International Journal of Stroke最新文献

Objectives: This study aims to evaluate the natural history of deep-seated brain arteriovenous malformation (AVMs), as well as the risk-benefit outcomes of interventional treatment versus conservative management.

Materials & methods: Patients with deep-seated AVMs were selected from a nationwide prospective multicenter registry study in China (the MATCH study), and univariate and multivariate analyses were conducted to identify factors associated with AVM rupture. In the analysis of outcomes, propensity score matching (PSM) was performed between the interventional and conservative treatment groups, adjusting for baseline differences. The primary outcomes were hemorrhagic stroke or death, while the secondary outcomes focused on obliteration rates and neurological status. Subgroup and sensitivity analyses were conducted, incorporating various study designs to assess the robustness and consistency of the results.

Results: Among 4286 consecutive AVM cases registered from August 2011 to December 2021, 1057 (24.7%) were classified as deep-seated AVMs. The natural annualized rupture risk before the treatment decision is 5.58%. The independent risk factors for rupture included diffuse lesions (aOR: 1.79 [1.29-2.49]), single drainage (aOR: 1.88 [1.20-2.93]), and drainage stenosis (aOR: 2.33 [1.44-3.75]). In the analysis of outcomes, 883 cases maintained continuous follow-up (128 conservative management, 755 intervention). After PSM, there were 119 cases in each group. After a median follow-up duration of 4.34 (1.72, 7.23) years in the intervention group, 47.93% achieved complete obliteration, with an annualized rupture risk of 4.82%. Compared to conservative management, intervention was associated with a higher rate of hemorrhagic stroke or death (AR: 3.85 [1.84-5.86] per 100 person-year, p < 0.001; HR: 4.862 [1.869-12.651] p < 0.001) and higher obliteration rates (OR: 108.56 [14.57-809.01], p < 0.001). No significant differences were observed in terms of neurological functional outcomes. In a further analysis stratified by interventional strategies, embolization and multimodality treatment significantly increased the risk of hemorrhagic stroke or death compared with conservative treatment (embolization: HR: 4.414 [95% CI, 1.642-11.867]; multimodality treatment: HR, 6.238 [95% CI, 2.146-18.136]), while microsurgical resection and stereotactic radiosurgery did not. Subgroup and sensitivity analyses showed consistent trends, though with slight differences in statistical power.

Conclusion: This study indicates that in deep-seated AVMs, interventional treatment is associated with an increased risk of hemorrhagic stroke or death. However, the negative effect may result from the adverse effects of embolization and multimodality treatment, whereas microsurgical resection and stereotactic radiosurgery did not.

Background and aims: Improving stroke action awareness is challenging in non-English-speaking populations. In this study, we evaluated the effectiveness of five Spanish-language educational tools in improving recognition and making an emergency response to stroke symptoms among Spanish-speaking adults in Mexico.

Methods: Spanish-speaking participants were recruited from public spaces. Individuals with a history of stroke were excluded. Participants were randomly assigned to receive an educational session tailored to one of five stroke awareness tools (RAPIDO, DALE, CAMALEON, CORRE, and ICTUS 911). Stroke knowledge was assessed using the Stroke Awareness Questionnaire before the educational intervention and after 6-9 days of follow-up. The primary outcome was the change in the proportions of correctly identified stroke symptoms. Secondary outcomes included changes in participants' achievement of adequate stroke knowledge in individual FAST domains and their understanding of the appropriate actions to take after identifying stroke symptoms.

Results: In data from 435 participants, all strategies improved stroke symptom recognition and risk factor awareness, although no statistically significant differences were observed in the primary outcomes. Changes ranged from 0.35 (DALE) to 0.49 (CAMALEON) for Facial Weakness, the symptom with the largest improvement, and from 0.00 (CAMALEON, CORRE, RAPIDO) to 0.15 (DALE) for Problems with Vision, the symptom with the smallest improvement. For the secondary outcomes, increases in adequate stroke knowledge ranged from 0.18 (CORRE, DALE) to 0.31 (ICTUS 911); between-group comparisons were statistically significant (p = 0.027). Improvements in appropriate action after symptom recognition ranged from 0.09 (RAPIDO) to 0.29 (ICTUS 911), with significant differences across groups (p = 0.034).

Conclusions: This study shows that brief educational interventions can improve stroke symptom recognition and intended response in Spanish-speaking adults. Among five strategies, ICTUS 911 yielded the largest short-term gains, supporting its potential utility. Further research is needed to assess long-term effectiveness and broader applicability.

Background and aims: The diagnosis of transient ischaemic attack (TIA) and minor stroke can be challenging. Current diagnostic criteria for TIA disqualify atypical clinical presentations which may nevertheless be associated with objective cerebral ischaemia on diffusion weighted imaging-magnetic resonance imaging (DWI-MRI). We aimed to (1) ascertain the proportion of DWI-positive patients with atypical clinical presentations and (2) identify clinical factors predicting DWI positivity.

Methods: We retrospectively reviewed case notes of consecutive patients with suspected TIA or minor stroke undergoing MRI at our comprehensive stroke center. We identified clinical factors predicting DWI positivity using multivariable logistic regression.

Results: We included 1615 patients. Of 442 (27.4%) who were DWI-positive, 38.5% had atypical presentations; common symptoms included headache (present in 17%), unsteadiness (15%), positive sensory symptoms (11%), presyncope (10%), confusion (9%), and vertigo (8%). Symptoms independently associated with DWI positivity included weakness (odds ratio (OR): 1.30, 95% confidence interval (CI): 1.01-1.67), dysarthria (OR: 2.05, CI: 1.56-2.70), and ataxia (OR: 3.76, CI: 2.27-6.21). Fluctuating symptoms (present in 21.5%) predicted DWI positivity (OR: 1.37, CI: 1.04-1.81), but sudden onset (80.1%) did not (OR: 1.05, CI: 0.80-1.38). Risk factors associated with DWI positivity included increasing age (OR: 1.02/year, CI: 1.01-1.02), hypertension (OR: 1.61, CI: 1.23-2.11), diabetes (OR: 1.40, CI: 1.04-1.90), and smoking (OR: 1.67, CI: 1.17-2.37). DWI-positive patients had significantly more risk factors (mean 2.65 vs 1.95 p = <0.001).

Conclusion: Over one-third of people with MRI-DWI-confirmed TIA or minor stroke present with atypical symptoms. MRI-DWI is essential to diagnose cerebral ischaemia in patients with atypical symptoms, particularly in those with vascular risk factors.

Background: Antithrombotic agents are essential for preventing cerebrovascular and cardiovascular diseases; however, bleeding complications remain a major concern, particularly among elderly patients and those receiving combination therapy.

Aims: We designed the Bleeding with Antithrombotic Therapy 2 (BAT2) Study, a prospective multicenter registry involving hospitals from a clinical research network in Japan, to clarify the risk of bleeding events in patients taking antithrombotic agents for cerebrovascular and cardiovascular diseases in recent clinical settings.

Methods: This prospective, multicenter, observational study followed bleeding and ischemic events for up to 2 years in patients with cerebrovascular and cardiovascular diseases. The primary outcome was major bleeding, and secondary outcomes included intracranial hemorrhage (ICH).

Results: The 5,250 patients enrolled comprised 3,134 (70±11 years old; male, 66.6%; HASBLED ≥3, 32.8%) treated with single antiplatelet therapy (SAPT), 551 (71±11 years; 25.8%; 40.8%, respectively) with dual antiplatelet therapy (DAPT), 870 (75±10 years; 37.1%; 39.8%, respectively) with direct oral anticoagulant (DOAC) alone, 433 (72±12 years; 34.2%; 41.4%, respectively) with warfarin alone, 143 (76±8 years; 16.8%; 42.7%, respectively) with DOAC plus antiplatelet agents (AP); and 119 (73±12 years; 18.5%; 47.5%, respectively) with warfarin plus AP. During follow-up (median, 1.98 years), 93 patients experienced major bleeding and 55 developed ICH. Compared to the SAPT group (37 events, 0.63%/year), the DOAC (18 events, 1.12%/year; adjusted hazard ratio [aHR] 1.94, 95% confidence interval [CI] 1.09-3.46), warfarin (16 events, 2.02%/year; 3.44, 1.90-6.23), and DOAC plus AP groups (6 events, 2.24%/year; 3.07, 1.28-7.35) exhibited significantly higher risks of major bleeding after multivariable adjustment. DAPT (aHR 2.47, 95%CI 1.11-5.48), warfarin (5.38, 2.65-10.92), and DOAC plus AP (3.86, 1.30-11.47) had significantly higher risks of ICH than SAPT. The DAPT (2.28, 95%CI 1.65-3.14), DOAC plus AP (1.96, 1.08-3.56) and warfarin plus AP (2.83, 1.62-4.92) groups showed significantly higher risks of ischemic events compared to the SAPT group.

Conclusions: Oral anticoagulant alone and DOAC with antiplatelet therapy were associated with higher risks of major bleeding events than SAPT in long-term follow-up for patients with stroke and cardiovascular disease.Data access statement:The dataset of the BAT2 study is available to the investigators who participated in this study group upon submission of a reasonable study plan.

Registration: ClinicalTrials.gov (NCT02889653) and the University Hospital Medical Information Network clinical trial registry in Japan (UMIN 000023669).

Background: Climate change is reshaping environmental exposures, which in turn influence cerebrovascular diseases. Brazil's continental dimensions and climate diversity offer a unique opportunity to examine climate-stroke associations within a unified healthcare system. Such regional analyses may inform adaptation strategies for other low-and middle-income countries facing similar environmental challenges.

Methods: A literature search was conducted across the PubMed, Scopus, and Web of Science databases, covering publications from January 2000 through August 2025 linking climate exposures to cerebrovascular outcomes. To examine climate-stroke associations, we analyzed national mortality data (DATASUS, 2020-2023) for Brazil's five geographic regions, yielding 127,424 stroke deaths (I61-I62, I63+I65-I66).

Findings: Global evidence consistently demonstrates non-linear, asymmetric associations between temperature extremes and stroke risk (RR 1.06-1.18 for extreme heat/cold, p<0.05), with PM₂.₅ conferring both short-term (RR 1.01, 95% CI 1.004-1.012 per 10 µg/m³) and long-term risks (HR 1.11-1.21, p<0.001). Brazilian analysis revealed climate-dependent patterns: cooler southern temperate regions showed higher ischemic-to-hemorrhagic stroke ratios (2.28:1, 70% ischemic) compared to hotter tropical regions (1.28:1 in Centro-Oeste, 56% ischemic). Both ischemic (Pearson r = -0.70, p = 0.001) and hemorrhagic (Pearson r = -0.65, p = 0.002) stroke deaths demonstrated negative associations with peak temperatures across pooled observations.

Interpretation: Stroke should be recognized as a climate-sensitive non-communicable disease. Global evidence demonstrates robust associations between temperature and stroke, while preliminary Brazilian regional patterns suggest potential climate influence on the distribution of stroke subtypes. Key priorities include establishing linkages between daily weather observations and atmospheric pollutant measurements, establishing multi-center surveillance networks, strengthening climate-resilient stroke care systems, and reducing PM₂.₅ through environmental regulation as a stroke prevention strategy.

Background: Acute kidney injury (AKI) is a common and serious complication in hospitalized patients and an important determinant of outcomes in stroke. However, evidence from long-term, nationwide studies in this population remains limited.

Aims: To examine temporal trends, factors associated with AKI, and clinical outcomes among patients hospitalized for stroke in Switzerland from 1998 to 2022.

Methods: We analyzed nationwide Swiss hospital discharge data from 1998 to 2022, covering over 98% of all hospitals. Stroke and AKI were identified using ICD-10 codes. Multivariable logistic and linear regression models were used to assess factors associated with AKI and its associations with intensive care unit (ICU) admission, length of stay, ICU duration, and in-hospital mortality.

Results: Among 439,465 stroke hospitalizations, 7674 (1.7%) were coded with AKI. The prevalence of coded AKI increased from below 1% in 1998 to approximately 4% in 2022, while overall in-hospital mortality declined from 10.4% to 5.1%. In multivariable regression, factors independently associated with AKI included older age, emergency admission, diabetes, hypertension, atrial fibrillation, heart failure, and chronic kidney disease, whereas female sex was associated with lower odds of AKI. AKI was associated with higher odds of ICU admission (OR 1.62; 95% CI 1.53-1.71), longer hospital stay (coefficient 0.12; 95% CI 0.11-0.14), and prolonged ICU duration (coefficient 0.33; 95% CI 0.28-0.37). In-hospital mortality was more than twice as high in patients with AKI (OR 2.40; 95% CI 2.25-2.56). The association between AKI and adverse in-hospital outcomes was stronger among male, younger, and non-CKD patients. Outcomes were worst among hospitalizations involving dialysis, with AKI associated with a markedly higher adjusted predicted probability of in-hospital mortality (0.47 vs 0.15 without dialysis).

Conclusion: AKI was associated with greater ICU use, longer hospital stay, and higher in-hospital mortality among patients hospitalized for stroke.

Background: Studies assessing the relationship between high ambient temperatures and stroke risk yielded conflicting results, while potential associations of humidity and heat stress with stroke risk remain underexplored.

Objective: To explore the association of ambient temperature, humidity, and heat index (HI) with the risk of total stroke (combined ischemic-intracerebral hemorrhage [ICH]), ischemic stroke (IS), ICH, and transient ischemic attack (TIA) among older adults during the warm season in the Mediterranean region.

Methods: In this time-stratified case-crossover study, we utilized data from the Israeli National Stroke Registry. We included all first stroke and TIA events among individuals aged ⩾18 years that occurred during the warm season (2014-2019). Temperature and relative humidity were assessed using high-resolution satellite-based models and monitoring stations, respectively, based on patients' residential addresses. A heat index (HI) was calculated based on a combination of temperature and relative humidity data. Conditional logistic regression models with Distributed Lag Non-Linear Models (DLNMs) were used with adjustment for potential confounders, including air pollution. The HI models were stratified by participants' demographic and health characteristics.

Results: The sample included 22,269 individuals with a first stroke (mean age 72 ± 14 years; 55% males) and 8728 individuals with a first TIA (mean age 69 ± 14 years; 52% males) during the warm season. Higher temperature (32°C vs. 27°C), particularly on the stroke event date, was associated with increased risk of total stroke (odds ratio (OR) = 1.32; 95% confidence interval (CI) = 1.23-1.41). The strongest association for relative humidity (90% vs. 70%) was observed 2 days before the stroke event (OR = 1.09; 95% CI = 1.06-1.12). An HI of 100°F was associated with an approximately 40% higher risk of total stroke compared to HI of 80°F on the event day (OR = 1.39; 95% CI = 1.32-1.47). Associations were slightly weaker for ICH, possibly reflecting its relatively smaller sample size, whereas associations with TIA were similar in magnitude to those observed for IS. No evidence of effect modification was observed across subgroups defined by sociodemographic characteristics or comorbidities.

Significance: High temperatures combined with high humidity are associated with an immediate increase in the risk of stroke and TIA, even in a region where the population is acclimatized and most buildings are air-conditioned. Preparedness and prevention strategies may be crucial for reducing stroke risk during periods of heat stress.

Background: Outcome prediction after endovascular thrombectomy (EVT) for ischemic stroke is important for patient counseling and rehabilitation planning. MR PREDICTS @24H, a nine-predictor model, showed excellent performance in predicting functional outcome at 90 days of patients with acute ischemic stroke. With the expanding treatment indications, we validated the model for patients receiving EVT within 24 hours after stroke onset and simplified it for easier clinical implementation.

Methods: We used individual patient data from the Dutch MR CLEAN Registry (2014-2018), a prospective observational cohort enrolling patients treated with EVT, and three randomized controlled trials MR CLEAN-MED, MR CLEAN-NOIV, and MR CLEAN-LATE (2018-2022). We included patients with an intracranial large-vessel occlusion in the anterior circulation treated with EVT within 24 hours of symptom onset or last seen well. We assessed the effect of predictors on functional outcome (modified Rankin Scale [mRS]) at 90 days with ordinal logistic regression. Predicted probabilities of functional independence (mRS 0-2) and survival (mRS 0-5) were derived from the model formula. We evaluated predictive performance with discrimination (C statistic) and calibration (intercept, slope). The model was simplified by excluding predictors based on the Akaike information criterion (AIC). We applied leave-one-study-out cross-validation to evaluate heterogeneity in model performance between the cohorts.

Results: The validation cohort included 6154 patients: 4737 from the Registry and 1417 from the trials. External validation of the original model showed excellent discrimination in predicting functional independence (C statistic 0.91, 95% CI 0.90-0.92) and survival (C statistic 0.90, 95% CI 0.89-0.91). The simplified model, comprising four predictors-NIHSS at 24 hours after EVT, age, pre-stroke mRS, and symptomatic intracranial hemorrhage-performed comparably (functional independence C statistic 0.91, 95% CI 0.90-0.92; and survival 0.89, 95% CI 0.88-0.90). Cross-validation revealed heterogeneity between LATE and the other cohorts, with the model overestimating the probability of functional independence in LATE (observed 39.1% vs predicted 44.2%), whereas the observed and predicted probability of survival was similar (75.5% vs 75.7%).

Conclusions: A simplified version of MR PREDICTS @24H including only four predictors performed as good as the full model, providing a practical tool that can be applied one day after EVT for reliable outcome estimation. Further validation and updating of the model are needed for patients treated in the late time window (6-24 h).

Background: Embolic stroke of undetermined source (ESUS) accounts for up to one quarter of ischemic strokes, with occult atrial fibrillation (AF) as a key underlying cause. Implantable cardiac monitors (ICMs) markedly improve AF detection but are limited by cost and resource demands. Existing AF-prediction models show modest accuracy and lack longitudinal validation. We developed and validated the CATCH-AF score to provide a simple, clinically applicable tool for stratifying early and long-term AF risk after ESUS.

Methods: We analyzed 543 consecutive ESUS patients systematically monitored with ICMs. Variable selection used LASSO-penalized Cox regression. Model performance was assessed with time-dependent ROC curves, restricted mean survival time (RMST) analysis, and 10-fold cross-validation. To evaluate geographic generalizability, internal-external cross-validation was performed across seven participating centers, estimating discrimination and calibration for each held-out cohort. Based on the final multivariable model, a point-based score was derived including age, coronary artery disease, heart failure, and prior transient ischemic attack or ischemic stroke.

Results: During 1558.5 patient-years of follow-up, 118 patients (22%) developed new AF. The CATCH-AF score showed excellent discrimination (AUC 0.85, 95% CI 0.82-0.89), stable over 4.5 years (0.84-0.87). Compared with low-risk patients (0-2 points), those at high risk (⩾5 points) had a 19-fold higher hazard of AF detection (HR 19.2, 95% CI 9.4-39.4; p < 0.001) and 918 fewer AF-free days (95% CI -1080 to -757).

Conclusions: The CATCH-AF score provides a robust, interpretable, and easily applicable tool for predicting AF after ESUS, supporting targeted and cost-effective rhythm monitoring.

Background: Although short-term outcomes are generally favorable in Cerebral venous sinus thrombosis (CVT), there are limited data on long-term complications and sequelae.

Methods: This ambispective study is from the Vellore CVT Registry, the largest single-center CVT registry in the world. Two thousand four hundred and eighty-four adults with CVT enrolled between 2000 and 2024 were analyzed for functional status and complications with follow-up up to 12 years.

Results: Of 2484 patients, 2380 (95.8%) survived the acute phase, with a mean follow-up of 3.2 years (range, 0-12 years). During follow-up, 41 patients (1.7%) died, the majority being within 1 year. Excellent functional outcomes (mRS ⩽ 2) were achieved by 92% of patients within 2 years. Complications were observed in 799 (33.5%) at follow-up, of whom 405 (50.6%) required rehospitalization. More than half (55.1%) of these complications occurred more than 2 years after the initial diagnosis of CVT. Common complications were seizures (9.6%) and headaches (7.7%). Bleeding events occurred in 3.9% of cases, predominantly due to anticoagulant use. Recurrent CVT developed in 1.3%, and other thrombotic events in 2.4%. Occurrences of malignancies (1%) and secondary dural arteriovenous fistulas (dAVFs) (0.6%) were significant complications that occurred after 2 years. Of the 108 pregnancies that occurred during follow-up, thrombotic events occurred in 2.7% in the absence of antithrombotic prophylaxis.

Conclusions: Most patients with CVT achieve long-term functional independence, yet one-third develop delayed complications. These findings underscore the importance of long-term surveillance in CVT survivors and give important insights into the natural history of CVT.