International Journal of Stroke最新文献

Introduction: Although the efficacy and safety of endovascular treatment (EVT) for large-core ischemic stroke have been proven, most trials used perfusion imaging or included early-window patients, limiting generalizability to the late window, particularly in developing countries.

Aim: We aimed to evaluate the safety and functional outcomes of EVT in large-core stroke patients treated between 12 and 24 h (late window) from last known well (LKW).

Methods: We conducted a prospective, multicenter observational study across four comprehensive stroke centers in Vietnam, enrolling consecutive patients who underwent EVT within 24 h of symptom onset between August 2023 and September 2024. Large core was defined by an Alberta Stroke Program Early CT Score (ASPECTS) of 3 to 5 on non-contrast computerized tomography (NCCT) or diffusion-weighted magnetic resonance imaging (DWI-MRI). Patients who underwent EVT within 12-24 h after LKW were compared to those treated before 12 h (early window). Primary and safety outcomes were independent ambulation (90-day modified Rankin scale (mRS) = 0-3) and symptomatic intracranial hemorrhage (sICH). Secondary outcomes were 90-day mRS 0-2, ordinal mRS, successful reperfusion (modified Thrombolysis in Cerebral Infarction score ⩾2b, early neurological deterioration (END)), and 90-day mortality.

Results: Of 1872 patients receiving EVT, 343 with large ischemic cores (median age = 64.0 years, 33.8% female) were included, with 103 (30.0%) treated in the 12- to 24-h window. Compared to early-window patients, late-window patients had lower rates of intravenous thrombolysis (2.9% vs. 32.9%, p < 0.001), higher brain MRI use (51.5% vs. 16.2%, p < 0.001), and longer pre-treatment imaging-to-groin puncture times (106 vs. 77 min, p < 0.001). After adjusting for confounders, there were no significant differences in 90-day mRS 0-3 (56.3% vs. 55.0%, adjusted odds ratio (aOR) = 0.71, 95% confidence interval (CI) = 0.39-1.28, p = 0.26), ordinal mRS (aOR = 1.21, 95% CI = 0.78-1.90, p = 0.39), and sICH (aOR = 1.12, 95% CI = 0.32-3.50, p = 0.85). Other secondary outcomes were also similar.

Conclusion: In patients with anterior circulation large vessel occlusion stroke and low ASPECTS, EVT at 12-24 h versus <12 h from symptom onset showed no significant differences in clinical or safety outcomes. Larger trials are needed to confirm these findings, especially in developing regions.

Background: Lacunes of presumed vascular origin are a key imaging marker of cerebral small-vessel disease (cSVD), predicting stroke and dementia risk. Their incidence and determinants have not been systematically quantified across different populations, and implications for clinical research remain unclear.

Aims: This study aims to estimate the annualized incidence of new lacunes across diverse populations, identify study-level factors contributing to heterogeneity, summarize patient-level risk factors for incident lacunes, and provide empirical data to inform sample size estimation for studies using incident lacunes as an imaging outcome.

Summary of review: Thirty-one studies comprising 12,646 participants and 56,073 person-years were included. The pooled overall incidence was 3.27 per 100 person-years (95% CI, 2.12-4.42), ranging from 1.50 to 8.03 across populations. Rates were highest in cSVD patients (8.03; 95% CI, 3.8-12.27), intermediate in stroke and memory-clinic patients, and lower in community-based, hypertensive, and non-specific artery disease cohorts. Meta-regression showed that baseline lacune prevalence was positively associated with incidence (β = 0.057; 95% CI, 0.006-0.108; P = 0.031). At the individual level, male sex, baseline lacunes, hypertension, and diabetes were associated with higher risk. In cSVD populations, detecting a 30% relative risk reduction required 563, 867, and 1782 participants per arm for 3-, 2-, and 1-year follow-up, respectively.

Conclusion: Incident lacune rates vary substantially across populations and are strongly influenced by baseline lacune burden and vascular risk factors. These findings provide context for population selection and sample size considerations in studies using incident lacunes as an imaging outcome.

Background: Sex disparities in stroke outcomes are well-recognized, but it remains unclear whether these disparities vary across stroke subtypes and how they relate to differences in acute care delivery.

Aim: To examine sex differences in long-term mortality, functional outcomes, and acute stroke management across stroke subtypes using a nationwide population-based cohort.

Methods: This retrospective cohort study analyzed linked clinical audit and claims data from 58,429 patients with acute stroke admitted to 269 hospitals in South Korea between 2018 and 2021. Clinical data were derived from the national Acute Stroke Quality Assessment Program and linked to claims. The primary outcome was all-cause mortality. The secondary outcome was poor functional outcome at discharge. Multivariable Cox and logistic regression models were used to assess associations between sex and outcomes, stratified by stroke subtype and adjusted for age, stroke severity, and comorbidities. Differences in acute stroke care were also analyzed.

Results: Of 58,429 patients (mean [SD] age, 68.6 [13.8] years; 43.9% female), 76.1% had IS, 15.7% ICH, and 8.2% SAH. Females were older than males across all subtypes and had different comorbidity profiles. After adjustment, females had significantly lower mortality in all subtypes (adjusted hazard ratios [95% CI]: IS, 0.77 [0.74-0.80]; ICH, 0.60 [0.56-0.64]; SAH, 0.60 [0.54-0.67]; all P < .001). Functional outcomes varied: females had worse outcomes in IS, better in ICH, and no difference in SAH. Males were more likely to receive reperfusion and surgical therapies; females were more likely to receive rehabilitation services. These care differences did not fully explain the observed disparities in outcomes.

Conclusion: In this national cohort, sex disparities in stroke outcomes differed by subtype. Despite lower adjusted mortality in females, functional outcomes were not uniformly better. These findings underscore the importance of adopting sex- and subtype-specific approaches to stroke care, secondary prevention, and rehabilitation.

Background: Although endovascular therapy (EVT) improves functional outcomes in acute ischemic stroke patients, some with large hemispheric infarction (LHI) post-EVT may still require decompressive hemicraniectomy (DHC). This study aimed to explore whether DHC benefits all patients with post-EVT LHI and to identify which patients are more likely to benefit from DHC.

Methods: This pooled analysis of the RESCUE-RE study and the ANGEL-ASPECT trial enrolled patients with LHI and severe neurological deficits after EVT. According to the treatment received, patients were categorized into DHC and conservative therapy groups. The primary outcome was 90-day mortality. Propensity score matching (PSM) analysis was used to control for differences between groups.

Results: In total, 136 of 2036 EVT-treated patients (6.7%) in the RESCUE-RE study and 59 of 230 (25.6%) in the ANGEL-ASPECT trial met inclusion criteria. Among the 195 patients included, 50 (25.6%) underwent DHC (41 after PSM), while 145 (74.4%) received conservative therapy (41 after PSM). Patients undergoing DHC after EVT had significantly lower 90-day mortality rates compared with those receiving conservative therapy (odds ratio (OR) = 0.26; 95% confidence interval (CI), 0.10-0.66; p = 0.005), but no significant improvement was observed in 90-day modified Rankin Scale (mRS) distribution (common OR = 0.47; 95% CI = 0.21-1.05; p = 0.06). Patients within an overlapping range of post-EVT midline shift (approximately 10-17 mm) or infarct volume (approximately 250-330 mL), where both 90-day mortality and ordinal mRS distribution models favored DHC, appeared more likely to derive a comprehensive clinical benefit. Baseline infarct-core volume was not associated with the treatment effect of DHC.

Conclusion: In patients with LHI after EVT, DHC was associated with reduced mortality when performed in accordance with current guidelines. Moreover, patients within a higher, but not the most extreme, range of injury severity after EVT might be more likely to benefit from DHC.

Intracranial atherosclerotic stenosis (ICAS) is an important cause of ischemic stroke and transient ischemic attack (TIA), which is also associated with increased risks of cognitive impairment and dementia. The prevalence of both asymptomatic and symptomatic ICAS (asICAS and sICAS) is significantly higher in Asian populations than in Western populations. In recent years, substantial new evidence has emerged regarding the epidemiology, diagnosis, assessment, prognosis and treatment of asICAS and sICAS. The China ICAS Research Group has developed this guideline based on published research and relevant domestic and international guidelines or expert consensus, to further clarify the definition, epidemiology and prognosis of ICAS and the profiles of high-risk ICAS patients, and provide evidence-based recommendations on screening, diagnosis, assessment and treatment strategies of asICAS and sICAS. For imaging exams, non-invasive and contrast-independent modalities are generally suitable for screening and assessment of ICAS in stroke-free individuals with multiple risk factors as well as for routine exams of stroke patients, while contrast-dependent or invasive imaging methods may be employed for further assessment or guiding treatment decision-making in sICAS patients. Additionally, vessel wall imaging is valuable for distinguishing the etiology of intracranial stenosis, particularly in young stroke patients. Multiple imaging modalities or methods are available for assessment of cerebral perfusion, hemodynamics and collateral circulation that may meet different needs. Regarding interventions, lifestyle modifications (healthy diet, safe exercise, smoking cessation) are recommended for both asICAS and sICAS patients. For stroke-free individuals with asICAS, controlling vascular risk factor is the primary strategy, while routine aspirin or endovascular treatment for primary stroke prevention is not recommended. For sICAS patients, the cornerstone is intensive medical management, including short-term dual antiplatelet therapy in high-risk patients (such as those with severe luminal stenosis, minor stroke or high-risk TIA) followed by lifelong monotherapy, aggressive lipid control (targeting low-density lipoprotein cholesterol <1.8 mmol/L), blood pressure control (<140/90 mmHg), and glycemic control (targeting HbA1c <7.0%), with structured follow-up to enhance treatment adherence. Endovascular treatment is not recommended for sICAS with mild to moderate luminal stenosis (<70%) but may be considered for carefully selected patients with severe (70-99%), medically refractory sICAS, particularly those with hypoperfusion, with a preference to delay the intervention for more than 21 days after stroke to enhance safety.

Background: Epidemiological evidence suggests associations between substance use disorders and risk of stroke, but whether these are due to confounding or are true yet causal relationships remain uncertain.

Aims: To meta-analyse the observational evidence on illicit substance use and stroke risk and apply Mendelian Randomisation to evaluate potential causal effects of substance dependence on stroke subtypes.

Methods: We conducted a systematic review and meta-analysis of studies reporting associations between illicit drug use and stroke (PROSPERO registration - CRD420251053702). The meta-analysis included 32 studies comprising more than 100 million total participants across administrative, hospital-based and population-based datasets. Pooled odds ratios (ORs) were estimated using multivariate random-effects models for ischemic and hemorrhagic subtypes. We then performed two-sample Mendelian randomisation using genome-wide association study summary statistics to examine associations between seven drug exposures and all stroke, ischemic and hemorrhagic stroke, and ischaemic stroke subtypes.

Results: Meta-analysis demonstrated significant associations of cannabis (OR 1.37, 95% confidence interval 1.14-1.65), cocaine (OR 1.96 [1.27-3.01]), and amphetamines (OR 2.22 [1.40-3.53]) with increased stroke risk, while no significant association was observed for opioids. Findings for cannabis showed some heterogeneity and small-study effects. Mendelian randomisation analyses revealed that cannabis use disorder was associated with any stroke (OR 1.11 [1.01-1.51]) and large artery stroke (OR 1.35 [1.01-1.80]), and cocaine dependence was associated with cardioembolic stroke (OR 1.08 [1.02-1.14]) and intracerebral hemorrhage (OR 1.38 [1.15-1.65]). Genetically predicted substance use disorder overall was associated with any stroke (OR 1.33 [1.02-1.72]) and intracerebral hemorrhage (OR 7.79 [3.46-17.54]). Problematic and dependent alcohol use were linked to large artery and cardioembolic stroke, whereas nicotine dependence showed no significant associations.

Conclusions: Our findings provide consistent observational and genetic evidence that several forms of substance misuse increase stroke risk, particularly cocaine, amphetamines and cannabis. These findings suggest important public health implications for prevention strategies targeting substance use disorders to mitigate stroke risk.

Dyslipidemia remains a major, modifiable determinant of global stroke burden, accounting for more than one-fifth of ischemic strokes (IS) worldwide. Recent evidence has shifted emphasis from conventional lipid fractions to apolipoprotein B (ApoB)-containing lipoproteins, including lipoprotein(a) [Lp(a)], which more accurately reflect atherogenic particle burden than low-density lipoprotein cholesterol (LDL-C) alone and are increasingly used for stroke risk stratification. While the principle "the faster and the lower, the better" underpins dyslipidemia management, evidence-based, subtype-specific lipid strategies in stroke remain limited. Intensive LDL-C reduction significantly lowers recurrent IS risk; however, uniform lipid targets are often applied without accounting for stroke etiology. High-intensity statins remain first-line therapy, with pleiotropic benefits extending beyond LDL-C reduction. For statin intolerance or suboptimal response, ezetimibe and PCSK9 inhibitors provide potent, bleeding-neutral LDL-C lowering. Inclisiran and bempedoic acid broaden therapeutic options, although stroke-specific efficacy data are still pending. Lp(a)-lowering agents, including pelacarsen, olpasiran, and lepodisiran, are under active evaluation and may address residual cardiovascular risk. For triglyceride lowering, recent randomized evidence supports icosapent ethyl for reducing IS risk. In intracerebral hemorrhage (ICH), the optimal intensity and thresholds of lipid lowering remain uncertain, warranting individualized weighting of ischemic against hemorrhagic risk, particularly in patients with lobar ICH or suspected cerebral amyloid angiopathy (CAA). In such cases, hydrophilic statins, ezetimibe, or PCSK9 inhibitors may represent reasonable options. This review synthesizes current evidence and proposes a phenotype-guided, individualized framework for dyslipidemia management across stroke subtypes. Moving beyond uniform targets toward etiologic and genetically informed lipid modulation may improve post-stroke outcomes and refine individualized stroke prevention.

Background: For neurodegenerative diseases, the inter-individual variability in the functional response to pathology is explained by the construct of cognitive reserve (CR). We aimed to evaluate the association of CR with stroke outcome to improve the understanding of its inter-individual variability and prediction.

Methods: The peer-reviewed protocol was preregistered on PROSPERO (CRD42021256175). The systematic review and meta-analysis followed PRISMA, MOOSE and CHARMS reporting guidelines. Original studies reporting the association between CR-proxies (e.g. level or years of education, occupational attainment) and measures of non-cognitive stroke outcome (e.g. NIHSS, modified Rankin Scale, Barthel Index, Functional Independence Measure) were selected. Risk of bias was assessed using QUIPS. Estimates were pooled using a random-effects model.

Results: Of 4129 studies identified, 17 were included in the systematic review. Based on quality check, ten of them involving 19308 patients were included in the meta-analysis, whereby only five studies directly addressed the association of CR-proxies with stroke outcome. Pooled standardized mean differences (SMD) showed evidence for the association of low CR with poor stroke outcome (SMD, 0.23; 95% CI, 0.04-0.42 corresponding to OR 1.52; 95% CI 1.08-2.14). Subgroup analysis showed a greater association of level of education (SMD, 0.37; 95% CI, 0.12-0.62) and occupational attainment (SMD, 0.34; 95% CI, 0.10-0.57) with stroke outcome, as compared to years of education (SMD, 0.01; 95% CI, -0.06-0.08). The effect of CR was greater in the acute-subacute stroke phase (≤3 months post-stroke, SMD, 0.28; 95% CI, 0.04-0.52) than in the chronic phase (SMD, 0.01; 95% CI, -0.06-0.08).

Conclusion: We found evidence that CR explains inter-individual variability in stroke outcome and thus may improve its prediction. Low CR increases the risk of poor stroke outcome, and its proxies should be considered in both clinical and research settings. However, we observed high heterogeneity across studies, and further research with specific focus on this topic and CR-proxies extending beyond educational and occupational attainment is needed.

Background: The risk of recurrent ischemic stroke during pregnancy or postpartum period in women with a history of ischemic stroke is unclear.

Aims: To determine the risk of incident ischemic stroke during pregnancy or early post-partum period (within 6 weeks) among women with and without a prior history of ischemic stroke.

Methods: We conducted a retrospective cohort study using Oracle Health Real-World Data (January 2015-February 2025). We identified 220,479 completed pregnancies; prior ischemic stroke by ICD-10-CM I69.3x/Z86.73; incident ischemic stroke by I63 during pregnancy or ≤42 days postpartum. Odds ratios (ORs) with 95% CIs were estimated using multivariable logistic regression after 1:10 propensity-score matching based on demographics and comorbidities.

Results: The incident ischemic stroke rates were 415 out of 1,192 pregnancies (34.82%, 95% confidence interval [CI]: 32.16%-37.56%) among pregnant women with a prior history of ischemic stroke and 737 out of 219,287 pregnancies (0.34%, 95% CI 0.31%-0.36%) among pregnant women without a history of ischemic stroke. In the multivariate analysis, the risk of ischemic stroke during pregnancy or early postpartum period was significantly higher among pregnancies in women with a prior history of ischemic stroke compared with those in women without a history of ischemic stroke (OR 2.37, 95% CI 1.97-2.87, p < 0.0001). Previous myocardial infarction (OR 1.82, 95% CI 1.38-2.39, p < 0.0001) and obesity (OR 1.25, 95% CI 1.07-1.47, p < 0.01) were also associated with recurrent ischemic stroke during pregnancy or early postpartum period. The odds of experiencing an incident ischemic stroke among women with a prior history of ischemic stroke was significantly higher in women during pregnancy or early postpartum period compared with those with neither of the two conditions (OR 3.35, 95% CI 2.67-4.22, p < 0.0001).

Conclusions: Women with a prior history of ischemic stroke had two times higher odds of having another ischemic stroke during pregnancy or postpartum period. Our findings have implications for counseling, surveillance, and enhanced recurrent stroke prevention in this high-risk group.

Background: India is facing a growing burden of stroke due to population aging, lifestyle changes, and increased exposure to risk factors. However, longitudinal data on stroke patterns and outcomes in India are limited.

Objectives: This study assessed stroke patterns, risk factors, management practices, and outcomes using data from the Hospital-Based Stroke Registries (HBSRs) in India.

Method: This prospective hospital-based registry included 34,792 stroke cases from 30 centers across India, recorded between 2020 and 2022. Data on demographics, clinical features, risk factors, diagnostics, treatments, and outcomes were collected, with follow-up at 28 days and three months. Functional outcome was assessed using the modified Rankin Scale (mRS), along with data on recurrence.

Results: The mean age was 59.4 years; 13.8% were aged under 45, 63.4% were male, and 72.1% were from rural areas. Hypertension (74.5%) was the most common risk factor, followed by smokeless tobacco use (28.5%) and diabetes mellitus (27.3%). Ischemic stroke accounted for 60% of cases. Only 20.1% were presented within 4.5 hours of symptom onset, while 37.8% cases presented after 24 hours. Motor impairment (74.8%) followed by speech disturbance (51.2%) were the commonest symptoms at onset. Thrombolysis was given in 4.6%, and thrombectomy in 0.7%, of ischemic strokes. At three months, 27.8% had died, 29.7% had significant disability (mRS 3-5), and 1.1% had a recurrent stroke.

Conclusion: In this study, one in seven stroke were in the young, two in five patients arrived after 24 hours of symptom onset, and thrombolysis and mechanical thrombectomy were underutilized. Over half had poor 3-month outcomes, highlighting the need for improving comprehensive stroke care across India.