International Journal of Stroke最新文献

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.

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.