Angiography-based hemodynamic features predict recurrent ischemic events after angioplasty and stenting of intracranial vertebrobasilar atherosclerotic stenosis.

OBJECTIVES: To assess the predictive value of hemodynamic features for stroke relapse in patients with intracranial vertebrobasilar atherosclerotic stenosis treated with percutaneous transluminal angioplasty and stenting (PTAS) using quantitative digital subtraction angiography (q-DSA). METHODS: In this retrospective longitudinal study, patients with intracranial vertebrobasilar atherosclerotic stenosis and who underwent PTAS treatment between January 2012 and May 2020 were enrolled. The q-DSA assessment was performed before and after PTAS. ROIs 1-4 were placed along the vertebral artery, proximal and distal basilar artery, and posterior cerebral artery; ROIs 5-8 were in 5 mm and 10 mm proximal and distal to the lesion, respectively. Relative time to peak (rTTP) was defined as the difference in TTP between ROIs. Cox regression analyses were performed to determine risk factors for recurrent stroke. RESULTS: A total of 137 patients (mean age, 62 years ± 10 [standard deviation], 83.2% males) were included, and 26 (19.0%) patients had stroke relapse during follow-up (median time of 42.6 months [interquartile range, 19.7-60.7]). Preprocedural rTTP4-1 (adjusted hazard ratio (HR) = 2.270; 95% CI 1.371-3.758; p = 0.001) and preprocedural rTTP8-5 (adjusted HR = 0.240; 95% CI 0.088-0.658; p = 0.006) were independently associated with the recurrent stroke. These hemodynamic parameters provided an incremental prognostic value for stroke relapse (AUC, 0.817 [0.704-0.931]; the net reclassification index, 0.431 [0.057-0.625]; and the integrated discrimination index, 0.140 [0.035-0.292]). CONCLUSIONS: In patients with intracranial vertebrobasilar atherosclerosis treated with PTAS, preprocedural prolonged TTP of the target vessel and shortened trans-stenotic TTP difference were associated with stroke relapse. Q-DSA-defined hemodynamic parameters provided incremental predictive value over conventional parameters for stroke recurrence. CLINICAL RELEVANCE STATEMENT: Quantitative DSA analysis enables intuitive observation and semi-quantitative evaluation of peri-therapeutic cerebral blood flow. More importantly, quantitative DSA-defined hemodynamic parameters have the potential for risk stratification of patients with intracranial atherosclerotic stenosis. KEY POINTS: Semi-quantitative angiography-based parameters can reflect pre- and postprocedural subtle changes in blood flow in patients with intracranial atherosclerotic stenosis. Although angioplasty procedures can significantly improve blood flow status, patients with more restricted baseline blood flow still show a higher risk of stroke recurrence. Angiography-based hemodynamic features possess prognostic value and can serve as clinical markers to assess stroke risk of patients with intracranial atherosclerotic stenosis.

The relationship between occlusion patterns and outcomes after thrombectomy in patients with acute internal carotid artery occlusion.

BACKGROUND AND PURPOSES: Ischemic stroke caused by acute internal carotid artery occlusions (AICO) is usually associated with high disability and mortality. We aimed to investigate whether occlusion patterns significantly influence clinical outcome in patients receiving endovascular thrombectomy (EVT). PATIENTS AND METHODS: We performed a retrospective analysis of databases from two comprehensive stroke centers and consecutively investigated patients who had underwent EVT. AICO was defined as acute internal carotid artery occlusions (cervical segment to terminal segment). The clinical characteristics, intervention parameters, and prognosis data were collected. Leptomeningeal collaterals (LMC) were assessed with the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology scale (ASITN/SIRs), graded on a 5-point scale. The occlusion patterns based on Willisian collaterals were categorized into I-type, L-type, and T-type by contralateral carotid artery injections at digital subtraction angiography. Multivariate regression models were applied to evaluate the relationship between occlusion patterns and the prognosis of patients at 90 days after stroke. RESULTS: A total of 213 patients were included in the study. Of those,142 (66.7%) achieved successful reperfusion and 64 (30.0%) achieved favorable outcomes at 90 days. Overall, 26 (12.2%), 117 (54.9%), and 70 (32.9%) cases respectively suffered from I-type, L-type, and T-type occlusion. In addition, patients with I-type occlusions had a higher percentage of complete LMC compared with L-type or T-type occlusions (88.5% versus 30.8% versus 27.1%, P< 0.0167). In multivariable logistic regression, we found T-type occlusion was no longer an independent predictor of poor functional outcomes in AICO after adjusting LMC (T versus I, OR, 2.555, 95%CI: 0.717-9.103, P = 0.148; L versus I, OR, 0.815, 95%CI: 0.258-2.574, P = 0.727). CONCLUSIONS: For ACIO, occlusion patterns are still a topic that needs attention. Furthermore, compensatory LMC may affect the association between occlusion patterns and functional prognosis in AICO. Occlusion patterns and LMC status distinguish the nature and impact of AICO on expected EVT and subsequent clinical outcomes.

Non-alcoholic fatty liver disease and stroke: A Mendelian randomization study.

BACKGROUND: The association between non-alcoholic fatty liver disease (NAFLD) and the risk of stroke is heterogeneous. Therefore, we aimed to examine any potential causal relationship between these two traits through Mendelian randomization. METHODS: The genetic instruments associated with NAFLD were selected from a large genome-wide association study in individuals of European ancestry (1483 cases and 17,781 controls, replicated in 559 cases and 945 controls). The genetic associations for stroke (40,585 cases and 406,111 controls) and ischemic stroke (34,217 cases and 406,111 controls) were selected from the MEGASTROKE consortium of European ancestry participants. The causal effects on ischemic stroke subtypes, including large artery atherosclerosis (LAA) (4373 cases and 146,392 controls), small vessel occlusion (SVO) (5386 cases and 192,662 controls), and cardioembolic stroke (7193 cases and 204,570 controls), were also analyzed. The inverse variant weighted method was performed to obtain the casual estimates. Heterogeneity and pleiotropy of individual single nucleotide polymorphisms were also tested for the robustness of the results. RESULTS: NAFLD was not associated with stroke (odds ratio [OR] 1.015; 95% confidence interval [CI] 0.996-1.034; p = 0.121) and ischemic stroke (OR 1.017; 95% CI 0.997-1.037; p = 0.092). Regarding ischemic stroke subtypes, there were positive causal inferences on LAA (OR 1.065; 95% CI 1.004-1.129; p = 0.037) and SVO (OR 1.058; 95% CI 1.003-1.116; p = 0.037), while it was not significant for cardioembolic stroke (OR 1.026; 95% CI 0.983-1.071; p = 0.243). CONCLUSION: This study suggests that the potential causal effect of NAFLD on ischemic stroke may be confined to the LAA and SVO subtypes.

Predictors of mortality for acute vertebrobasilar artery occlusion receiving endovascular treatment.

OBJECTIVES: Acute vertebrobasilar artery occlusion (VBAO) is a devastating type of stroke with a high mortality rate. This study aimed to investigate the predictors of 3-month and 1-year mortality in VBAO patients receiving endovascular treatment (EVT). MATERIALS & METHODS: Consecutive acute VBAO patients undergoing EVT between January 2014 and December 2019 were retrospectively analyzed in a prospectively maintained database. Multivariate logistical regression models were used to explore the potential predictors of mortality at 3 months and 1 year, respectively. The discrimination of the final model was assessed with the area under the receiver operating characteristic curve. RESULTS: A total of 100 patients were enrolled in this study (mean age 62 years; 77.0% male). After excluding patients lost to follow-up, the overall mortality rate was 34.3% (34/99) at 3 months and 45.4% (44/97) at 1 year. The Glasgow Coma Scale (GCS) score at 24 h (Odds ratio [OR], 0.676; 95% confidence interval [CI], 0.540-0.846; p = .001) and mechanical ventilation (MV) (OR, 7.356; 95% CI, 2.200-24.593; p = .001) were predictors of 3-month mortality after adjusting for potential confounders in multivariable analysis. Furthermore, the GCS score at 24 h (OR, 0.714; 95% CI, 0.590-0.864; p = .001), intracranial hemorrhage (OR, 7.330; 95% CI, 1.772-30.318; p = .006), and MV (OR, 5.804; 95% CI, 1.841-18.294; p = .003) were independently associated with mortality at 1 year. Sensitivity analyses showed similar results. CONCLUSION: The 24-h GCS score and MV were common predictors of 3-month and 1-year mortality, and ICH was an additional predictor of 1-year mortality.

Increased intracranial hemorrhage of mechanical thrombectomy in acute ischemic stroke patients with atrial fibrillation.

The impact of atrial fibrillation (AF) on outcomes of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is controversial, and with a paucity of evidence base. This study aimed to investigate the potential association between AF and outcomes after MT in AIS patients. A post-hoc analysis of a multi-center prospective clinical trial was conducted. Before and after propensity score matching (PSM), the clinical features were compared between patients with and without AF. Multivariable logistic regression and mediation analyses were performed to assess the relationship between AF and ICH. Of the total 245 patients, 123 patients were included in the AF group. After PSM, the AF group showed more retrieval attempts (P = 0.004), comparable favorable outcome (P = 0.493), and mortality (P = 0.362) at 90 days. Multivariate analysis revealed that AF was significantly associated with increased risk for ICH (OR 2.198; 95%CI 1.099-4.395; P = 0.026). INR and retrieval attempts were found to act as partial mediations. In the subgroup with lower INR, AF still had a significant association with ICH (OR 2.496; 95%CI 1.331-4.679; P = 0.004). In AIS patients undergoing MT, AF was associated with more retrieval attempts and higher risk of any ICH. Of note, the effect of AF on the increased risk of ICH was partly attributable to the adjusted anticoagulation status and more retrieval attempts. It is crucial to elaborately prevent ICH after thrombectomy for stroke patients with AF.

Bridge mechanical thrombectomy may be a better choice for acute large vessel occlusions.

Direct mechanical thrombectomy (DMT) was confirmed non-inferior to bridge mechanical thrombectomy (BMT, MT preceded by intravenous alteplase within 4.5 h after symptom onset) for acute ischemic stroke with large vessel occlusions (AIS-LVO) in mothership patients. However, the noninferiority of DMT in the general population (including drip and ship mode) is controversial, and the impact of thrombolysis on retrieval attempts remains uncertain. This was a post-hoc analysis of a multi-center, prospective enrolled study. Patients were divided into the BMT group and the DMT group. Baseline characteristics and clinical outcomes were compared by using univariate analysis, multivariable analysis, and propensity score matching analysis, respectively. Of all 245 patients enrolled in this study, 79 (32.2%) patients underwent BMT. In the multivariable analysis, the ratio of excellent prognosis (defined as modified Rankin Scale [mRS] score 0-1 at 90 days) was significantly higher in the BMT group compared with the DMT group (odds ratio, 2.731; 95% confidence interval, 1.238-6.023; P = 0.013). The ratio of good prognosis (mRS score 0-2 at 90 days), successful recanalization rate [modified Thrombolysis In Cerebral Ischemia (mTICI) score 2b-3] and mortality rate were similar between the two groups. The excellent prognosis rate was significantly higher in the BMT group after propensity score matching (P = 0.023). BMT was associated with a higher ratio of excellent prognosis (mRS 0-1) and a similar successful recanalization rate without increasing peri-operation complications compared with DMT in AIS-LVO patients. It is prudent to continue BMT until further data is available.

The effect of noise exposure on insulin sensitivity in mice may be mediated by the JNK/IRS1 pathway.

BACKGROUND: Epidemiological studies have suggested that noise exposure may increase the risk of type 2 diabetes mellitus (T2DM), and experimental studies have demonstrated that noise exposure can induce insulin resistance in rodents. The aim of the present study was to explore noise-induced processes underlying impaired insulin sensitivity in mice. METHODS: Male ICR mice were randomly divided into four groups: a control group without noise exposure and three noise groups exposed to white noise at a 95-dB sound pressure level for 4 h/day for 1, 10, or 20 days (N1D, N10D, and N20D, respectively). Systemic insulin sensitivity was evaluated at 1 day, 1 week, and 1 month post-noise exposure (1DPN, 1WPN, and 1MPN) via insulin tolerance tests (ITTs). Several insulin-related processes, including the phosphorylation of Akt, IRS1, and JNK in the animals' skeletal muscles, were examined using standard immunoblots. Biomarkers of inflammation (circulating levels of TNF-α and IL-6) and oxidative stress (SOD and CAT activities and MDA levels in skeletal muscles) were measured via chemical analyses. RESULTS: The data obtained in this study showed the following: (1) The impairment of systemic insulin sensitivity was transient in the N1D group but prolonged in the N10D and N20D groups. (2) Noise exposure led to enhanced JNK phosphorylation and IRS1 serine phosphorylation as well as reduced Akt phosphorylation in skeletal muscles in response to exogenous insulin stimulation. (3) Plasma levels of TNF-α and IL-6, CAT activity, and MDA concentrations in skeletal muscles were elevated after 20 days of noise exposure. CONCLUSIONS: Impaired insulin sensitivity in noise-exposed mice might be mediated by an enhancement of the JNK/IRS1 pathway. Inflammation and oxidative stress might contribute to insulin resistance after chronic noise exposure.

Study on the Modification of Silty Soil Sites Using Nanosilica and Methylsilicate.

The special particle grading properties of silt lead to the strong water sensitivity and low soil strength of silt sites, many of which are severely damaged and urgently need to be repaired. This article takes the powder soil from a certain burial site area in Xizhu Village, Luoyang as the research object, which is improved by adding nanosilica and potassium methylsilicate. The modified soil is studied through mechanical and waterproof performance tests, and the mechanism of action of the modified material is analyzed through SEM and XRD. The experimental results show that the mechanical properties and waterproof properties of the composite modified soil were improved when the nanosilica content was 2% and the potassium methylsilicate content was 0.5%; the durability of the composite modified soil is improved, making this the optimum ratio. The mechanical properties and water resistance of the silty soil were significantly improved by adding the appropriate amount of nanosilica and potassium methylsilicate. Nanosilica can be evenly dispersed in the soil matrix, absorb a small amount of water to form a gel state, fill the pores in the silt aggregates, and improve soil compactness. In addition, nanosilica aggregates can attach to the surface of the soil particles and extend from the particle surface to the particle edge. By increasing the contact between soil particles and increasing the particle size, the mechanical properties of the modified soil are improved. When potassium methylsilicate solution is added to the soil, it reacts with water and carbon dioxide, decomposes into methylsilicate, and quickly generates a polymethylsiloxane film to cover the surface of soil particles, forming a waterproof film on the surface and thereby improving the waterproof performance of modified soil. Our research results can provide a reference for the restoration and protection of silty and silt-like sites. The next step is to apply the composite modified soil in engineering restoration through field tests in order to study the repairing ability of composite modified soil and its actual protective effects.

Delayed neurological improvement is predictive to long-term clinical outcome on endovascular thrombectomy patients.

OBJECTIVES: This study aims at exploring the 3-month outcome predicting ability of delayed neurological improvement and the cause of delayed neurological improvement. MATERIALS AND METHODS: Early neurological improvement and delayed neurological improvement were calculated to represent the neurological improvements. Good functional outcome was defined as a 90-day modified Rankin Scale score 0-2. We used multivariant logistic regression to explore the influential factors of good functional outcome as well as delayed neurological improvement. We applied net reclassification improvement and integrated discrimination improvement to assess the quantitative improvement of the predictive model. RESULTS: Early neurological improvement was observed in 50 (23%) patients and delayed neurological improvement exhibited in 67 (30%) patients. Early neurological improvement and delayed neurological improvement were both independent predictive factors to good functional outcome. In the basic model (adjusted for age, admission glucose level, baseline National Institute of Health Stroke Scale, and complications and number of retrieval attempts), early neurological improvement and delayed neurological improvement statistically improved the predictive ability (early neurological improvement: net reclassification improvement = 0.34, 95% confidence interval, 95% confidential interval (0.06, 0.69); integrated discrimination improvement = 0.05, p < 0.001; delayed neurological improvement: net reclassification improvement = 0.79, 95% confidential interval (0.47, 1.12); integrated discrimination improvement = 0.14, p < 0.001) delayed neurological improvement could predict clinical outcomes more accurately than early neurological improvement (early neurological improvement vs. delayed neurological improvement: integrated discrimination improvement = 0.09, p < 0.001). Moreover, delayed neurological improvement was affected by hypertension (odds ratio = 0.40, 95% CI (0.18, 0.88), p = 0.02), early neurological improvement (odds ratio = 20.10, 95% confidential interval (8.24, 19.02), p < 0.001), number of retrieval attempts (odds ratio = 0.39, 95% confidential interval (0.24, 0.66), p < 0.001), and complication (odds ratio = 0.25, 95% confidential interval (0.12, 0.54), p < 0.001). CONCLUSIONS: Delayed neurological improvement could predict clinical outcomes more accurately than early neurological improvement. Hypertension, early neurological improvement, numbers of retrieval attempts, and complications were all predicting factors to delayed neurological improvement.

Off-hour effect on time metrics and clinical outcomes in endovascular treatment for large vessel occlusion: A systematic review and meta-analysis.

BACKGROUND: There is an ongoing debate on the off-hour effect on endovascular treatment (EVT) for acute large vessel occlusion (LVO). AIM: This meta-analysis aimed to compare time metrics and clinical outcomes of acute LVO patients who presented/were treated during off-hour with those during working hours. SUMMARY OF REVIEW: Structured searches on the PubMed, Embase, Web of Science, and Cochrane Library databases were conducted through 23 February 2021. The primary outcomes were onset to door (OTD), door to imaging, door to puncture (DTP), puncture to recanalization, procedural time, successful recanalization, symptomatic intracranial hemorrhage (SICH), mortality in hospital, good prognosis (90-day modified Rankin Scale (mRS) score 0-2), and 90-day mortality. The secondary outcomes were imaging to puncture (ITP), onset to puncture (OTP), onset to recanalization (OTR), door to recanalization (DTR) time, mRS 0-2 at discharge, and consecutive 90-day mRS score. The odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (CI) of the outcomes were calculated using random-effect models. Heterogenicity and publication bias were analyzed. Subgroup and sensitivity analyses were conducted as appropriate. Nineteen studies published between 2014 and 2021 with a total of 14,185 patients were eligible for quantitative synthesis. Patients in the off-hour group were significantly younger than those in the on-hour group and with comparable stroke severity and intravenous thrombolysis rate. The off-hour group had longer OTD (WMD [95% CI], 12.83 [1.84-23.82] min), DTP (WMD [95% CI], 11.45 [5.93-16.97] min), ITP (WMD [95% CI], 10.39 [4.61-16.17] min), OTP (WMD [95% CI], 25.30 [13.11-37.50] min), OTR (WMD [95% CI], 25.16 [10.28-40.04] min), and DTR (WMD [95% CI], 18.02 [10.01-26.03] min) time. Significantly lower successful recanalization rate (OR [95% CI], 0.85 [0.76-0.95]; p = 0.004; I2 = 0%) was detected in the off-hour group. No significant difference was noted regarding SICH and prognosis. But a trend toward lower OR of good prognosis was witnessed in the off-hour group (OR [95% CI], 0.92 [0.84-1.01]; p = 0.084; I2 = 0%). CONCLUSIONS: Patients who presented/were treated during off-hour were associated with excessive delays before the initiation of EVT, lower successful reperfusion rate, and a trend toward worse prognosis when compared with working hours. Optimizing the workflows of EVT during off-hour is needed.