International Journal of Stroke最新文献

Background: It remains unclear whether the serum levels of the brain injury biomarkers (glial fibrillary acidic protein [GFAP] and ubiquitin C-terminal hydrolase-L1 [UCH-L1]) can be used to quantitatively evaluate brain tissue injury and predict prognosis in patients with intravenous thrombolysis (IVT).

Aim: This study investigates the association between serum GFAP and UCH-L1 levels with functional outcomes in patients receiving IVT.

Methods: Patients were prospectively enrolled from 16 hospitals. We measured serum GFAP and UCH-L1 levels 24 hours after IVT. Infarct volume, hemorrhagic transformation (HT), and short- and long-term prognostic indicators were evaluated. GFAP and UCH-L1 cutoff levels for predicting 3-month unfavorable outcomes were derived, and a biomarker-based model was established and subjected to internal and external validation.

Results: This study included 1028 patients. Higher GFAP and UCH-L1 levels were independently associated with larger infarct volume, HT, higher 24-hour and 7-day National Institutes of Health Stroke Scale scores, and 3-month modified Rankin Scale scores. The cutoff levels for GFAP and UCH-L1 (116 and 292 pg/mL, respectively) predicted patients with 3-month unfavorable outcomes with a specificity and positive predictive value (PPV) of 97.56% (95% confidence interval [CI], 94.51-99.00) and 88.68% (95% CI, 76.28-95.31), respectively, in the training cohort. In the testing and validation cohorts, specificity was 97.83% (95% CI, 91.62-99.62) and 96.90% (95% CI, 91.77-99.00), respectively, and PPV was 90.00% (95% CI, 66.87-98.25) and 75.00% (95% CI, 47.41-91.67), respectively. Furthermore, the biomarker-based nomogram model showed good predictability of 3-month prognosis in the different cohorts.

Conclusions: Serum GFAP and UCH-L1 levels can be used to quantitatively evaluate brain tissue injury and predict the prognosis of patients with IVT.

There were 56.9 million people worldwide living with dementia in 2021, according to the Global Burden of Disease study, and this number is projected to exceed 137 million by 2050. Vascular dementia (VaD) is the second leading cause of dementia. While high-quality global epidemiological data on VaD remain limited, population-based studies with autopsy confirmation allow an approximate estimation. These show that pure VaD represents approximately 15% of all dementia cases, with mixed vascular and degenerative dementia accounting for an additional 16%. According to these estimates, approximately 8.5 million people worldwide suffer from pure VaD, and 9.1 million from mixed dementia. Under the assumption that existing proportional rates remain constant, the global burden of total VaD (i.e. pure VaD and mixed dementia) will reach 42.7 million cases by 2050. However, the impact of cerebrovascular disease is likely to be even greater. Increasing evidence demonstrates that vascular pathology commonly coexists with Alzheimer's and other neurodegenerative pathologies, increasing the risk that these neurodegenerative pathologies cause clinical dementia. Despite the importance of VaD, it remains underrecognized and underresearched compared to other forms of dementia. This fact sheet highlights the urgent need for improved recognition, standardized diagnostic approaches, and enhanced preventive strategies for this highly prevalent yet underrecognized cause of dementia. The factsheet has been reviewed and approved by the World Stroke Organization (WSO) executive.

Background: There is a need for accessible and affordable rehabilitation services in low-resource settings (low- and middle-income countries) to support the increasing number of survivors of stroke.

Aims: To synthesize existing literature on the delivery of community-based stroke rehabilitation programs in low-resource settings.

Summary of review: We followed the PRISMA Scoping Review guidelines. Seven databases (including MEDLINE, PsycINFO, and CINAHL) were searched to identify relevant articles published between January 2012 and December 2024. Studies were considered if they included physical rehabilitation strategies as part of a community-based rehabilitation program for individuals with stroke aged ⩾18 years in low-resource settings. Titles, abstracts, and full texts were screened by multiple authors for inclusion. A predefined template that covered physical rehabilitation strategies, setting, providers, frequency, session duration, and program duration was used for data extraction. Results were synthesized narratively. After screening 2892 abstracts, 25 studies were included from 11 countries throughout Asia, Africa, and South America. Most studies were carried out in middle-income countries, with only one study taking place in a low-income country (Uganda). Over half of the studies (n = 16) were randomized controlled trials (RCTs). The physical rehabilitation programs were primarily delivered at home, in person, by a single healthcare professional, typically a physiotherapist or nurse. Session duration was not specified for more than half of the studies. Where reported, sessions were 1 h or less, usually occurring at least once weekly over a 2-to-3-month period. Over 36 different outcome measures were identified, with the Barthel Index being the most common (48%). Overall, 10 RCTs showed a statistically significant difference between intervention and control groups, while five RCTs had no significant difference at the post-intervention outcome evaluation. None of the included publications reported costs or cost-effectiveness data.

Conclusion: Community-based rehabilitation programs in low-resource settings differ in their physical rehabilitation strategies and characteristics. While the evidence base in this field is growing, the lack of cost-effectiveness evaluations means there is limited guidance to inform investment in, or optimization of, these multi-component, community-based programs.

Background and objectives: Race and ethnicity have been shown to affect healthcare outcomes among patients diagnosed with cerebral aneurysms. Our study analyzes baseline demographics, lifestyle, healthcare resource utilization, and perception of health status among patients with ruptured and unruptured cerebral aneurysms based on race and ethnicity.

Methods: This was a cross-sectional study that utilized survey data and electronic health record (EHR) data from the All of Us Research Program. Patients with unruptured and ruptured aneurysms were identified using ICD-9/10 codes. Cohorts were classified into three categories based on self-reported race/ethnicity: Black, Hispanic, or White.

Results: A total of 2975 patients with unruptured cerebral aneurysms and 1498 ruptured cerebral aneurysms were included. Black and Hispanic patients with cerebral aneurysms reported lower income, education, and employment rates, in addition to higher rates of daily cigarette smoking compared to White patients (P < 0.001). After adjusting for confounders, Hispanic patients reported higher odds of being unable to afford specialist care (odd ratio (OR) = 1.86 [1.02-3.37], P = 0.04) and follow-up care (OR = 2.76 [1.52-5.00], P < 0.001), while Black patients reported higher odds of being unable to afford prescription medications (OR = 1.55 [1.03-2.33], P = 0.03) compared to White patients. Black and Hispanic patients reported lower odds of feeling respected by their healthcare provider (OR = 0.45 [0.21-0.94], P = 0.03 and OR = 0.32 [0.15-0.67], P < 0.01), demonstrated lower confidence in completing medical forms independently (OR = 0.58 [0.37-0.89], P = 0.01 and OR = 0.31 [0.20-0.47], P < 0.001) and were more likely to consider their provider's race/religion important compared to White patients (OR = 2.09 [1.51-2.88], P < 0.001 and OR = 2.28 [1.56-3.34], P < 0.001).

Discussion: Our study identified disparities in baseline characteristics, healthcare access, and perception of health status among racial/ethnic minorities with unruptured and ruptured aneurysms. Future research could emphasize on addressing these disparities by ensuring more equitable access to healthcare.

Background and objectives: In patients with minor stroke, intravenous thrombolysis is recommended only for those with disabling symptoms, yet no standardized definition exists, and the treatment decisions remain subjective. This study aimed to evaluate the effect of thrombolysis in minor stroke using routine care registry data.

Patients and methods: A Danish nationwide register-based cohort study included patients with minor stroke (Scandinavian Stroke Scale (SSS) ⩾ 45) from 2011 to 2021. Patients were categorized as having mild strokes (SSS 45-49, approximated National Institutes of Health Stroke Scale (NIHSS) = 5-6) or very mild strokes (SSS 50-58, approximated NIHSS 1-4) to pragmatically distinguish disabling from non-disabling symptoms. Return-to-work, use of homecare, typical stroke complications, recurrent stroke, and mortality were compared in patients treated with and without thrombolysis. Analyses were adjusted for vascular risk factors, demographics, and clinical characteristics using inverse probability of treatment weighting.

Results: Among 31,007 included patients, 1910 with mild strokes and 4052 with very mild strokes received thrombolysis. In patients with mild strokes, thrombolysis was associated with a higher rate of return-to-work (adjusted hazard ratio = 1.33), lower risk of pneumonia (adjusted relative risk (aRR) = 0.40), and lower mortality (aRR = 0.58, 0.50, and 0.50 at 30, 90, and 365 days, respectively). In patients with very mild strokes, thrombolysis was not associated with improved outcomes, except lower mortality at 365 days (aRR = 0.78).

Discussion: Intravenous thrombolysis was more often associated with better outcomes in patients with mild strokes than in patients with very mild strokes.

Background: While managing spontaneous intracerebral hemorrhage (sICH) has advanced, achieving favorable outcomes remains challenging. Recent studies suggest that decompressive craniectomy (DC) may offer benefits over conservative treatment, consisting of the best medical treatment (BMT) in certain sICH cases.

Aim: This study aims to compare DC to BMT alone for sICH regarding functional neurological outcomes, mortality, and length of hospitalization.

Methods: Randomized and observational studies were identified comparing surgery (DC) to conservative management alone for patients with sICH. The outcomes analyzed were modified Rankin Scale (mRS), mortality at 30 days, 90 days, and overall mortality, and length of hospital stay. The odds ratio (OR) and mean difference (MD) were calculated for binary and continuous outcomes.

Results: Our analysis included eight studies (n = 743), with 345 patients undergoing surgery and 398 undergoing conservative management. BMT alone was associated with a poor neurological function (mRS of 5-6) (OR = 0.44; 95% CI = 0.24-0.78; p-value = 0.005; I² = 39.8%), while the rate of good neurological function (mRS = 0-4) was superior in the surgical cohort (OR = 2.29; 95% CI = 1.28-4.10; p = 0.005; I² = 39.8%), despite the lack of statistical significance for mRS 0-2 (OR = 1.25; 95% CI = 0.47-3.33; p = 0.66; I² = 0%) and mRS 0-3 (OR = 1.43; 95% CI = 0.82-2.51; p = 0.21; I² = 0%). Conservative management was associated with higher mortality at 30 days (OR = 0.36; 95% CI = 0.19-0.66; p-value = 0.001; I² = 0%), at 90 days (OR = 0.35; 95% CI = 0.14-0.86; p = 0.022; I² = 68.7%), and at last follow-up (OR = 0.33; 95% CI = 0.21-0.52; p-value < 0.001; I² = 34.8%). Length of hospital stay was superior in the DC cohort, but without statistical significance (MD = 16.05; 95% CI = -3.24 to 35.34; p-value = 0.1; I² = 92.9%).

Conclusions: In patients with sICH, decompressive craniectomy shows potential for reducing mortality and improving neurological function compared to BMT alone. Further randomized studies, with improved methods, are needed to increase the quality of evidence.

Background: The optimal blood pressure control strategy after mechanical thrombectomy (MT) is not well understood, especially for patients with successful recanalization. We hypothesized that low systolic blood pressure (SBP) after MT is associated with infarct growth (IG), even in patients with successful recanalization.

Aims: The aim of the present study was to clarify the relationships between IG and SBP parameters in patients treated with MT.

Method: Consecutive acute stroke patients who underwent emergent MT from September 2014 through December 2019 were retrospectively enrolled. Diffusion-weighted imaging (DWI) was performed on admission and approximately 24 h after the procedure. IG was calculated as the difference between infarct volume on 24-h DWI and initial DWI. SBP from recanalization to 24-h DWI was used. The associations between IG and SBP parameters, including maximum, minimum, and mean SBPs and coefficient of variation (CV) of SBPs, were evaluated with multiple regression analyses.

Results: A total of 377 MT cases (225 male (60%), median age = 76 (interquartile range (IQR) = 68-83) years, median National Institutes of Health Stroke Scale (NIHSS) score = 17 (10-23), median onset to initial DWI time = 131 (79-350) min) were enrolled in this study. Successful recanalization modified the association between SBP parameters and IG (p for interaction < 0.05). In cases with successful recanalization (n = 314), SBP was recorded 7007 times between recanalization and 24-h follow-up magnetic resonance imaging (MRI). Minimum SBP from recanalization to 24-h DWI (standardized coefficient = -0.144, 95% confidence interval (CI) -0.269 to -0.019, p = 0.024, i.e. low minimum SBP was associated with higher IG) and CV of SBP (0.122, 0.003 to 0.241, p = 0.045) were independently associated with IG, even after adjusting for various factors including age, sex, initial NIHSS score, baseline infarct volume, and symptomatic intracerebral hemorrhage.

Conclusion: Minimum SBP and CV of SBP after recanalization were associated with IG in consecutive acute stroke patients who underwent successful MT. IG is a sensitive imaging marker for evaluating the effect of post-procedural SBP, and extremely low SBP after MT should be avoided to mitigate IG.

Background: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) improve the cardiovascular outcomes of patients with type 2 diabetes (T2D). However, whether this effect extends to stroke prevention in high-risk patients remains unclear.

Aims: This study aims to investigate the effect of SGLT2i in stroke prevention in patients with T2D and concomitant risk factors.

Methods: Patients with T2D and various risk factors for stroke were identified from the TriNetX platform from 2013 to 2024. These patients were divided into two cohorts: one treated with SGLT2i, and the other with metformin or dipeptidyl peptidase-4 inhibitors. Propensity score matching was used to balance the patients' demographic characteristics, underlying comorbidities, and antiplatelet and anticoagulant drug use patterns. The primary outcome was the development of ischemic or hemorrhagic stroke or the onset of a transient ischemic attack (TIA) within 1 year. Unadjusted Cox proportional hazards models were applied to estimate hazard ratios (HRs). Sensitivity analyses stratified by age, sex, and hemoglobin A1c (HbA1c) levels were performed, and interaction tests were used to assess potential effect modifiers. In addition, the two cohorts were compared for estimation of numbers needed to treat (NNTs).

Results: A total of 3,715,058 patients were identified, of whom 971,727 (26.2%) were SGLT2i users. After matching, 932,419 patients were included in each group. SGLT2i use was associated with a significantly reduced risk of ischemic stroke (HR: 0.84, 95% confidence interval (CI): 0.81-0.87; NNT: 669), hemorrhagic stroke (HR: 0.73, 95% CI: 0.68-0.79; NNT: 1837), and TIA (HR: 0.81, 95% CI: 0.77-0.86; NNT: 1615). The protective effect against ischemic stroke was more pronounced in males and individuals aged over 65 years. Greater benefit was observed in patients with chronic kidney disease (NNT: 466), atrial fibrillation (NNT: 492), and heart failure (NNT: 415). In contrast, the protective effect was attenuated in patients with obesity, among whom SGLT2i use was associated with a modestly increased risk of ischemic stroke after 1 year (HR: 1.05, 95% CI: 1.01-1.09).

Conclusion: SGLT2i use is associated with a significant reduction in the risk of stroke among selected T2D patients. SGLT2i may be used as a first-line therapy for diabetes patients with concomitant chronic kidney disease, atrial fibrillation, and heart failure.

Background: Stroke globally impacts mortality and disability. Compliance with international standards and evidence-based practices for acute stroke management would improve patient outcomes.

Objectives: We aimed to present a descriptive analysis of the quality of acute stroke care across different countries using the Registry of Stroke Care Quality (RES-Q).

Method: In a cross-sectional study, data from key quality indicators such as Emergency Medical Services (EMS) deployment rates, hospital arrival to imaging time (door-to-imaging: DIT), hospital arrival to thrombolysis time (door-to-needle: DNT), and Stroke Unit Care/Intensive Care Unit (SU/ICU) admission frequencies were examined. The analysis employed descriptive statistics and Spearman correlation tests.

Results: Of 334,184 patients from 1130 hospitals in 70 countries, 218,832 patients (65.5%) from 47 countries were diagnosed with acute ischemic stroke after exclusions. The number of patients per country ranged from 226 to 62,080. International variability in care quality was observed: EMS (7-97%); SU/ICU (12-100%); and median DIT (7-41 min); and DNT (20-75 min). IVT rates varied markedly across countries, ranging from <1% to 52%. Higher patient volumes were positively correlated with SU/ICU admission and negatively with DIT and DNT (ρ = 0.10, -0.22, -0.42, respectively).

Conclusion: This study demonstrates substantial international variation in the use of quality monitoring in clinical practice as well as in key indicators of acute ischemic stroke care, including intravenous thrombolysis rates and treatment timelines. The extent of variability highlights opportunities for benchmarking and targeted quality improvement efforts across diverse healthcare systems.

Background: Stroke is a leading cause of death and disability worldwide, with women facing unique risks due to a combination of well-established, under-recognized, and female-specific factors.

Aims: This prospective cohort study aimed to quantify the population attributable fractions (PAFs) of stroke with distinct risk factor profiles and to explore disparities across age strata.

Methods: Data were from 239,200 women recruited in the UK Biobank. Following the framework established by the Lancet Women and Cardiovascular Disease Commission, stroke risk factors were sorted into three categories, including eight well-established risk factors, four social-psychological risk factors, and 11 reproductive factors. The Cox regression model with correction of multiple comparisons was used to assess their associations with incident stroke and its subtypes. PAFs were calculated to estimate the attributable stroke burden for individual risk factors, each risk factor category, and all risk factors combined. Age-stratified analyses were further conducted.

Results: During a median follow-up of 13.8 years, 4580 (1.9%) women developed incident stroke. Hypertension served as the leading individual risk factor (PAF 23.3%, 95% confidence interval [CI] = 20.1%, 26.4%). Under the assumption of multiplicative effect, well-established risk factors accounted for 32.8% of stroke cases, followed by social-psychological factors (15.2%) and reproductive factors (6.3%). The overall PAF (95% CI) of total stroke with all risk factors combined was 47.6% (47.6%, 47.7%) or 40.2% (40.1%, 40.2%) with multiplicative or additive effect. Across the age groups, the highest total stroke PAFs for overall risk factors (51.9%) and well-established risk factors (37.0%) were observed among women aged 60-65 years. For reproductive factors, the highest PAFs were observed among women aged 60-65 years (9.2%) and ⩾65 years (4.5%).

Conclusion: While the conventional risk factors contributed to the greatest stroke burden, the potential benefit of addressing issues related to unfavorable social-psychological conditions and adverse reproductive profiles should not be neglected. Integrated and targeted prevention strategies are in urgent need to protect women's cardio-cerebrovascular health throughout the lifespan.