Prediction of Severe Baseline Asymptomatic Carotid Stenosis and Subsequent Risk of Stroke and Cardiovascular Disease

严重基线无症状颈动脉狭窄和随后的卒中和心血管疾病风险的预测

Risk models to identify patients at high risk of asymptomatic carotid artery stenosis (ACAS) can help in selecting patients for screening, but long-term outcomes in these patients are unknown. We assessed the diagnostic and prognostic value of the previously published Prevalence of ACAS (PACAS) risk model to detect ACAS at baseline and to predict subsequent risk of stroke and cardiovascular disease (CVD) during follow-up. The PACAS risk model can reliably identify patients at high risk of severe baseline ACAS. Incidence rates of stroke and CVD during follow-up were significantly higher in patients with high PACAS sum scores. Selective screening of patients with high PACAS sum scores may help to prevent future stroke or CVD.

识别无症状颈动脉狭窄 (ACAS) 高风险患者的风险模型可以帮助选择筛查患者，但这些患者的长期结果尚不清楚。我们评估了先前发表的ACAS患病率 (PACAS) 风险模型的诊断和预后价值，以检测基线ACAS并预测后续的卒中和心血管疾病 (CVD) 风险。PACAS风险模型可以可靠地识别严重基线ACAS高风险的患者。PACAS总分高的患者在随访期间卒中和CVD的发生率明显更高。选择性筛查PACAS总分高的患者可能有助于预防未来的卒中或CVD。

REF: Poorthuis MHF, Hageman SHJ, Fiolet ATL, et al. Prediction of Severe Baseline Asymptomatic Carotid Stenosis and Subsequent Risk of Stroke and Cardiovascular Disease. Stroke. Published online September 25, 2024. doi:10.1161/STROKEAHA.123.046894 PMID: 39319460

Hemorrhagic Moyamoya Angiopathy in European Patients

欧洲患者的出血性烟雾病

Moyamoya angiopathy (MMA) is an important cause of juvenile stroke but an overall rare disease among European populations compared with East Asian cohorts. Consecutively, hemorrhagic MMA is described well in East Asian cohorts, but knowledge in non-Asian patients is limited. Literature suggests that disease presentation may vary between those cohorts, also including hemorrhage frequencies. Hence, this article aims to analyze hemorrhagic MMA in European patients. Bypass surgery was negatively associated with the development of intracranial hemorrhage in MMA in European patients. There was no difference in terms of a history of hypertension between groups, indicating that blood pressure is not the major contributor for rupture of fragile collateral vessels. The investigated imaging characteristics were not associated to hemorrhage onset and, therefore, are not suitable as a tool of screening for patients at risk.

Moyamoya血管病变 (MMA) 是青少年卒中的重要原因，但与东亚人群相比，在欧洲人群中总体罕见。连续地，出血性MMA在东亚队列中得到很好的描述，但非亚洲患者的知识有限。文献表明，这些队列之间的疾病表现可能有所不同，还包括出血频率。因此，本文旨在分析欧洲患者的出血性MMA。搭桥手术与欧洲患者MMA颅内出血的发展呈负相关。两组之间的高血压病史没有差异，表明血压不是脆弱的侧支血管破裂的主要因素。研究的影像学特征与出血发作无关，因此不适合作为筛查高危患者的工具。

REF: Brokbals M, Pilgram-Pastor S, Focke JK, Strunk D, Veltkamp R, Kraemer M. Hemorrhagic Moyamoya Angiopathy in European Patients. Stroke. Published online September 18, 2024. doi:10.1161/STROKEAHA.124.046859 PMID: 39291379

Transcranial Doppler With Microbubbles: Screening Test to Detect and Grade Right-to-Left Shunt After an Ischemic Stroke: A Literature Review

微泡经颅多普勒: 缺血性卒中后右向左分流的筛查试验: 文献综述

Right-to-left shunt, mainly due to patent foramen ovale (PFO), is likely responsible for ≈5% of all ischemic strokes and 10% of those occurring in young and middle-aged adults. Randomized clinical trials demonstrated that, in selected young and middle-aged patients with otherwise cryptogenic acute ischemic stroke and high-risk PFO, percutaneous PFO closure is more effective than antiplatelet therapy alone in preventing recurrence. However, PFO is generally a benign finding and is present in about one-quarter of the population. Therefore, in clinical practice, identifying PFOs that are likely to be pathogenetic is crucial for selecting suitable patients for PFO closure to prevent recurrent stroke and to avoid potentially harmful and costly overtreatment. Contrast transthoracic echocardiography has a relatively low sensitivity in detecting PFO, whereas transesophageal echocardiography is currently considered the gold standard for PFO detection. However, it is a relatively invasive procedure and may not always be easily feasible in the subacute setting. Contrast transcranial Doppler is a noninvasive, inexpensive, accurate tool for the detection of right-to-left shunt. We conducted a literature review on the use of contrast transcranial Doppler to detect and grade right-to-left shunt after an acute ischemic stroke and present a clinical workflow proposal for young and middle-aged patients.

右向左分流，主要是由于卵圆孔未闭 (PFO)，可能是约5% % 的缺血性中风和10% 发生在年轻和中年人的原因。随机临床试验表明，在某些患有其他原因不明的急性缺血性卒中和高危PFO的年轻和中年患者中，经皮PFO封堵术在预防复发方面比单独使用抗血小板治疗更有效。然而，PFO通常是良性的发现，并且存在于约四分之一的人口中。因此，在临床实践中，确定可能致病的全氟辛烷磺酸对于选择合适的患者进行全氟辛烷磺酸封堵术至关重要，以防止复发卒中并避免潜在的有害和昂贵的过度治疗。对比经胸超声心动图在检测PFO方面具有相对较低的灵敏度，而经食道超声心动图目前被认为是PFO检测的金标准。然而，这是一种相对侵入性的手术，在亚急性情况下可能并不总是容易可行的。对比经颅多普勒是一种无创，廉价，准确的工具，用于检测右向左分流。我们对急性缺血性卒中后使用对比经颅多普勒检测和分级右向左分流进行了文献综述，并提出了针对中青年患者的临床工作流程建议。

REF: Palazzo P, Heldner MR, Nasr N, Alexandrov AV. Transcranial Doppler With Microbubbles: Screening Test to Detect and Grade Right-to-Left Shunt After an Ischemic Stroke: A Literature Review. Stroke. Published online September 13, 2024. doi:10.1161/STROKEAHA.124.046907 PMID: 39268611

The Imaging-Neuropathological Gap in Acute Large Vessel Occlusive Stroke

急性大血管闭塞性卒中的影像神经病理间隙

While imaging has traditionally played a fundamental role in the selection of patients undergoing endovascular thrombectomy, recent thrombectomy trials involving patients with large ischemic strokes demonstrated a consistent benefit of endovascular thrombectomy across all imaging strata, suggesting that reperfusion benefit may exist independent of current imaging constructs. Although these findings attest to the uniformly beneficial effects of reperfusion, they also shed doubt on the accuracy and utility of our imaging modalities in defining reversible versus irreversible ischemia and challenge the premise of imaging-based selection. We aimed to review the histopathologic studies and clinical trials that have shaped our understanding of current imaging constructs aiming to outline the existing imaging-neuropathological gap that may be far wider than previously perceived.

传统上，影像学在选择接受血管内血栓切除术的患者中起着至关重要的作用，但最近针对大面积缺血性卒中患者的血栓切除术试验表明，血管内血栓切除术在所有成像层中均具有一致的益处，这表明再灌注益处可能独立于当前的成像结构而存在。尽管这些发现证明了再灌注的一致有益效果，但它们也对我们的成像方式在定义可逆与不可逆缺血方面的准确性和实用性提出了质疑，并挑战了基于成像的选择的前提。我们旨在回顾组织病理学研究和临床试验，这些研究和临床试验已经形成了我们对当前成像结构的理解，旨在概述现有的成像-神经病理学差距，该差距可能比以前认为的要大得多。

REF: Ballout AA, Liebeskind DS, Jovin TG, Najjar S. The Imaging-Neuropathological Gap in Acute Large Vessel Occlusive Stroke. Stroke. Published online September 5, 2024. doi:10.1161/STROKEAHA.124.047384 PMID: 39234750