypertension, regardless of age. Our findings do not suggest that the higher occurrence of ICH in older patients or in patients with CAA-associated ICH is because of a higher frequency of anticoagulant use.

Neuropsychiatric Symptoms of Moyamoya Disease: Considerations for the Clinician.

Neurocognitive impairment in moyamoya disease is common, under recognized, and potentially devastating. The purpose of this paper is to provide an updated overview on this topic for the practicing clinician. We searched PubMed for keywords including cognitive impairment, neurocognitive dysfunction, and neuropsychological recovery in moyamoya disease. We summarized the literature to provide a concise review of the treatment and management of neuropsychiatric symptoms associated with moyamoya disease. Neuropsychiatric sequelae have conventionally been attributed to chronic cerebral hypoperfusion and/or stroke. Cognitive dysfunction in adults with moyamoya disease is most commonly in the form of impaired executive function, whereas intelligence is the predominant impairment in children with moyamoya disease. Pharmacotherapy for treatment of the neuropsychiatric symptoms associated with moyamoya disease is appropriate and can improve quality of life; however, careful consideration is needed to avoid adverse cerebrovascular events. It remains unclear as to whether surgical revascularization improves or stabilizes cognitive performance and outcomes. Additional prospective studies are warranted to better understand the long-term impact of revascularization on cognitive functioning in moyamoya disease.

Concurrent Moyamoya-like Intracranial Steno-Occlusive Disease and Dural Arteriovenous Fistulas.

The simultaneous presentation of intracranial steno-occlusive disease, Moyamoya disease, or Moyamoya-like vasculopathy and dural arteriovenous fistulas (DAVFs) has been documented in very few case reports worldwide. We aimed to better characterize this association by reviewing the clinical and radiologic findings of 4 patients with concurrent intracranial steno-occlusive disease or Moyamoya-like vasculopathy and DAVFs evaluated in our institution. All 4 patients were of Asian descent. One patient presented with ischemic stroke secondary to intracranial stenosis, 2 presented with symptoms related to the DAVF, and the diagnosis was incidental in the fourth patient. Three patients underwent embolization of the DAVF, which was followed by surgical ligation in 2. One patient underwent extracranial-intracranial bypass for Moyamoya-like intracranial steno-occlusive disease. One patient is being managed conservatively with close follow-up. Our case series details findings in 4 patients with associated intracranial steno-occlusive disease and DAVFs. Further studies and reporting of similar cases are necessary to establish whether this is pure coincidence or if there is indeed a relationship between these 2 conditions, especially in certain ethnic groups.

The Heart Brain Team and Patient-Centered Management of Ischemic Stroke.

The multifaceted connections between the heart and the brain have been extensively studied at the anatomy, pathophysiology, and clinical levels. Studies have suggested a vital role for both cardiologists and neurologists in the management of various cardiovascular and neurological disorders. However, a true heart-brain team-based approach remained confined to large, specialized centers. In this paper, we review the various intersection areas of cardiology and neurology with regard to ischemic stroke. We focus our discussion on the challenges and opportunity for a heart-team approach to stroke in the context of atrial fibrillation, carotid disease, and patent foramen ovale, and in the setting of strokes complicating transcatheter endovascular interventions.

Change of Heart: The Underexplored Role of Plaque Hemorrhage in the Evaluation of Stroke of Undetermined Etiology.

In the evaluation of embolic strokes of undetermined source, great emphasis is often placed on cardiovascular disease, namely on atrial fibrillation. Other pathophysiologic mechanisms, however, may also be involved. Carotid artery intraplaque hemorrhage (IPH)-the presence of blood components within an atheromatous plaque-has become increasingly recognized as a possible etiologic mechanism in some cryptogenic strokes. IPH is a marker of plaque instability and is associated with ipsilateral neurologic ischemic events, even in nonstenotic carotid plaques. As recognition of carotid IPH as an etiology of embolic strokes has grown, so too has the complexity with which such patients are evaluated and treated, particularly because overlaps exist in the risk factors for atrial fibrillation and IPH. In this article, we review what is currently known about carotid IPH and how this clinical entity should be approached in the context of the evaluation of embolic strokes of undetermined source.