Cerebrovascular diseases are a leading cause of disability and death worldwide. The definition of stroke etiology is mandatory to predict outcome and guide therapeutic decisions. The diagnosis of pathological processes involving intracranial arteries is especially challenging, and the visualization of intracranial arteries’ vessel walls is not possible with routine imaging techniques. Vessel wall magnetic resonance imaging (VW-MRI) uses high-resolution, multiparametric MRI sequences to directly visualize intracranial arteries walls and their pathological alterations, allowing a better characterization of their pathology. VW-MRI demonstrated a wide range of clinical applications in acute cerebrovascular disease. Above all, it can be of great utility in the differential diagnosis of atherosclerotic and non-atherosclerotic intracranial vasculopathies. Additionally, it can be useful in the risk stratification of intracranial atherosclerotic lesions and to assess the risk of rupture of intracranial aneurysms. Recent advances in MRI technology made it more available, but larger studies are still needed to maximize its use in daily clinical practice.

BACKGROUND: The prognostic impact of intracerebral hemorrhage (ICH) volume varies according to location, with smaller volume tolerance in deep ICH, and hematoma expansion (HE) contributes to final ICH volume. We tested the hypothesis that HE influences outcome only when the final ICH volume achieves a critical threshold that differs according to ICH location. METHODS: Retrospective analysis of patients with supratentorial ICH admitted at 10 centers in North America and China (development cohort) and Europe (replication cohort). HE was defined as growth >33% and/or >6 mL. Location-specific (lobar versus deep) volume cutoffs for the prediction of poor outcomes were derived using receiver operating characteristic curves and the Youden index. The prognostic impact of HE stratified by location and final volume was explored with logistic regression (poor outcome: 90-day modified Rankin Scale score of 4–6), accounting for age, Glasgow Coma Scale, baseline volume, intraventricular hemorrhage, and admission center. RESULTS: We identified 1774 patients with ICH in the development cohort and 1746 in the replication cohort. A total of 1058 (mean age, 68 years; 47.8% men) and 1423 (mean age, 71 years; 44.7% men) subjects met the inclusion criteria, respectively. The optimal final ICH volume cutoff for poor outcome differed by location: ≥36 mL for lobar and ≥17 mL for deep ICH. HE with final volume below the cutoff was not associated with higher odds of poor outcome compared with patients without HE (adjusted odds ratio, 1.85 [95% CI, 0.78–4.38]; P =0.163 in lobar ICH; adjusted odds ratio, 0.85 [95% CI, 0.38–1.89]; P =0.685 in deep ICH). The combination of HE and final volume over the critical threshold was, however, significantly associated with poor prognosis, and the magnitude of this effect was substantial (adjusted odds ratio, 8.55 [95% CI, 2.87–25.48]; P <0.001 in lobar ICH; adjusted odds ratio, 10.34 [95% CI, 2.86–37.44]; P <0.001 in deep ICH). These findings were confirmed in the replication cohort. CONCLUSIONS: HE significantly impacts severe outcomes only when the final ICH volume exceeds a critical target threshold, and this threshold is lower in deep versus lobar ICH. These findings might inform clinical practice and future trials.

This study investigates the impact of general anesthesia (GA) versus conscious sedation/local anesthesia (CS/LA) on the outcome of patients with minor stroke and isolated M2 occlusion undergoing immediate mechanical thrombectomy (iMT). The databases of 16 comprehensive stroke centers were retrospectively screened for consecutive patients with isolated M2 occlusion and a baseline National Institute of Health Stroke Scale score ≤ 5 who received iMT. Propensity score matching (PSM) was used to estimate the effect of GA versus CS/LA on clinical outcome and procedure-related adverse events. Primary outcome measure was a 90-day modified Rankin Scale (mRS) score 0-1. Secondary outcome measures were 90-day mRS score 0-2 and all-cause mortality, successful reperfusion, procedural-related symptomatic subarachnoid hemorrhage (sSAH), intraprocedural dissections and new territory embolism. Of the 172 patients that were selected, 55 received GA and 117 CS/LA. After PSM, 47 pairs of patients were available for analysis. We found no significant differences in clinical outcome, rates of efficient reperfusion and procedural-related complications between patients receiving GA or LA/CS. (mRS 0-1: p=0.815; mRS 0-2: p=0.401; all-cause mortality: p=0.408; modified Treatment In Cerebral Infarction score 2b-3: p=0.374; sSAH: p=0.082; intraprocedural dissection: p=0.408; new territory embolism: p=0.462) CONCLUSIONS: In patients with minor stroke and isolated M2 occlusion undergoing iMT, the type of anesthesia does not affect clinical outcome or the rate of procedural-related complications. Our results agree with recent data showing no benefit of one specific anesthesiologic procedure over the other and confirm their generalizability also to patients with minor baseline symptoms.

Background: Noncontrast computed tomography hypodensities are a validated predictor of hematoma expansion (HE) in intracerebral hemorrhage and a possible alternative to the computed tomography angiography (CTA) spot sign but their added value to available prediction models remains unclear. We investigated whether the inclusion of hypodensities improves prediction of HE and compared their added value over the spot sign. Methods: Retrospective analysis of patients admitted for primary spontaneous intracerebral hemorrhage at the following 8 university hospitals in Boston, US (1994–2015, prospective), Hamilton, Canada (2010–2016, retrospective), Berlin, Germany (2014–2019, retrospective), Chongqing, China (2011–2015, retrospective), Pavia, Italy (2017–2019, prospective), Ferrara, Italy (2010–2019, retrospective), Brescia, Italy (2020–2021, retrospective), and Bologna, Italy (2015–2019, retrospective). Predictors of HE (hematoma growth >6 mL and/or >33% from baseline to follow-up imaging) were explored with logistic regression. We compared the discrimination of a simple prediction model for HE based on 4 predictors (antitplatelet and anticoagulant treatment, baseline intracerebral hemorrhage volume, and onset-to-imaging time) before and after the inclusion of noncontrast computed tomography hypodensities, using receiver operating characteristic curve and De Long test for area under the curve comparison. Results: A total of 2465 subjects were included, of whom 664 (26.9%) had HE and 1085 (44.0%) had hypodensities. Hypodensities were independently associated with HE after adjustment for confounders in logistic regression (odds ratio, 3.11 [95% CI, 2.55–3.80]; P <0.001). The inclusion of noncontrast computed tomography hypodensities improved the discrimination of the 4 predictors model (area under the curve, 0.67 [95% CI, 0.64–0.69] versus 0.71 [95% CI, 0.69–0.74]; P =0.025). In the subgroup of patients with a CTA available (n=895, 36.3%), the added value of hypodensities remained statistically significant (area under the curve, 0.68 [95% CI, 0.64–0.73] versus 0.74 [95% CI, 0.70–0.78]; P =0.041) whereas the addition of the CTA spot sign did not provide significant discrimination improvement (area under the curve, 0.74 [95% CI, 0.70–0.78]). Conclusions: Noncontrast computed tomography hypodensities provided a significant added value in the prediction of HE and appear a valuable alternative to the CTA spot sign. Our findings might inform future studies and suggest the possibility to stratify the risk of HE with good discrimination without CTA.

Psychosis and agitation are among the most distressing neuropsychiatric symptoms (NPSs) of Alzheimer’s disease (AD), linked to faster disease progression and earlier admission to nursing homes. While nonpharmacological treatments may alleviate mild behavioral symptoms, more severe syndromes often require pharmacological intervention. Brexpiprazole is the only medication approved for agitation in AD, although its limited clinical efficacy has raised criticism. No drugs have been approved for treating psychosis in AD, highlighting the critical need for new, effective, and safe treatments. Recent studies have elucidated part of the neurobiological basis of NPSs in the AD brain, offering insights for testing repurposed and novel drugs. We conducted a comprehensive nonsystematic literature review, aiming to provide a critical overview of both current treatments and emerging pharmacological interventions under clinical development for treating psychosis and agitation in AD. Additionally, we present strategies to optimize the clinical development of new drug candidates. We identify three promising compounds that are currently in phase 3 trials: xanomeline-trospium for AD psychosis, and dextromethorphan-bupropion and dexmedetomidine for agitation in AD. We propose that biomarkers linked to the neuropsychiatric traits of AD patients should be identified in dedicated studies and then included in phase 2 dose-range-finding studies with novel compounds to establish biological engagement. Furthermore, phase 3 placebo-controlled studies should be carried out in AD biomarker-confirmed subjects with narrower cognitive impairment ranges and precise NPS severity at screening. Alternative study designs, such as sequential phase approaches, may also be adopted.

Background: The objective of this study was to assess the performance of the first publicly available automated 3D segmentation for spontaneous intracerebral hemorrhage (ICH) based on a 3D neural network before and after retraining. Methods: We performed an independent validation of this model using a multicenter retrospective cohort. Performance metrics were evaluated using the dice score (DSC), sensitivity, and positive predictive values (PPV). We retrained the original model (OM) and assessed the performance via an external validation design. A multivariate linear regression model was used to identify independent variables associated with the model’s performance. Agreements in volumetric measurements and segmentation were evaluated using Pearson’s correlation coefficients (r) and intraclass correlation coefficients (ICC), respectively. With 1040 patients, the OM had a median DSC, sensitivity, and PPV of 0.84, 0.79, and 0.93, compared to thoseo f 0.83, 0.80, and 0.91 in the retrained model (RM). However, the median DSC for infratentorial ICH was relatively low and improved significantly after retraining, at p < 0.001. ICH volume and location were significantly associated with the DSC, at p < 0.05. The agreement between volumetric measurements (r > 0.90, p > 0.05) and segmentations (ICC ≥ 0.9, p < 0.001) was excellent. Conclusion: The model demonstrated good generalization in an external validation cohort. Location-specific variances improved significantly after retraining. External validation and retraining are important steps to consider before applying deep learning models in new clinical settings.