Magnesium and Hematoma Expansion in Intracerebral Hemorrhage: A FAST-MAG Randomized Trial Analysis

镁与脑出血血肿扩大的FAST-MAG随机试验分析

Observational studies suggest that magnesium may have hemostatic effects. FAST-MAG (Field Administration of Stroke Therapy-Magnesium) was a pragmatic clinical trial of magnesium sulfate administered prehospital for acute clinical stroke syndromes and included patients with intracerebral hemorrhage. Exploratory secondary analysis by the treatment group found no reduction in hematoma expansion (HE) associated with magnesium treatment in intracerebral hemorrhage but did not consider serum magnesium levels achieved. We analyzed FAST-MAG intracerebral hemorrhage data for associations between serum magnesium level, HE, and early neurological deterioration, accounting for groupwise biases. Magnesium may exhibit a hemostatic effect that was only observable in the FAST-MAG magnesium treatment group. Equipoise should be maintained, and specific trials are needed.

观察性研究表明，镁可能有止血作用。FAST-MAG(现场给药卒中疗法-镁)是一项实用的临床试验，院前给予硫酸镁治疗急性临床中风综合征，包括脑出血患者。治疗组的探索性二次分析发现，在脑出血中，镁治疗没有减少血肿扩大(HE)，但没有考虑达到的血清镁水平。我们分析了FAST-MAG脑出血数据，以寻找血清镁水平、HE和早期神经恶化之间的关系，这是GroupWise偏向的原因。镁可能表现出只有在快速MAG镁治疗组中才能观察到的止血作用。应该保持均衡，并需要进行具体的试验。

REF: Liotta EM, Maas MB, Prabhakaran S, et al. Magnesium and Hematoma Expansion in Intracerebral Hemorrhage: A FAST-MAG Randomized Trial Analysis. Stroke. Published online December 21, 2023. doi:10.1161/STROKEAHA.123.043555 PMID: 38126183

Evolving Role of Imaging in Acute Ischemic Stroke Care

影像在急性缺血性卒中救治中的作用

Neuroimaging is an indispensable link in patients with a neurological deficit that swiftly confirms the clinical suspicion of stroke and guides decisions for potential interventions With the success of revascularization strategies being tightly linked to the promptness of their initiation and adequate patient selection, the insights gained with acute imaging need to be precise and then rapidly translated into patient-specific therapeutic actions...

神经成像是患有神经功能缺陷的患者不可或缺的一环，它能迅速确认中风的临床怀疑，并指导潜在干预措施的决策。血管重建策略的成功与启动的迅速和患者的充分选择密切相关，通过急性成像获得的洞察力需要精确，然后迅速转化为患者特定的治疗行动。

REF: Ospel JM, Boulouis G. Evolving Role of Imaging in Acute Ischemic Stroke Care. Stroke. Published online December 21, 2023. doi:10.1161/STROKEAHA.123.044264 PMID: 38126180

Experimental Models of Posterior Reversible Encephalopathy Syndrome: A Review From Pathophysiology to Therapeutic Targets

后部可逆性脑病综合征的实验模型：从病理生理到治疗靶点的综述

Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological entity characterized by nonspecific symptomatology (eg, headache, visual disturbances, encephalopathy, and seizures) and classically cortical and subcortical vasogenic edema predominantly affecting the parietooccipital region. PRES etiologies are usually dichotomized into toxic PRES (eg, antineoplastic drugs, illicit drugs) and clinical condition-associated PRES (eg, acute hypertension, dysimmune disorders). Although the pathophysiology of PRES remains elusive, 2 main pathogenic hypotheses have been suggested: cerebral hyperperfusion due to acute hypertension and cerebral hypoperfusion related to endothelial dysfunction. Research into the pathogenesis of PRES has emerged through the development of animal models in the last decade. The motivation for developing a suitable PRES model is 2-fold: to fill in knowledge gaps of the pathophysiological mechanisms involved, and to open new perspectives for clinical assessment of pharmacological targets to improve therapeutic management of PRES. All current models of PRES have a hypertensive background, on which other triggers (acute hypertension, inflammatory, drug toxicity) have been added to address specific facets of PRES (eg, seizures). The initial model consisted in inducing a reduced uterine perfusion pressure that mimics preeclampsia, a leading cause of PRES. More recently, a model of stroke-prone spontaneously hypertensive rats on high-salt diet, originally developed for hypertensive small vessel disease and vascular cognitive impairment, has been studied in PRES. This review aims to discuss, depending on the research objective, the benefits and limitations of current experimental approaches and thus to define the desirable characteristics for studying the pathophysiology of PRES and developing new therapies.

可逆性后部脑病综合征（PRES）是一种临床和放射学实体，其特征为非特异性脑病（例如头痛、视力障碍、脑病和癫痫发作）和典型的皮质和皮质下血管源性水肿，主要影响顶枕区。PRES病因通常分为毒性PRES（如滥用药物、违禁药物）和临床疾病相关PRES（如急性高血压、免疫障碍）。虽然PRES的病理生理学仍然难以捉摸，但已提出2种主要的致病假设：急性高血压引起的脑灌注过度和与内皮功能障碍相关的脑灌注不足。在过去的十年中，通过动物模型的发展，PRES发病机制的研究已经出现。开发合适的PRES模型的动机有两个方面：填补了相关病理生理机制的知识空白，并为临床评估药理学靶点开辟了新的视角，以改善PRES的治疗管理。（急性高血压、炎症、药物毒性），以解决PRES的特定方面（例如癫痫发作）。最初的模型包括诱导子宫灌注压降低，模仿先兆子痫，一个主要原因的PRES。最近，一个模型的中风倾向自发性高血压大鼠高盐饮食，最初开发的高血压小血管疾病和血管认知障碍，已在PRES研究。这篇综述旨在讨论，根据研究目的，目前的实验方法的优点和局限性，从而确定研究PRES的病理生理学和开发新疗法的理想特征。

REF: Largeau B, Bergeron S, Auger F, et al. Experimental Models of Posterior Reversible Encephalopathy Syndrome: A Review From Pathophysiology to Therapeutic Targets. Stroke. Published online December 21, 2023. doi:10.1161/STROKEAHA.123.044533 PMID: 38126184

Vessel Wall MRI in the Diagnosis and Follow-Up of Nonstenosing Intracranial Atherosclerotic Lesions in Acute Stroke

血管壁MRI对急性脑卒中颅内非狭窄性动脉粥样硬化病变的诊断及随访

A 65-year-old man was admitted to the emergency department of our hospital following a 10-minute episode of left hemiparesis and hypoesthesia. Blood pressure at admission was 160/90 mm Hg, and heart rate was 90 bpm. He had a previous medical history of acute myocardial infarction and active smoking. In the following hours, the patient experienced 2 additional similar episodes. Symptoms receded after about 10 minutes and eventually resolved completely. Noncontrast computed tomography did not show acute ischemic or hemorrhagic lesions, and computed tomography angiography was negative for large vessel occlusion...

一位65岁的男性在10分钟的左侧轻偏瘫和感觉减退发作后被收治到我院急诊科。入院时血压为160/90 mm Hg，心率为90 bpm。患者既往有急性心肌梗死和主动吸烟病史。在接下来的几个小时内，患者发生了另外2起类似事件。症状在大约10分钟后消退，最终完全消退。非对比计算机断层扫描未显示急性缺血性或出血性病变，计算机断层扫描血管造影对大血管闭塞呈阴性。

REF: Del Bello B, Rognone E, Pichiecchio A, Cavallini A, Mazzacane F. Vessel Wall MRI in the Diagnosis and Follow-Up of Nonstenosing Intracranial Atherosclerotic Lesions in Acute Stroke. Stroke. Published online December 21, 2023. doi:10.1161/STROKEAHA.123.044710 PMID: 38126182

Combined Technique for Internal Carotid Artery Terminus or Middle Cerebral Artery Occlusions in the ASTER2 Trial

ASTER2试验中颈内动脉末端或大脑中动脉闭塞的联合技术

The aim of this study was to report the results of a subgroup analysis of the ASTER2 trial (Effect of Thrombectomy With Combined Contact Aspiration and Stent Retriever vs Stent Retriever Alone on Revascularization in Patients With Acute Ischemic Stroke and Large Vessel Occlusion) comparing the safety and efficacy of the combined technique (CoT) and stent retriever as a first-line approach in internal carotid artery (ICA) terminus±M1-middle cerebral artery (M1-MCA) and isolated M1-MCA occlusions. First-line CoT was associated with higher reperfusion grades in patients with ICA terminus±M1-MCA at the end of the procedure.

本研究的目的是报道ASTER2试验的亚组分析结果(血栓摘除联合接触性抽吸和支架取出器与单独支架取出器对急性缺血性卒中和大血管闭塞患者血管重建的影响)的亚组分析结果，比较联合技术(COT)和支架取出器作为颈内动脉(ICA)终末±M1-大脑中动脉(M1-MCA)和单独的M1-MCA闭塞的安全性和有效性。ICA终末为±M1-MCA的患者，一线COT与较高的再灌流分级相关。

REF: Sgreccia A, Desilles JP, Costalat V, et al. Combined Technique for Internal Carotid Artery Terminus or Middle Cerebral Artery Occlusions in the ASTER2 Trial. Stroke. Published online December 21, 2023. doi:10.1161/STROKEAHA.123.045227 PMID: 38126181

Code ICH: A Call to Action

Code ICH：行动的号召

Intracerebral hemorrhage is the most serious type of stroke, leading to high rates of severe disability and mortality. Hematoma expansion is an independent predictor of poor functional outcome and is a compelling target for intervention. For decades, randomized trials aimed at decreasing hematoma expansion through single interventions have failed to meet their primary outcomes of statistically significant improvement in neurological outcomes. A wide range of evidence suggests that ultra-early bundled care, with multiple simultaneous interventions in the acute phase, offers the best hope of limiting hematoma expansion and improving functional recovery. Patients with intracerebral hemorrhage who fail to receive early aggressive care have worse outcomes, suggesting that an important treatment opportunity exists. This consensus statement puts forth a call to action to establish a protocol for Code ICH, similar to current strategies used for the management of acute ischemic stroke, through which early intervention, bundled care, and time-based metrics have substantially improved neurological outcomes. Based on current evidence, we advocate for the widespread adoption of an early bundle of care for patients with intracerebral hemorrhage focused on time-based metrics for blood pressure control and emergency reversal of anticoagulation, with the goal of optimizing the benefit of these already widely used interventions. We hope Code ICH will endure as a structural platform for continued innovation, standardization of best practices, and ongoing quality improvement for years to come.

脑出血是最严重的中风类型，导致高致残率和死亡率。血肿扩大是功能预后不良的独立预测因子，也是一个引人注目的干预目标。几十年来，旨在通过单一干预减少血肿扩大的随机试验未能达到在统计学上显著改善神经预后的主要结果。广泛的证据表明，超早期捆绑护理，在急性期同时进行多项干预，是限制血肿扩大和改善功能恢复的最大希望。未能接受早期积极治疗的脑出血患者预后更差，这表明存在重要的治疗机会。这份共识声明呼吁采取行动，为Code ICH制定一项协议，类似于目前用于急性缺血性中风管理的策略，通过这些策略，早期干预、捆绑护理和基于时间的指标显著改善了神经预后。根据目前的证据，我们主张对脑出血患者广泛采用早期护理，重点是血压控制和紧急逆转抗凝的基于时间的指标，目的是优化这些已经广泛使用的干预措施的好处。我们希望Code ICH将在未来几年作为持续创新、最佳实践标准化和持续质量改进的结构性平台而持久存在。

REF: Li Q, Yakhkind A, Alexandrov AW, et al. Code ICH: A Call to Action. Stroke. Published online December 15, 2023. doi:10.1161/STROKEAHA.123.043033 PMID: 38099439

Making Sense of Vagus Nerve Stimulation for Stroke

对卒中迷走神经刺激的意义

Implantable vagus nerve stimulation, paired with high-dose occupational therapy, has been shown to be effective in improving upper limb function among patients with stroke and received regulatory approval from the US Food and Drug Administration and the Centers for Medicare & Medicaid Services. Combining nonsurgical and surgical approaches of vagus nerve stimulation in recent meta-analyses has resulted in misleading reports on the efficacy of each type of stimulation among patients with stroke. This article aims to clarify the confusion surrounding implantable vagus nerve stimulation as a poststroke treatment option, highlighting the importance of distinguishing between transcutaneous auricular vagus nerve stimulation and implantable vagus nerve stimulation. Recent meta-analyses on vagus nerve stimulation have inappropriately combined studies of fundamentally different interventions, outcome measures, and participant selection, which do not conform to methodological best practices and, hence, cannot be used to deduce the relative efficacy of the different types of vagus nerve stimulation for stroke rehabilitation. Health care providers, patients, and insurers should rely on appropriately designed research to guide well-informed decisions.

植入式迷走神经刺激与高剂量职业疗法相结合，已被证明可有效改善中风患者的上肢功能，并获得美国食品和药物管理局以及医疗保险和医疗补助服务中心的监管批准。在最近的荟萃分析中，迷走神经刺激的非手术和手术方法相结合，导致对中风患者中每种类型刺激的疗效的误导性报告。本文旨在澄清围绕植入式迷走神经刺激作为卒中后治疗选择的困惑，强调区分经皮耳迷走神经刺激和植入式迷走神经刺激的重要性。最近关于迷走神经刺激的荟萃分析不适当地结合了根本不同的干预措施，结局指标和参与者选择的研究，这些研究不符合方法学的最佳实践，因此不能用于推断不同类型的迷走神经刺激对中风康复的相对疗效。卫生保健提供者、患者和保险公司应该依靠适当设计的研究来指导明智的决策。

REF: Malakouti N, Serruya MD, Cramer SC, Kimberley TJ, Rosenwasser RH. Making Sense of Vagus Nerve Stimulation for Stroke. Stroke. Published online December 14, 2023. doi:10.1161/STROKEAHA.123.044576 PMID: 38095119

Causal Association of Iron Status With Functional Outcome After Ischemic Stroke

缺血性卒中后铁状态与功能预后的因果关系

Iron status has been associated with functional outcomes after ischemic stroke (IS). Nonetheless, this association may be affected by confounders. We perform Mendelian randomization to clarify the causal association between iron status and functional outcome after IS. Our study provides evidence suggesting a potential causal relationship between iron status and poor functional outcomes after IS. Future studies are required to illuminate the underlying mechanism.

铁状态与缺血性卒中(IS)后的功能结局有关。然而，这种联系可能会受到混杂因素的影响。我们进行孟德尔随机化研究，以阐明IS后铁状态与功能结果之间的因果关系。我们的研究提供了证据，表明铁状态与IS后不良功能结局之间存在潜在的因果关系。还需要进一步的研究来阐明其潜在的机制。

REF: He Q, Wang W, Xu D, et al. Causal Association of Iron Status With Functional Outcome After Ischemic Stroke. Stroke. Published online December 14, 2023. doi:10.1161/STROKEAHA.123.044930 PMID: 38095120