International Journal of Stroke最新文献

Background: Different stroke etiologies are associated with varied incidences of early neurological deterioration (END) in patients with acute ischemic stroke (AIS). The Tirofiban for the Prevention of Neurological Deterioration in Acute Ischemic Stroke (TREND) trial demonstrated the efficacy of tirofiban in preventing END in patients with AIS. Herein, we conducted a pre-specified subgroup analysis of this trial data to investigate whether stroke etiologies influenced the effects of tirofiban.

Methods: We performed a pre-specified subgroup analysis of the TREND trial, including 413 patients with AIS classified into large-artery atherosclerosis (n = 114), small-vessel occlusion (n = 124), and undetermined etiology (n = 175). The primary outcome was the incidence of END₄ (defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) score by ⩾ 4 points) within 72 h. Other outcomes included END₂ (increase in NIHSS score by ⩾ 2 points), early improvement, functional outcomes at 90 days, and safety profiles.

Results: Tirofiban significantly reduced the risk of END₄ in patients with large-artery atherosclerosis (4.1% vs. 21.5%; adjusted odds ratio (OR), 0.17; 95% confidence interval (CI), 0.04-0.78; P = 0.023), while no significant differences were observed in small-vessel occlusion (adjusted OR, 0.24; 95% CI, 0.02-2.67; P = 0.248) and undetermined etiology (adjusted OR, 0.53; 95% CI, 0.18-1.55; P = 0.247) subgroups (P for interaction = 0.376). Similar trends were observed for END₂, with a significant benefit observed in the large-artery atherosclerosis (adjusted OR 0.24; 95% CI 0.08-0.72; P = 0.011). The early improvement rates and 90-day functional outcomes were comparable between the treatment groups across all stroke subtypes. Safety outcomes were similar between antiplatelet therapies in each subgroup.

Conclusions: In patients who developed ischemic stroke within 24 h of symptom onset, there was no evidence of a treatment interaction across stroke etiologies when comparing intravenous tirofiban to oral aspirin for reducing END. However, the absolute risk reduction observed with tirofiban was greatest in patients with large-artery atherosclerosis compared with those with small-vessel occlusion or undetermined etiology.

Background: Neurological complications in patients with infective endocarditis (IE), such as ischemic and hemorrhagic stroke, are well described; however, predicting which patients are most likely to experience stroke remains uncertain.

Aims: We conducted a systematic review and meta-analysis to identify the factors associated with the risk of stroke in patients hospitalized with IE.

Methods: A systematic search of Ovid MEDLINE, EMBASE, and Web of Science up to 27 June 2024 was conducted. Articles evaluating risk of acute ischemic stroke (AIS) or intracranial hemorrhage (ICH) in patients with IE were included. Meta-analysis of odds ratios was feasible for only some predictive factors due to study heterogeneity. Cochrane's Risk of Bias in Non-Randomized Studies of Exposure tool was used for risk-of-bias assessment.

Summary of review: Of 3538 studies identified, 35 were included: 9 prospective and 26 retrospective cohort. Staphylococcus aureus infection (odds ratio (OR) 3.05; 95% CI, 1.96-4.73, I² = 77.2%; 9 studies) and 1-mm increment in vegetation size (OR, 1.26; 95% CI, 1.02-1.55, I² = 90.1%; 3 studies) were associated with a higher risk of AIS, after adjusting for other covariates. High-intensity signals on transcranial Doppler, and comorbidities such as hypertension, atrial fibrillation, and hyperlipidemia were also found to be associated with a higher risk of AIS. The risk of ICH was increased by thrombocytopenia, mycotic aneurysms, prior ICH or AIS, and cerebral microbleeds.

Conclusion: Our study has identified factors which are associated with increased stroke risk in IE and may help physicians predict risk. While echocardiographic and neuroimaging findings may be particularly informative, underlying comorbidities and various laboratory values may also contribute to predicting IE-associated strokes.

Background and objectives: Aneurysmal subarachnoid hemorrhage (aSAH) remains a significant global health concern, and therefore, understanding their functional outcomes is essential. The aim of this study was to investigate the 1-year functional outcomes of patients with aSAH.

Methods: We retrospectively analyzed data of patients with aSAH from the Korean Stroke Cohort for Functioning and Rehabilitation study, up to 1 year post-onset. The cohort data were collected twice. The first data was collected from August 2012 through May 2015, and the second data was collected from January to December in 2020, from nine different hospitals. Assessments were performed from 7 days to 1 year. Disability, measured by modified Rankin Scale (mRS), was analyzed in terms of good outcome (mRS 0 or 1) and mortality. In addition, functional level was further assessed using Functional Independence Measure (FIM) in aSAH survivors at 1 year post-onset. A subgroup analysis was conducted, with participants further classified into two groups: one with mild-to-moderate disability (mRS 0-3) and another with severe disability (mRS 4 or 5), as reported 7 days after onset. Multiple imputation method was used to handle missing data. In addition, mixed-effects model was used to analyze the trajectory of FIM.

Results: A total of 517 patients with aSAH were included. Of these, 246 (47.6%) showed mild-to-moderate disability and 271 (52.4%) showed severe disability at 7 days. At 1 year after onset, the mortality rate was 6.0% and the good outcome was reported in 76.2% of patients. In aSAH survivors at 1 year, FIM showed a significant improvement over time, with a significant difference demonstrated between the subgroups. Age, initial clinical severity, and cognitive function at 7 days were also identified as significant covariates.

Conclusions: The majority of patients reporting mild-to-moderate disability at 7 days exhibited good functional outcome, and even among those with severe disability, there was a favorable outcome with continuous improvement in their functional levels. Therefore, proper assessments and effective management should be employed to achieve favorable functional outcomes among aSAH survivors.

Background: It is acknowledged that penumbra can exist beyond 24 h after stroke onset.

Aims: The aim of this study was to explore the association between penumbral persistence at 24-72 h and clinical outcomes in patients who did not achieve major reperfusion.

Methods: Eligible patients participating in the International Stroke Perfusion Imaging Registry with repeated 24-72 h perfusion imaging were retrospectively included in this study. Persistent penumbra was evaluated as the volume of hypoperfusion lesion on repeated perfusion imaging divided by infarct volume on the follow-up imaging at 24-72 h post arrival. Short-term clinical outcomes were defined as neurological deterioration at 24-72 h and modified Rankin Scale (mRS) 0-2 at discharge. Long-term outcome was defined as mRS 0-2 at 3 months. The association between persistent penumbra and clinical outcomes was explored using multivariable-adjusted logistic regression models.

Results: A total number of 203 patients were included in this study. Persistent penumbra was associated with decreased odds of neurological deterioration at 24-72 h (multivariable-adjusted odds ratio (OR) = 0.3, 95% confidence interval (CI) = 0.1-0.8, p = 0.01) and increased odds of mRS 0-2 at 3 months (multivariable-adjusted OR = 2.7, 95% CI = 1.1-6.8, p = 0.03). Persistent penumbra was not associated with mRS 0-2 at discharge (multivariable-adjusted OR = 2.5, 95% CI = 0.4-14.7, p = 0.30).

Conclusions: Persistent penumbra in acute stroke patients without major reperfusion was generally associated with a better clinical outcome. This evidence suggested that there were patients with persistent hemodynamic support, for whom major reperfusion might not be pivotal to achieve a good clinical outcome. How to identify these patients and what treatment strategy can be made to stabilize the hemodynamics need future investigation.

Data access statement: Anonymized data not published within this article will be made available at the request of qualified investigators whose proposal of data use has been approved by an independent review committee.

Background: Intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) related to underlying intracranial artery dissection (IAD) poses potential risks, including the exacerbation of intramural hematoma and the rupture of the dissected arterial wall. However, the safety of IVT in this specific population remains uncertain.

Aims: This study aimed to assess whether IAD is associated with an increased risk of intracranial hemorrhage (ICH) following IVT and to evaluate its impact on functional outcomes.

Methods: This retrospective matched-pair cohort study used a nationwide inpatient database that includes discharge abstracts and administrative claims data in Japan. We included adult patients with AIS treated with IVT between July 2010 and July 2024. We excluded patients with carotid or vertebral artery dissections due to difficulties distinguishing between intracranial and extracranial involvement, those lacking premorbid/discharge modified Rankin Scale (mRS) data, and those who received intra-arterial thrombolysis. Patients with IAD were matched 1:4 with non-IAD controls based on age, sex, premorbid mRS, endovascular treatment (EVT), and teaching hospital status. We assessed ICH, functional independence at discharge (mRS = 0-2), and in-hospital mortality using multivariable logistic regression with generalized estimating equations to account for clustering within matched pairs, adjusting for age, sex, premorbid mRS, body mass index, smoking history, hypertension, diabetes mellitus, atrial fibrillation, coagulopathy, Japan Coma Scale, EVT, and teaching hospital status.

Results: Of 83,139 patients with AIS treated with IVT, 242 (0.3%) had underlying IAD (median age = 54 (46-67) years; 34% women). These patients were matched with 968 non-IAD controls. IAD was associated with a higher risk of ICH (odds ratio (OR) = 3.18; 95% confidence interval (CI) = 1.26-8.06) and a lower likelihood of functional independence at discharge (OR = 0.51; 95% CI = 0.37-0.72), but not with increased in-hospital mortality (OR = 1.09; 95% CI = 0.50-2.38).

Conclusion: Patients with underlying IAD may face an increased risk of ICH and a reduced chance of functional recovery following IVT compared to those without.

Background: Endovascular therapy (EVT) has been proved to benefit patients with acute large vessel occlusion (LVO) with large infarcts, but it is unknown whether the benefit isaffected by the interhospital-transfer status. We investigated the efficacy of EVT according to the interhospital-transfer status in such patients.

Methods: This was a secondary analysis of the ANGEL-ASPECT trial. Patients with acute anterior-circulation LVO and large infarcts, defined by ASPECTS 3-5 or infarct core volume 70-100mL, were enrolled from forty-six centers across China and randomized (1:1) to receive EVT with medical management (MM) versus MM alone. We dichotomized patients into two subgroups based on whether admitted directly to the EVT-capable center or transferred from a primary center. The primary outcome was the 90-day modified Rankin Scale (mRS).

Results: From October 2020 to May 2022, 456 patients were recruited and one withdrew consent. 455 patients were included in this analysis, with 210 (46.2%) in the direct subgroup and 245 (53.8%) in the transfer subgroup. The transfer subgroup had longer median onset-to-arrival time than the direct patients (379 vs 279mins, p <0.001), while there was no significant difference in the arrival-to-recanalization time (197 vs 205 mins, p=0.087) between the two subgroups. A significant ordinal shift of 90-day mRS towards a better functional outcome in EVT than MM (generalized odds ratio [gOR], 1.67; 95% CI, 1.03-2.70, p=0.036 versus gOR, 1.60; 95% CI, 1.02-2.50, p=0.039) was found in the direct and transfer group, respectively. There was no significant interaction of the two subgroups over the treatment effect of EVT versus MM on the primary outcome (p for interaction=0.706).

Conclusions: In acute anterior-circulation LVO patients with large infarcts, the benefit of EVT compared to MM did not vary by the interhospital-transfer status.

Background: Collateral circulation provides compensatory flow to ischemic brain regions in acute large vessel occlusion (LVO), which had been associated with better outcomes after endovascular treatment (EVT).

Aims: We aimed to reveal the pre-EVT collateral status and its associations with outcomes after EVT, in patients with acute LVO with different etiologies.

Methods: Based on a prospective, multicenter registry, we analyzed patients with acute, intracranial anterior-circulation LVO due to large artery atherosclerosis (LAA) and cardioembolism (CE), who underwent EVT within 24 h. Pre-EVT leptomeningeal collateral status was classified on digital subtraction angiography by ASITN/SIR grading system. Outcomes included good 3-month functional outcome (modified Rankin Scale [mRS] 0-2), 3-month mRS distribution, successful recanalization, early neurological deterioration, symptomatic intracranial hemorrhage (sICH), and 3-month mortality.

Results: Among 805 patients (median age 66 years), 450 and 355, respectively, had LVO due to LAA and CE, of whom 57.8% and 56.6% (p = 0.742) had good pre-EVT collaterals. In LAA patients, good collaterals were associated with lower risk of sICH (adjusted odds ratio [OR]= 0.40; 95% CI = 0.17-0.94; p = 0.036) but not functional outcomes. In CE patients, good collaterals were associated with a higher chance of good functional outcome (adjusted OR = 1.55; 95% CI = 0.96-2.51; p = 0.072) and lower mRS at 3 months (adjusted common OR = 0.64; 95% CI = 0.43-0.94; p = 0.021). However, there was no significant CE/LAA and collateral status interaction on any outcome.

Conclusions: The study revealed comparable pre-EVT collateral status in patients with LVO due to LAA versus CE who received EVT within 24 h, but the pre-EVT collaterals may have different protective effects for post-EVT outcomes in these two groups of patients.

Background: Arteriovenous malformations (AVMs) are complex vascular anomalies with a high risk of hemorrhage and neurological deficits, especially when located in eloquent brain regions. The eloquence of an AVM location is a critical factor in the treatment planning, influencing both the risk of complications and long-term functional outcomes. This study aims to compare outcomes between eloquent and non-eloquent AVMs.

Methods: This multicenter, retrospective study utilized data from the Multicenter International Study for Treatment of Brain AVMs (MISTA) consortium. Patients with eloquent and non-eloquent AVMs were compared on baseline characteristics, angiographic outcomes, and functional outcomes using the modified Rankin Scale (mRS). Propensity score weighting (IPTW) was applied to adjust for confounding variables.

Results: The study included 1013 patients, with 498 (49.2%) AVMs located in eloquent regions and 515 (50.8%) in non-eloquent regions. In unadjusted analysis, eloquent AVMs had lower complete obliteration rates (67.6% vs 79.5%, OR: 0.53, 95% CI: 0.39-0.72, p < 0.001) and higher complication rates (24.5% vs 19.0%, OR: 1.38, 95% CI: 1.02-1.86, p = 0.03) compared to non-eloquent AVMs. After IPTW adjustment, eloquent AVMs continued to show significantly higher odds of overall complications (OR: 1.68, 95% CI: 1.12-2.52, p = 0.01) and symptomatic complications (OR: 1.77, 95% CI: 1.12-2.80, p = 0.01). Secondary analysis within the eloquent group indicated that embolization was linked to an elevated risk of complications. Surgery and radiosurgery showed comparable functional outcomes at last follow-up and complications rates with higher complete obliteration rates in surgery.

Conclusion: AVMs in eloquent brain areas present higher risks of complications and lower obliteration rates, emphasizing the need for cautious, individualized treatment planning. Within the eloquent group, embolization increased the risk of complications, while surgery and radiosurgery showed comparable functional outcomes at last follow-up and complication rates with higher complete obliteration rates in surgery. These findings highlight the importance of location in AVM management and support further research focusing on comparing treatment strategies for AVMs in eloquent brain areas.

Introduction: Recent evidence suggests a possible role of non-stenotic carotid atherosclerotic plaques in the etiology of embolic stroke of undetermined source (ESUS).

Methods: We conducted a systematic review and meta-analysis of prevalence and characteristics of non-stenotic carotid plaques (NSPs) with high-risk features (complicated NSP) in internal carotid artery in unilateral ESUS in the anterior circulation. We searched MEDLINE and Ovid-Embase databases. High-risk features were intraplaque hemorrhage, thickness ⩾ 3 mm, ulceration, and hypodensity. We assessed the risk of bias (RoB), extracted the data, calculated the pooled prevalence and 95% confidence intervals (CI) using Inverse Variance Weighting method, and Random Effect models.

Results: We included 16 studies and 1406 patients with different imaging for NSP assessment (1 ultrasound, 11 computed tomography (CT)-angiography, 4 magnetic resonance (MR) angiography). The RoB was moderate to low in most studies. Definition of complicated NSP differed across studies. The combined prevalence of any complicated NSP was 31% (95% CI = 27-36%) ipsilateral and 14% (95% CI = 9-19%) contralateral to the index stroke, the finding of any high-risk NSP was fourfold higher ipsilateral to the index stroke (OR = 3.63; 95% CI = 2.09-6.33). The prevalence of single high-risk features ipsilateral to ESUS was as follows: 35% (95% CI = 30-41%) for thickness ⩾ 3 mm; 24% (95% CI = 8-39%) for ulceration; 45% (95% CI = -2; 93%) for hypodensity, 16% (95% CI = 5-26%) for intraplaque hemorrhage.

Conclusion: Complicated NSPs are present in around a third of all ESUS, and are four times more frequent ipsilaterally to the index stroke. Our results confirm the possible causal role in ESUS and highlight the need for greater diagnostic uniformity of plaque at risk.