高下 純平

BACKGROUND: The effect of renal function on long-term dual antiplatelet therapy using cilostazol for secondary stroke prevention is unknown. We investigated the effect of estimated glomerular filtration rate (eGFR) on the efficacy and safety of long-term dual antiplatelet therapy involving cilostazol. METHODS: We performed a post hoc analysis of a multicenter, open-label, randomized controlled trial of patients with high-risk non-cardioembolic ischemic stroke who were randomly assigned to take aspirin or clopidogrel alone, or a combination of cilostazol with aspirin or clopidogrel and followed for 0.5-3.5 years. Patients were divided into three groups according to their baseline eGFR [normal or increased eGFR (≥90); mildly decreased eGFR (60-89); moderately decreased eGFR (<60 mL/min/1.73m2)]. RESULTS: A total of 1749 patients with complete eGFR data were included. The recurrence of ischemic stroke was less common with dual therapy than with monotherapy in patients with mildly decreased eGFR (adjusted HR, 0.35; 95 % CI, 0.19-0.66), but there was no difference between dual therapy and monotherapy in patients with moderately decreased eGFR (0.78; 0.34-1.82) or in those with normal or increased eGFR (0.48; 0.14-1.64). CONCLUSIONS: Long-term dual antiplatelet therapy with cilostazol was more efficacious in decreasing recurrent ischemic stroke than monotherapy for patients with mildly decreased eGFR, but not for those with moderately decreased eGFR or those with normal or increased eGFR. Trial Registration Information: ClinicalTrials.govNCT01995370.

BACKGROUND: Insertable cardiac monitoring (ICM) detects atrial fibrillation (AF) in substantial proportions of cryptogenic stroke, noncryptogenic ischemic stroke without known AF, and nonstroke patients who are at risk of underlying AF. Given differences in patient characteristics across studies, there may be differences in AF detection rates on ICM across these subgroups that have not been identified. We investigate whether AF detection rates on ICM are higher in cryptogenic stroke or transient ischemic attack (C-IS/TIA) patients compared with individuals with noncryptogenic stroke or without stroke, when accounting for differences in study populations. METHODS: This is an individual-participant data meta-analysis of prospective studies and randomized controlled trials of ICM in C-IS/TIA, noncryptogenic ischemic stroke, and nonstroke patients. Multilevel multivariable logistic regression models were used to test whether C-IS/TIA is associated with increased AF detection relative to other categories. We performed multiple imputation to derive values for variables with <20% missing data and used Rubin's rules to estimate adjusted odds ratios by combining 100 postimputation data sets. The primary outcome was detection of AF. The attributable risk was derived by application of Bayes' Theorem. RESULTS: Two randomized controlled trials and 12 prospective studies were included with a total of 1562 C-IS/TIA patients and 474 non-C-IS/TIA patients. In adjusted multilevel logistic regression analyses, AF detection was higher in C-IS/TIA patients (adjusted odds ratio, 1.90 [95% CI, 1.18-3.06]; P=0.009), indicating that 47% of AF detected in C-IS/TIA is pathogenic. Limiting the comparator group to ischemic stroke or history of stroke yielded similar results (adjusted odds ratio, 2.83 [95% CI, 1.47-5.44]; P=0.002). Days to AF detection were significantly shorter in C-IS/TIA patients (median 65 versus 169; P<0.001). CONCLUSIONS: In this individual-participant data meta-analysis of patients undergoing ICM, AF detection was higher in C-IS/TIA patients, with shorter time to AF detection compared with noncryptogenic/nonstroke individuals. These findings suggest that some of the AF detected in patients with C-IS/TIA may be pathogenic.

BACKGROUND AND OBJECTIVES: We aimed to clarify the association between neurological deterioration pre-endovascular therapy (EVT) and outcome in patients with large-vessel occlusion due to intracranial atherosclerotic disease (ICAD-LVO) undergoing EVT. METHODS: Consecutive patients with acute ischemic stroke due to ICAD-LVO within 24 h of onset who underwent EVT were enrolled in the Japanese multicenter registry from 2017 to 2019. Patients were grouped according to neurological severity transition as follows: mild symptoms (baseline National Institutes of Health Stroke Scale [NIHSS] score <6 and NIHSS score pre-EVT <6), symptom deterioration (baseline NIHSS score <6 and NIHSS score pre-EVT ≥6), and severe symptoms (baseline NIHSS score ≥6 and NIHSS score pre-EVT ≥6). Outcomes included favorable outcomes (modified Rankin Scale [mRS] score of 0-2 at 90 days), ordinal mRS shift, and symptomatic intracranial hemorrhage. Multivariable logistic regression assessed the association of outcomes with the transition of neurological severity by calculating odds ratios and 95% CIs, with mild symptoms as reference. RESULTS: In total, 480 patients with acute ICAD-LVO who underwent EVT (150 women [31.2%]; median age, 72 years IQR, 66-80) and had median baseline NIHSS score 12 (IQR, 6-20) were analyzed. Patients with symptom deterioration (n = 34) and severe symptoms (n = 375) had lower favorable outcomes (deterioration 38.2% vs mild 62.9%; adjusted odds ratio 0.30, 95% CI 0.09-0.97, severe 35.3%; 0.47, 0.33-0.65) and a significant mRS shift (deterioration vs mild; 3.63, 1.46-9.03, severe; 2.27, 1.74-2.96) than those with mild symptoms (n = 71). Symptomatic intracranial hemorrhage rates did not differ (mild 0%; deterioration 0%; severe 1.9%). CONCLUSION: Patients with ICAD-LVO who experienced worsening symptoms were less likely to achieve favorable outcomes after EVT than those with mild symptoms. Early identification of neurological deterioration and EVT intervention may improve outcomes in these patients.

PURPOSE: The Woven EndoBridge (WEB) was introduced in Japan in January 2021 and approved for all subtypes of wide-neck bifurcation aneurysms (WNBA). This retrospective study evaluated the safety and efficacy of the WEB device for all subtypes of WNBA. MATERIALS AND METHODS: All patients treated with the WEB at our facility between January 2021 and May 2024 was reviewed. We selected the WEB device according to an oversizing policy, based on cumulative clinical evidence from global experience. RESULTS: We analyzed 120 aneurysms in 117 patients (56 males and 61 females with a mean age of 65.5±12.7 years). There were 45 anterior communicating artery aneurysms, 27 middle cerebral artery aneurysms, 17 internal carotid artery-posterior communicating artery aneurysms, 15 basilar artery top aneurysms, and 16 aneurysms in other locations. Aneurysm characteristics included a maximum diameter of 6.5 [5.3, 7.7] mm, height of 4.9 [3.9, 6.0] mm, width of 4.8 [4.0, 6.2] mm, and dome/neck ratio of 1.2 [1.1, 1.4]. All data are expressed in median [interquartile range]. Angiographic follow-up at 12 months in 96 cases showed complete obliteration in 68.8% and adequate obliteration in 90.6% of cases. Intraoperative ischemic events occurred in 5 cases (4.2%). Hemorrhagic events occurred in 2 cases (1.7%), with symptoms resolving by discharge, except for 1 case of mild paralysis. During follow-up, 1 patient developed a major stroke, resulting in morbidity (0.8%). Retreatment was required in 3 cases (2.5%). On multivariate analysis for complete occlusion at 12 months following WEB treatment, age was statistically associated with the outcome (odds ratio, 0.957 per year; 95% confidence interval, 0.919-0.996; P=0.033). CONCLUSION: WEB is safe and effective for all subtypes of WNBA, with a low retreatment rate using an oversizing policy. This is the first report in a Japanese population.

PURPOSE: Digital subtraction angiography (DSA) is the gold standard for follow-up evaluation of intracranial aneurysms treated with the Woven EndoBridge (WEB) device. This study aimed to assess the efficacy of high-resolution CT angiography (HR-CTA) as a less invasive alternative by comparing its diagnostic performance with that of DSA. METHODS: This single-center retrospective study analyzed the angiographic and clinical data of patients treated with the WEB device for cerebral aneurysms between January 2021 and December 2024. Patients who underwent HR-CTA within 2 weeks before or after follow-up DSA were included. Occlusion status was assessed using the Bicêtre Occlusion Scale Score (BOSS) and binary classification. The concordance rate between HR-CTA and DSA was evaluated. RESULTS: A total of 54 eligible examinations were identified. Using the BOSS, 46 examinations were concordant, resulting in an agreement rate of 85.2%. The Cohen's κ coefficient was 0.81 (95% CI 0.69 to 0.93), indicating a very high level of agreement. All discordant cases resulted from HR-CTA overestimating occlusion status; however, HR-CTA accurately identified aneurysm remnants. Univariate analyses identified BOSS 0' as the only significant factor contributing to discrepancies. In the binary evaluation, all 54 examinations were fully concordant (κ=1.00, 95% CI 1.00 to 1.00). CONCLUSIONS: HR-CTA demonstrated a high concordance rate with DSA for evaluating occlusion status after WEB placement. Its reliable assessment of aneurysm remnants suggests HR-CTA could serve as a practical and less invasive alternative to DSA in follow-up evaluations.