International Journal of Stroke最新文献

Introduction: Intracranial large artery stenosis (ILAS) is one of the most common causes of stroke worldwide and is associated with the risk for future vascular events. Asymptomatic ILAS is a frequent finding on neuroimaging and shares many risk factors with atherosclerotic vascular disease. Whether asymptomatic ILAS is driven by genetic variants is not well-understood.

Methods: This study included 4960 participants from seven geographically diverse population-based cohorts (34% Whites, 16% African Americans, 22% Hispanics, 24% Asians, 5% native Ecuadorians). We defined asymptomatic ILAS as luminal stenosis >50% in any large brain artery using time-of-flight magnetic resonance angiography.

Results: A genome-wide association study revealed one variant in RP11-552D8.1 (rs75615271; odds ratio (OR), 1.22 (1.11-1.33); p = 4.85×10^-8) associated with global ILAS at genome-wide significance (p < 5×10^-8). Gene-based association analysis identified a gene-set enriched in chr1q32 region, including NEK2, LPGAT1, INTS7, DTL, and TMEM206, in global ILAS (p = 1.34 ×10^-7) and anterior ILAS (p = 1.77 ×10^-8).

Discussion and conclusion: This study reveals one variant rs75615271 and a gene-set enriched in chr1q32 region associated with asymptomatic ILAS in a multi-population. Further functional studies may help elucidate the role that this variant plays in the pathophysiology of asymptomatic ILAS.

Background: Endothelial inflammation is involved in cerebral small vessel disease (CSVD) pathogenesis. Vascular cell adhesion molecule 1 (VCAM-1) and intercellular adhesion molecule 1 (ICAM-1) are biomarkers of endothelial inflammation.

Aims: This study investigated the association of VCAM-1 and ICAM-1 with the presence of CSVD and CSVD burden.

Methods: This cross-sectional study included community residents from the Polyvascular Evaluation for Cognitive Impairment and Vascular Events (PRECISE) study. Fasting venous blood was drawn to assay VCAM-1 and ICAM-1. Cognition was assessed by the Montreal Cognitive Assessment (MoCA). Cognitive impairment was defined as MoCA scores < 26. White matter hyperintensity, lacunes, cerebral microbleeds, and enlarged perivascular spaces were evaluated in a 3.0T MRI scanner. CSVD burden was rated according to the criteria of Wardlaw's (score 0-4) and Rothwell's (score 0-6), and classified into four grades. Presence of CSVD was defined as CSVD burden score ⩾ 1.

Results: This study included 2596 participants with a mean age of 61.2 ± 6.7 years and 50.9% of males. Elevated VCAM-1 was associated with increased odds of presence of CSVD (Rothwell: odds ratio (OR) = 1.16, 95% confidence interval (CI): 1.06-1.26, P = 0.001), higher CSVD burden (Wardlaw: common OR (cOR) = 1.11, 95% CI: 1.02-1.21, P = 0.02; Rothwell: cOR = 1.16, 95% CI: 1.07-1.25, P < 0.001), and presence of cognition-impaired CSVD (Rothwell: OR = 1.15, 95% CI: 1.05-1.25, P = 0.003). VCAM-1 improved net reclassification index and integrated discrimination improvement for the presence of CSVD (Rothwell) and cognition-impaired CSVD (Rothwell). However, ICAM-1 was not associated with CSVD and did not improve prediction of CSVD.

Conclusion: Endothelial inflammation, especially VCAM-1, was associated with the presence of CSVD and higher CSVD burden.

Background and objectives: Fibromuscular dysplasia (FMD) is a vascular disorder affecting medium-sized arteries, including the extracranial cervical arteries, and can lead to aneurysmal subarachnoid hemorrhage (aSAH). We aimed to determine the prevalence of cervical FMD in aSAH patients and assess whether cervical FMD in these patients is associated with more severe aneurysmal disease and internal carotid artery (ICA) elongation.

Methods: We retrospectively reviewed computed tomography angiography (CTA) scans acquired on admission in a consecutive series of aSAH patients (2019-2024). The prevalence of FMD in the extracranial segments of the ICA and vertebral arteries (VAs) was determined. In addition, differences in aneurysm size, number of aneurysms, rebleeding rates, and ICA elongation were assessed between patients with and without FMD using logistic regression, adjusting for potential confounders.

Results: Cervical FMD was identified in 40 of 485 aSAH patients (prevalence 8.3%, 95% confidence interval (CI) = 6.0-11.1%). aSAH patients with FMD were older, more frequently women, and more likely to have hypertension than those without FMD. We found no statistically significant differences in aneurysm size, number of aneurysms, rebleeding rates, or ICA elongation.

Discussion: We report a high prevalence (8.3%) of cervical FMD among aSAH patients, but no clear differences in aneurysm severity and ICA elongation compared to those without. Given the high prevalence, we recommend routine screening for cervical FMD in aSAH patients on CTA (or another angiography modality). If FMD is suspected, full-body CTA (or other angiographic modality) should be considered for further vascular assessment.

Background and objectives: We examined the timing of suicide after stroke, the sociodemographic factors associated with the risk of suicide, and whether major depression modified the stroke-suicide association.

Methods: We conducted a population-based retrospective cohort study of all adults in Ontario hospitalized for stroke between January 1, 2008, and December 31, 2017, who were matched 1:1 to controls from the general Ontario population on age, sex, neighborhood-level income, rurality, and comorbidities. Suicide, a composite of deliberate self-harm or death by suicide, was ascertained based on hospitalizations and emergency department visits. Cause-specific hazard models were used to evaluate the association between stroke and suicide, and major depression was treated as a time-varying covariate. Cause-specific hazard models evaluated the association between sociodemographic factors and suicide in stroke survivors. The modifying effect of major depression was assessed by adding an interaction term between stroke and major depression.

Results: We included 64,719 matched pairs of patients with stroke and general population controls (45.4% female, mean age 71.4 years). In the 627,774 person-years follow-up, 436 cases and controls had an episode of self-harm or died by suicide, with 203 (67.4%) events in stroke survivors occurring after the first year. Compared to matched controls, stroke survivors had a higher rate of suicide (11.1 vs 3.2 per 10,000 person-years, hazard ratio (HR) 2.87; 2.35-3.51). The association between stroke and suicide did not vary by the presence of major depression (P_{stroke*depression} = 0.51). Suicide rates were elevated in younger stroke survivors (HR_{18-40 vs ⩾ 80 years} 4.34; 2.48-7.61), those living in low-income neighborhoods (HR_{lowest vs highest quintile} 1.88; 1.30-2.70), and those with major depression (HR 12.3; 7.63-19.7).

Discussion: The elevated rate of suicide after stroke persists beyond one year, highlighting the need for long-term screening for suicidality, especially in younger stroke survivors and those residing in low-income neighborhoods and with major depression after stroke.

Background: Evidence on the role of herpes-zoster (shingles) vaccination in reducing stroke risk is inconsistent and limited, particularly concerning intracerebral hemorrhage (ICH). We aimed to examine the association between zoster live vaccine (ZVL) and overall stroke, as well as its main subtypes.

Methods: We conducted a population-based nested case-control study using the database of Israel's largest healthcare provider. The underlying cohort consisted of individuals aged 50 years or older, regardless of prior stroke status, from 2015 to 2022, with follow-up through June 2023. Stroke cases diagnosed during follow-up were matched with controls based on age, sex, population sector, and index date. ZVL exposure was defined as the prior filling of a prescription of the vaccine.

Results: Among 37,027 matched case-control pairs, ZVL was associated with significantly reduced odds of stroke, with an adjusted odds ratio (OR) of 0.65 (95% confidence interval (CI), 0.58-0.72) for overall stroke, 0.65 (95% CI, 0.58-0.73) for ischemic stroke, and 0.64 (95% CI, 0.47-0.89) for ICH. The protective association with overall stroke decreased as time since vaccination increased; adjusted OR of 0.56 (0.48-0.65) within the first 2.5 years, 0.71 (95% CI, 0.58-0.87) after 2.5 to 5 years, and 0.81 (95% CI, 0.65-1.01) after 5 years. The association between ZVL and stroke was modified by age and sex, with a stronger association in individuals younger than 65 years (p for interaction = 0.004) and males (p for interaction = 0.031).

Conclusions: ZVL is associated with a reduced risk of both ischemic stroke and ICH. The protective association appears to decrease over time and to be stronger in males and younger individuals.

Background: A substantial proportion of ischemic strokes remain classified as embolic stroke of undetermined source (ESUS) despite standard diagnostic evaluation. Prolonged cardiac monitoring with implantable cardiac monitors (ICMs) increases atrial fibrillation (AF) detection, but the optimal timing of ICM implantation after ESUS remains uncertain.

Aims: To evaluate whether early versus delayed ICM implantation after ESUS influences AF detection and time to diagnosis.

Methods: We conducted a multicentre observational cohort study emulating a target trial. Consecutive ESUS patients undergoing ICM implantation were classified as ICMEARLY (≤30 days) or ICMDELAYED (31-365 days) implantation after the index event. Inverse probability weighting was applied to adjust for baseline confounding. Primary and secondary outcomes included AF detection within 30, 90, and 120 days after implantation, assessed using weighted logistic regression, Poisson models for detection rates per person-time, Cox proportional hazards models, and restricted mean survival time (RMST). Sensitivity analyses included centre-level clustering and competing-risk models.

Results: Among 333 patients (90 ICMEARLY, 243 ICMDELAYED), early implantation was associated with significantly higher AF detection within 30 days (7.8% vs 1.6%; OR 4.49, 95% CI 1.17-17.27; p=0.028) and higher detection rates per person-time (IRR 4.26, 95% CI 1.16-15.60; p=0.029). Consistent associations were observed at 90 and 120 days. Time-to-event analyses showed higher hazards of AF detection with early implantation (HR 4.29 at 30 days; HR 2.97 at 90 days; HR 2.77 at 120 days; all p<0.01). RMST analyses demonstrated progressively shorter time to AF diagnosis in the ICMEARLY group across multiple time horizons. Results were robust across sensitivity analyses.

Conclusions: Early ICM implantation after ESUS is associated with higher and faster AF detection compared with delayed implantation. When ICM monitoring is indicated, avoiding unnecessary delays may substantially enhance diagnostic yield.

Background: Randomized trials have shown that endovascular thrombectomy improves functional outcomes in patients with acute ischemic stroke and large infarct. However, there is continued debate about the generalizability of these results to routine clinical practice.

Aims: To investigate whether functional outcomes reported in the randomized TENSION trial can be achieved in routine clinical practice.

Methods: TENSION was a prospective, multicenter, randomized trial that enrolled patients with acute ischemic stroke and large infarct at 41 centers across Europe and Canada. Patients were randomized to thrombectomy or best medical treatment. The main inclusion criteria of TENSION were defined as pre-stroke mRS 0-2, randomization within 11 hours of symptom onset, occlusion of the intracranial ICA or M1 segment of the MCA, ASPECTS 3-5, and baseline NIHSS score 0-25. Patients from the thrombectomy arm of TENSION (TENSION-RCT) were compared to patients from the German Stroke Registry meeting the main inclusion criteria of TENSION (TENSION-GSR) using 1:1 propensity score matching. Primary outcome was the 90-day mRS score (shift analysis).

Results: Of 308 patients who met the inclusion criteria, 198 were matched (median age, 74 [IQR, 64-81]; 98 [49.5%] female; median 90-day mRS, 5 [IQR, 3-6]). There was no significant shift in 90-day mRS scores between TENSION-RCT and TENSION-GSR (acOR, 1.19; 95% CI, 0.70-2.02; P=.52). The proportions of independent ambulation (90-day mRS 0-3; 33.3% vs. 31.3%, P=.76) and severe disability or death (90-day mRS 5-6; 50.5% vs. 52.5%, P=.78) did not differ between TENSION-RCT and TENSION-GSR.

Conclusion: Functional outcomes of the TENSION thrombectomy arm are achievable within comprehensive stroke centers in Germany. These findings support endovascular thrombectomy for acute ischemic stroke with large infarct and its broad implementation in routine care.

Data availability: The data that support the findings of this study are available upon reasonable request after approval of the steering committees of the TENSION trial and the GSR-ET.

BackgroundPregnancy-associated stroke (PAS) is a rare but clinically important complication of pregnancy. Despite its clinical significance, nationwide data on PAS are lacking in South Korea, a representative country with advanced maternal age.AimsThis study aimed to investigate the incidence, temporal trends, and risk factors of PAS in South Korea.MethodsWe retrospectively analyzed nationwide data from the Korean National Health Insurance Service (NHIS) to identify women of reproductive age (15-49 years) who delivered between 2014 and 2021. PAS was defined as an ischemic or hemorrhagic stroke occurring during pregnancy or within 6 weeks postpartum. Multivariable logistic regression analysis was performed to identify independent predictors of PAS.ResultsOf 2,000,110 deliveries between 2014 and 2021, 909 first-ever strokes occurred during pregnancy or within six weeks postpartum, including 500 ischemic (55%) and 409 hemorrhagic (45%) strokes. The overall incidence of PAS was 45.6 per 100,000 deliveries (95% confidence interval [CI], 42.7-48.6) and increased from 41.5 in 2014 to 51.0 in 2021 (P = 0.049), mainly driven by ischemic stroke. PAS occurred predominantly during the postpartum period (P <0.0001) and among older women (P for trend <0.0001). In multivariable analysis, advanced maternal age (odds ratio [OR] per year, 1.02; 95% CI, 1.01-1.05), hypertension (OR, 2.04; 95% CI, 1.37-3.04), migraine (OR, 1.33; 95% CI, 1.02-1.74), gestational hypertension (OR, 1.49; 95% CI, 1.04-2.12), preeclampsia/eclampsia (OR, 5.00; 95% CI, 3.59-6.96), and peripartum cardiomyopathy (OR, 14.26; 95% CI, 4.48-45.42) were identified as independent predictors of PAS.ConclusionsThe incidence of PAS is increasing in South Korea, with advanced maternal age, vascular risk factors, and pregnancy-related complications serving as independent predictors. These findings underscore the clinical importance of heightened awareness of PAS, as well as early identification and proactive management of high-risk women.Data access statementData are available from the NHIS upon reasonable request and with permission of the NHIS.

Background: Depression is common after stroke and is associated with increased mortality. However, there are few data on the prevalence after TIA, and it is unclear whether TIA can trigger depression and, if so, what factors might suggest susceptibility in an individual.

Methods: We completed a systematic review (Medline/PsychInfo/EMBASE searched to 20 March 2025) of published cross-sectional or cohort studies that reported the prevalence of depression at any time point after a TIA and validated the findings in an population-based cohort (Oxford Vascular Study; OXVASC). Pooled prevalence rates were calculated, risk factors reported and regression analyses were used to determine the proportion of between-study heterogeneity that could be accounted for by study methodology.

Results: The search identified 26 studies; 23 reported data at a uniform time point after the TIA but the prevalence rates of depression were highly heterogeneous at each time point studied (phet<0.001 at <1, 1-6 and 12 months). However, among studies with serial assessments (196 patients from 4 published longitudinal studies and 478 from OXVASC) there was less heterogeneity and the pooled prevalence of depression fell from 20.1% (16.9-23.4%;phet=0.35) at 0-1 month to 14.1% (11.5-16.7%;phet=0.40) at 3-12 months (pdiff=0.004). In the few studies that reported risk factors for depression after a TIA, younger age was the only consistent predictor, but this was similarly validated in the OXVASC population. On regression analysis for heterogeneity, 83% of the variance in prevalence rates between studies was explained by assessment method (postal questionnaire: 5.6%, 95%CI 3.1-8.1 versus face-to-face interview 17.7%, 13.7-21.7; p<0.001), the screening tool used, TIA definition and exclusion criteria. A model, based on these study methods in published studies, predicted a prevalence rate of 22.1% in OXVASC, which was close to the observed rate of 20.7% at 1-month validating the findings.

Conclusions: Depression affects about 1-in-5 patients early after a TIA but prevalence falls with time, suggesting that it may be triggered by the event in some cases, but further work is required to identify risk factors. Additionally, when planning future research, investigators must remain cognisant of the significant influence that study design has on the observed prevalence rates.