Background and Objectives Diffusion-weighted imaging (DWI)-positive lesions are increasingly recognized as markers of cerebral small vessel disease (cSVD) in acute intracerebral hemorrhage (ICH), but their underlying mechanisms, clinical-radiologic associations, and prognostic significance remain uncertain. We therefore aimed to determine their prevalence, anatomical distribution, and associations with baseline clinical-radiologic features and 6-month functional outcome assessed by the modified Rankin Scale (mRS). Methods In this prospective cohort study, we analyzed consecutive patients with ICH included in the Stroke Investigation Group in North and Central London registry. We assessed the presence and anatomical distribution of DWI-positive lesions on acute MRI, as well as other cSVD markers rated according to the STandards for ReportIng Vascular changes on nEuroimaging criteria. The primary outcome was disability at 6 months assessed using the mRS. We investigated associations between DWI-positive lesions, clinical-radiologic features, and poor 6-month functional outcome (mRS >= 3) using adjusted multivariable logistic regression. Results We included 342 patients (median age 67 years [interquartile range (IQR) 55-78]; 142 (41.5%) women; 138 (40.3%) lobar ICH; median cSVD burden 2 [IQR 1-3]). Overall, 74 patients (21.6%) had DWI-positive lesions, most commonly in lobar regions (33 [44.6%]). Patients with cerebral amyloid angiopathy (CAA) more frequently had strictly lobar DWI-positive lesions compared with those without (78.6% vs 36.7%); strictly deep DWI-positive lesions were exclusively observed in the non-CAA group (25.0% vs 0%). Compared with patients without DWI-positive lesions, those with DWI-positive lesions more frequently had severe white matter hyperintensities (WMH; Fazekas >= 2: 81.1% vs 64.2%, p < 0.001), higher cerebral microbleed (CMB) burden (median = 3 vs 1, p = 0.034), and larger ICH volume (median = 14 mL vs 7 mL, p = 0.0006). In adjusted analyses, DWI-positive lesions were independently associated with severe WMH (odds ratio [OR] 3.37, 95% CI 2.72-6.89), ICH volume >= 30 mL (OR 2.29, 95% CI 1.76-3.42), CMBs (OR 1.61, 95% CI 1.21-2.93), and poor functional outcome at 6 months (OR 2.16, 95% CI 1.67-3.48). Discussion DWI-positive lesions are common after acute ICH and are independently associated with cSVD and poor functional outcome, supporting their role as a prognostic biomarker. Their anatomical distribution differs according to the underlying cSVD subtype.
Background and Objectives Current recommended blood pressure (BP) targets during mechanical thrombectomy (MT) rely on a one-size-fits-all approach aiming at preventing hypertension. The efficacy and safety of an individualized BP control during thrombectomy for ischemic stroke has not been well studied. We aimed to evaluate whether an individualized BP control during MT could improve functional outcome at 90 days.Methods We conducted a multicenter, open-label, blinded-endpoint, randomized clinical trial at 8 academic comprehensive stroke centers in France. Adult patients with an acute ischemic stroke due to an anterior large vessel occlusion and an indication for MT were eligible. Recruitment was performed between March 10, 2021, and September 18, 2023. Patients were randomly assigned (1:1) to an individualized BP group during MT (where the mean arterial pressure [MAP] was maintained within 10% of the first MAP measured before MT) or a control BP group (systolic BP maintained within 140 and 180 mm Hg). The primary outcome was favorable functional outcome, defined as a modified Rankin Scale score between 0 and 2 at 90 days. Safety outcomes included symptomatic intracranial hemorrhages at 24 hours and mortality at 90 days.Results Overall, 433 patients (median age, 69.3 years, 228 females [52.8%]) were assigned to an individualized BP group (n = 215) or the control BP group (n = 218); one was excluded because of consent withdrawal. No significant differences in mean BP levels or BP variability were observed between groups during the procedure. Favorable functional outcome at 90 days was observed in 94 patients (44.2%) in the individualized BP group and 106 patients (48.8%) in the control group (adjusted odds ratio, 0.82; 95% CI 0.54-1.24; p = 0.34). Mortality from any cause at 90 days was not significantly different between groups (18.8% in the individualized BP group vs 16.4% in the control BP group: adjusted odds ratio, 1.19; 95% CI 0.70-2.03). Rates of symptomatic intracranial hemorrhages were not different between the 2 groups.Discussion In patients with acute ischemic stroke due to an anterior large vessel occlusion, an individualized BP management during MT did not increase rates of favorable functional outcome at 90 days compared with a standard BP management.Trial Registration Information ClinicalTrials.gov, DETERMINE, number NCT04352296.Classification of Evidence This study provides Class II evidence that in patients undergoing mechanical thrombectomy for stroke due to anterior large vessel occlusion, functional outcomes at 90 days were similar with individualized BP management and standard BP management.
Background and Objectives Patients with myasthenia gravis (MG) are frequently associated with other autoimmune diseases. However, the temporal relationship between autoimmune diseases and MG remains unclear. This study aimed to evaluate the rates and temporal patterns of autoimmune diseases during the 10 years preceding MG diagnosis.Methods This retrospective population-based cohort study analyzed claims data from the Korean National Health Insurance Service between 2010 and 2021 and included individuals aged >= 20 years. MG was defined using the International Classification of Diseases, 10th Revision (ICD-10) code (G70.0) and Rare Intractable Disease registration (V012). Each MG case was matched with 10 controls by age, sex, and index year. Outcomes were autoimmune thyroid disease (AITD), systemic lupus erythematosus (SLE), seropositive rheumatoid arthritis (SRA), Sj & ouml;gren syndrome (SjS), psoriasis, type 1 diabetes mellitus (T1DM), Crohn disease, and ulcerative colitis occurring during the 10 years before the index year. Rate ratios (RRs) and 95% CIs were estimated using Poisson regression models for 0-2, 2-5, and 5-10 years before the index year.Results A total of 8,355 patients with MG and 83,550 matched controls were included. The mean age (SD) was 53.7 (16.0) years, and 44.1% were male. Patients with MG had a higher rate of any autoimmune disease during 10 years before diagnosis than controls (RR 2.12, 95% CI 1.97-2.28), with the highest rates in 0-2 years before diagnosis (RR 4.27, 95% CI 3.78-4.83). SLE (RR 4.87, 95% CI 2.71-8.77), SjS (RR 4.75, 95% CI 3.01-7.50), AITD (RR 3.66, 95% CI 3.29-4.07), and SRA (RR 2.45, 95% CI 1.89-3.19) showed the strongest associations. Psoriasis (RR 1.68, 95% CI 1.25-2.25) and T1DM (RR 2.03, 95% CI 1.52-2.71) were associated with MG only within 0-2 years before diagnosis, whereas Crohn disease and ulcerative colitis were not associated.Discussion Autoimmune diseases were more frequent in the years preceding MG diagnosis than in controls, particularly within 2 years before diagnosis. Strong associations were observed for SLE, SjS, AITD, and SRA. However, these findings should be interpreted with caution because of limitations of administrative claims data.
Background and Objectives Myelitis is a common manifestation of aquaporin-4 immunoglobulin G-seropositive (AQP4-IgG+) neuromyelitis optica spectrum disorder (NMOSD), with longitudinally extensive transverse myelitis (LETM) as a characteristic MRI feature. Bright spotty lesions (BSLs) and a novel "double-contoured LETM" sign have also been increasingly observed, but their prevalence and diagnostic utility are unclear. This study aimed to characterize spinal cord MRI findings and evaluate the diagnostic performance of established and novel MRI signs in AQP4-IgG+ NMOSD myelitis. Methods We retrospectively reviewed spinal cord MRI scans from adults with AQP4-IgG+ NMOSD myelitis at a university-based hospital across acute (<30 days), subacute (1-3 months), and remission (>3 months) stages. MRI features were descriptively analyzed. Acute scans were assessed for specific MRI signs, including the H sign, double-contoured LETM sign, BSLs, and sagittal ring enhancement and compared with other causes of myelopathy. Sensitivity, specificity, and likelihood ratios were calculated. Results Among 217 patients with AQP4-IgG+ NMOSD (median age at onset 44.5 years, 95.9% women), 170 (78.3%) experienced myelitis. A total of 331 NMOSD spinal MRI scans were reviewed. The comparison group included 72 scans, most commonly from patients with spinal cord infarction (39) and idiopathic transverse myelitis (14). Restricting the analysis to first-ever myelitis (53 scans), LETM was observed in 88.7%, and sensitivities of BSLs, the double-contoured LETM sign, and sagittal ring enhancement were 64.0% (95% CI 50.1%-75.9%), 47.2% (95% CI 34.4%-60.3%), and 60.0% (95% CI 46.2%-72.4%), respectively, with specificities of 98.6% (95% CI 92.2%-99.7%), 98.6% (95% CI 92.4%-99.8%), and 96.4% (95% CI 87.9%-99.0%). Combining these signs increased specificity further but reduced sensitivity to approximately 30%. When acute first-ever and recurrent myelitis were analyzed together (161 scans), the prevalence of these signs decreased to 56.5%, 19.9%, and 44.1%, respectively. During remission, complete radiologic resolution was observed in 12.4% of 129 scans, whereas spinal cord atrophy was present in 56.6%. Discussion BSLs, the double-contoured LETM sign, and sagittal ring enhancement demonstrate high specificity and may aid in differentiating NMOSD from other causes of longitudinally extensive myelopathy. The double-contoured LETM sign represents a novel imaging feature, particularly in first-ever acute myelitis. However, the comparison cohort was enriched with noninflammatory myelopathies, which may limit generalizability. Further validation in independent cohorts is warranted.
Background and Objectives Long-term risk of dementia after TIA remains poorly characterized, despite a known impact on cognition. We aimed to quantify the rate, relative risk, and time course of incident dementia after TIA compared with a matched reference population (controls) and individuals with stroke.Methods We conducted a population-wide cohort study using linked administrative health data for the province of Ontario, Canada (2002-2022). Adults with a first TIA were identified from emergency department visits or hospital admissions and followed from 90 days after the index event. Individuals with prior dementia, prior stroke, early death, or long-term care admission were excluded. Patients with TIA were matched to population controls on age, sex, neighborhood-level deprivation, rurality, and vascular comorbidities. Patients with TIA were also matched to those with first stroke. Incident dementia was ascertained using a validated algorithm based on hospital diagnoses, physician claims, and dementia-specific medications. Cause-specific and subdistribution hazard models accounting for competing risk of death were used for 1-, 5-, and 10-year risk of dementia, with time-varying analyses.Results Among 113,081 matched patients with TIA (mean age 70 years; 50% female), dementia was diagnosed in 19.3% over a mean follow-up of 7.11 years (SD 5.16). Dementia rates after TIA were consistently higher than in matched controls across all time horizons (overall rate 2.71 vs 2.03 per 100 person-years). The hazard ratio for dementia after TIA was highest within the first year (hazard ratio [HR] 1.75, 95% CI 1.66-1.85) and remained elevated over 20 years of follow-up (overall HR 1.34, 95% CI 1.31-1.36). Compared with stroke, the hazard of dementia was lower after TIA early on (1-year HR 0.67, 95% CI 0.64-0.70) but converged and became similar after 5 years of follow-up. Dementia incidence substantially exceeded stroke incidence, and adjustment for incident stroke minimally attenuated results.Discussion TIA is associated with a large and sustained increase in dementia risk, approaching that observed after stroke over long-term follow-up. Dementia occurs far more frequently than incident stroke after TIA, highlighting cognitive decline as a major long-term complication and a target for prevention with new strategies that include and extend beyond stroke prevention.
