International Journal of Stroke最新文献

Net water uptake (NWU) is an emerging quantitative imaging biomarker for assessing cerebral edema in acute ischemic stroke. By quantifying the increase in brain water content within ischemic regions on computed tomography (CT), NWU offers a direct assessment of edema formation and its temporal evolution. Unlike conventional imaging markers such as infarct volume or ASPECTS, NWU provides specific information about the degree of tissue injury, which is a key determinant of clinical outcome. Observational studies have demonstrated that higher NWU is associated with malignant edema, hemorrhagic transformation, and worse functional outcomes, and that lower NWU may identify patients more likely to benefit from reperfusion and anti-edema therapies.This narrative review, based on a structured PubMed search of CT-based NWU studies in acute ischemic stroke, summarizes the technical methods for measuring NWU, its pathophysiological basis, and its potential clinical applications. We discuss the use of NWU for predicting outcomes, identifying patients at risk for malignant edema and hemorrhagic transformation, and selecting patients for emerging neuroprotective therapies. We also highlight the potential role of NWU in extending treatment windows and monitoring treatment response. Finally, we address the practical limitations of NWU, including situations in which reliable quantification is not feasible, and outline future directions for validation in multi-center cohorts and clinical trials before NWU-based thresholds can be adopted for routine decision-making.

Background: While infarcts and white matter hyperintensities (WMH) are critical determinants of post-stroke cognitive impairment (PSCI), their comprehensive network disconnection mechanisms remain poorly characterized.

Aims: This study aimed to systematically map the functional and structural network disconnection patterns underlying PSCI, elucidate the relationship between network disconnection and cognitive status-particularly the mediating role of WMH-and identify potential neuromodulation targets based on the disconnection maps.

Methods: In a cohort of 376 mild-to-moderate first acute ischemic stroke patients without pre-stroke dementia, we employed connectome-based lesion-symptom mapping (CLSM) to construct comprehensive disconnection maps derived from infarct and WMH lesions. The distinctiveness was validated against an independent cohort of 78 cerebral small vessel disease patients. CLSM-derived lesion impact scores were analyzed using regression models to assess their domain-specific cognitive relationships and using mediation modeling to quantify the mediating effects of WMH. Potential neuromodulation targets were subsequently identified based on the disconnection patterns.

Results: Results revealed that spatially heterogeneous infarcts and WMH converge on functionally/structurally coherent disconnection patterns through distinct pathological mechanisms, with attention and processing speed (APS) deficits emerging as the most sensitive domain. Lesion impact scores were significantly correlated with cognitive deficits and demonstrated greater predictive contribution for 3-month cognitive outcomes than traditional volumetric measures. WMH-induced disconnections significantly mediated the relationship between infarct and PSCI/APS deficits. The left temporo-parieto-occipital junction could be considered a potential neuromodulation target for PSCI.

Conclusions: This study establishes a network-level pathophysiological framework for PSCI, demonstrating distinct yet synergistic roles of acute and chronic vascular lesions.

Background: Previous studies suggest that blood-brain barrier (BBB) disruption may play a role in the pathophysiology of vessel rupture in cerebral amyloid angiopathy (CAA). Here, in a cross-sectional cohort study, we apply contrast-enhanced 3 Tesla MRI to test the hypothesis that the BBB is damaged in patients with CAA, and to determine whether BBB leakage is associated with hemorrhagic brain injury in CAA.

Methods: Parenchymal BBB leakage rate (Ki) was assessed in the cortex and white matter with dynamic contrast-enhanced (DCE)-MRI and quantified with pharmacokinetic modeling. Leptomeningeal BBB leakage was assessed visually on post-contrast heavily T2-weighted FLAIR images. Cortical cerebral microbleeds (CMBs) and cortical superficial siderosis (cSS) were assessed on susceptibility-weighted images. Analyses included descriptive statistics, group comparisons using the Mann-Whitney U test, and Spearman's rank correlation for associations with imaging markers.

Results: 25 patients with a clinical diagnosis of probable CAA without prior intracerebral hemorrhage and 19 age- and sex-matched controls were included. In patients with CAA, BBB leakage rates were lower in the cortex (4.2*10-4 min-1 vs 5.6*10-4 min-1; p=0.004) and in the white matter (1.2*10-4 min-1 vs 2.1*10-4 min-1; p<0.001) compared with controls. The presence of leptomeningeal enhancement was higher in patients with CAA (68%) compared with controls (47%) (p=0.007). Within the group with CAA, we did not find an correlation between number of cortical leakage and cortical CMBs and (Spearman's p=0.06, p=0.79) or number of foci of leptomeningeal enhancement and cSS hemisphere score (Spearman's p=0.30, p=0.15).

Discussion: Our results suggest that global parenchymal gadolinium extravasation across the BBB is lower in patients with CAA compared with controls. This observation can be explained in terms of limited capillary blood perfusion and/or raising the possibility that vascular amyloid-β deposition impairing molecular transport across the BBB. In contrast, focal leptomeningeal enhancement was higher in CAA reflecting vessel wall infiltration.

Background: The antithrombotic strategies for symptomatic intracranial atherosclerotic stenosis (sICAS) remains challenging. Dual pathway inhibition (DPI) has demonstrated clinical benefit in coronary and peripheral artery disease.

Aims: This study aimed to evaluate the efficacy of DPI with low-dose rivaroxaban plus antiplatelet therapy (APT) compared with APT alone on recurrent stroke with sICAS.

Methods: This prospective cohort study included patients with sICAS identified from the Ischemic Cerebrovascular Disease Database of the First Affiliated Hospital of Zhengzhou University between January 2019 to August 2023. Low-dose rivaroxaban was prescribed off-label to patients in the DPI group. The outcomes were ischemic stroke, transient ischemic attack (TIA), acute coronary syndrome (ACS), all-cause death and cardio-cerebrovascular death within one year of discharge. Cox regression with inverse probability of treatment weighting (IPTW) was applied to compare outcomes between the DPI and APT groups. The win-ratio method was used to assess the major adverse cardiovascular events (MACE), prioritized in the order of all-cause death, recurrent ischemic stroke or TIA, and ACS.

Results: Among the 1217 patients with sICAS, 131 (10.8%) received DPI therapy. The recurrence rate of ischemic stroke was lower in the DPI group compared to the APT group (8/131 [6.1%] vs. 136/1086 [12.5%]). DPI significantly reduced the risk of ischemic stroke recurrence (HR=0.46, 95% CI: 0.23-0.94, P=0.034) and the incidence of MACE (HR=0.53, 95% CI: 0.29-0.97, P=0.041) during the 1-year follow-up, consistent with the IPTW-based cohort (HR=0.35, 95% CI: 0.16-0.76, P=0.008; HR=0.43, 95% CI: 0.22-0.83, P=0.012). The win-ratio analysis of MACE favored DPI therapy (win ratio=2.34, 95% CI: 1.41-3.90, P=0.001). Symptomatic intracranial hemorrhage, fatal bleeding, and hospitalization for gastrointestinal bleeding were infrequent in this cohort.

Conclusions: DPI therapy may be associated with a lower risk of recurrent stroke compared with antiplatelet therapy alone in patients with sICAS. These findings warrant further investigation through large-scale randomized controlled trials.

Background: Stroke is increasingly recognised as an important cause of morbidity and mortality in people living with HIV (PLWH). Although advances in antiretroviral therapy (ART) have transformed HIV into a chronic condition, cerebrovascular complications remain common and often under-recognised.

Aims: This review summarises current understanding of the pathogenesis, clinical features, investigations, and management of stroke in PLWH, highlighting knowledge gaps and priorities for future research.

Summary of evidence: HIV-associated stroke is multifactorial. Mechanisms include HIV-associated vasculopathy, opportunistic infections, immune reconstitution inflammatory syndrome (IRIS), and traditional vascular risk factors accelerated by HIV and ART. Clinical presentations may resemble those in HIV-negative individuals, but occur at a younger age, with distinct subtype distributions and a higher frequency of concomitant infection. Investigation requires a tiered approach: standard stroke imaging and cardiac work-up, supplemented by cerebrospinal fluid analysis and advanced vessel wall imaging in patients with suspected inflammatory or infectious aetiology. Reperfusion therapies appear feasible in stable HIV disease, but evidence remains limited. Outcomes are shaped by immune status, access to care, and comorbidities, with higher recurrence and cognitive decline reported in several cohorts. Real-world challenges include stigma, clinician awareness gaps, and inequities in diagnostics and treatment, particularly in low-resource settings.

Conclusions: Stroke in PLWH is an emerging global health challenge. Clinicians should maintain a high index of suspicion in younger patients and those with advanced disease or recent ART initiation. Multidisciplinary care pathways and equitable access to diagnostics and secondary prevention are essential. Future research must address unresolved questions around vasculopathy, IRIS, small vessel disease, and long-term cognitive outcomes to guide evidence-based management.

BackgroundThe Global Burden of Disease (GBD) 2021 study and population-based stroke registers are principal sources of stroke incidence estimates. This study aims to assess the concordance and correlation between GBD stroke incidence rates and stroke incidence rates from population-based stroke registers.MethodsCrude and age-standardized stroke incidence rates were sourced from high quality population-based stroke registers and compared to GBD estimates matched by year and location, using GBD subnational data where available. Studies were categorized by country income group status using the World Bank country classifications; High income countries (HICs); Upper middle-income countries (UMICs) and Lower middle-income countries. Studies were categorized as to whether they were reported as informing the GBD 2021 model, using the online GBD 2021 sources tool. Concordance and correlation were assessed using Lin's concordance correlation coefficient and Pearson's correlation coefficient respectively. Bland-Altman plots were created to display 95% limits of agreement.Findings50 crude matched incidence rates and 31 matched age-standardized rates were compared. Concordance and correlation for crude stroke incidence were 0.67 and 0.68 overall, 0.66 and 0.68 for HICs, 0.59 and 0.77 for UMICs and 0.03 and 0.97 for LMICs respectively. Overall, 11 (22.0%) GBD estimates, accounting for UIs, matched population-based stroke register crude incidence rates. 95% limits of agreement were -110.2/100,00 to 134.1/100,000 overall. Concordance and correlation for age-standardized incidence rates were 0.56 and 0.59 overall, 0.59 and 0.63 for HICs, 0.12 and 0.17 for UMICs and 0.25 and 0.42 for LMICs. 95% limits of agreement were from -94.6 to 84.1/100,000. Subgroup analysis including only studies where more specific subnational geographical GBD estimates were available marginally improved crude incidence (n=18) concordance (0.67 to 0.71) but not age-standardized incidence (n=13) concordance (0.53 to 0.49). Subgroup analysis limited to population-based stroke registers included as GBD 2021 sources, did not significantly improve correlation or concordance.InterpretationOur findings demonstrate limited concordance and corelation in crude and age-standardized stroke incidence rates between population-based stroke registers and the GBD 2021 model, with lower concordance for UMICs and LMICs, compared to HICs. The wide 95% limits of agreement demonstrated should provide caution in the use of GBD stroke incidence estimates to guide policy or assess progress in the primary prevention of stroke.

Background: An increased risk of femoral fractures after ischemic stroke (IS) and transient ischemic attack (TIA) has been shown previously. However, it remains unclear whether the ischemic cerebral event is directly associated with the risk of femoral fractures.

Aims: The aim of this study was (1) to assess the association between the frequency of femoral fractures in patient with IS and TIA, and (2) to compare the risk of femoral fractures to the Austrian general population.

Methods: Population-based observational secondary analysis of the Austrian Stroke Cohort to assess the incidence of femoral fractures in the year after IS/TIA compared with the year before, and both intervals compared with the Austrian general population. All patients ⩾20 years treated for IS/TIA in Austria between 1 January 2016 and 31 December 2018 were identified using medical record linkage. Patient trajectories were reconstructed from 1 January 2015 to 31 December 2019 to have a 1-year observational period before and after the event. Femoral fractures within 1 year after IS/TIA compared to 1 year before IS/TIA were analyzed using McNemar test and Cox regression analysis considering sex and age. The 1-year age- and sex-adjusted relative risk of femoral fractures was calculated for patients with IS/TIA and compared to the Austrian general population.

Results: A total of 48,996 survivors of IS (n = 34,997) and TIA (n = 13,999) were included. The incidence of femoral fractures increased significantly from the year before the IS/TIA (8.9 per 1000 person-years, 95% CI 7.7-10.2) to the year after the event (11.8 per 1000 person-years, 95% CI 10.1-13.5; p = 0.022). Compared to the Austrian general population including 21.1 million patient-years at risk and 37,436 femoral fractures, the risk of femoral fractures was increased both in the year before (RR 2.08, 95% CI 2.06-2.11) and after (RR 3.52, 95% CI 3.48-3.56) the IS/TIA.

Conclusion: The risk of femoral fractures was found to be increased in the year following an IS/TIA, indicating a direct association with the IS/TIA event.Data access statement:Reconstruction of medical record linkage and individual patient trajectory reconstruction were reported previously. Data from individual patient trajectories was used for this analysis.

Background: Several randomized clinical trials have indicated that intensive blood pressure (BP) lowering is associated with worse outcomes, leaving the optimal BP targets following endovascular thrombectomy (EVT) uncertain.

Aims: This study aimed to investigate the relationship between specific systolic BP (SBP) thresholds, time spent outside these thresholds, and clinical outcomes.

Methods: This post hoc analysis of the Outcome in Patients Treated With Intra-Arterial Thrombectomy-Optimal Blood Pressure Control (OPTIMAL-BP) trial, included patients with successful EVT randomized to intensive (<140 mmHg) or conventional (140-180 mmHg) BP management. We analyzed SBP parameters, including mean, maximum, and minimum SBP during study period, as well as excursions beyond predefined SBP thresholds (<90, <100, <110, >170, >180, and >190 mmHg), and the cumulative and continuous durations of these excursions. Associations with 3 month modified Rankin Scale (mRS) and symptomatic intracerebral hemorrhage (sICH) were assessed using multivariable logistic and ordinal regression models.

Results: A total of 302 patients (median 75 years; 180 [59.6%] men) were analyzed with 11,461 BP measurements recorded during the first 24 hours after EVT. Prolonged hypoperfusion (SBP below 100 mmHg for continuous duration) was associated with worse mRS score (adjusted OR [aOR] 1.21 per hour, 95% CI [1.02-1.45]; P = 0.030) and increased sICH risk (aOR 1.49 per hour, 95% CI [1.15-1.97]; P = 0.004). SBP surges above 190 mmHg were linked to mRS worsening (aOR 2.60, 95% CI [1.05-6.53]; P = 0.039), but upper threshold-related parameters were not significantly associated with sICH.

Conclusion: Prolonged hypoperfusion below 100 mmHg and extreme surges above 190 mmHg, rather than specific SBP parameters, were associated with poor functional outcomes. These findings highlight the need for a threshold-based BP management approach post-EVT to minimize prolonged hypotension and excessive surges.