International Journal of Stroke最新文献

Background: A large proportion of early neurological deterioration (END) in stroke due to middle cerebral artery (MCA) stenosis remains unexplained. Unstable plaques on MCA and impaired perforators might contribute to unexplained END.

Methods: We included patients with symptomatic MCA stenosis and classified them into three groups according to symptoms: END, stable, and transient ischemic attack (TIA). High-resolution 7 T vessel wall magnetic resonance imaging (MRI) (VW-MRI) and time-of-flight magnetic resonance (MR) angiography (TOF-MRA) were used to investigate MCA plaque features and lenticulostriate artery (LSA) morphology. We compared demographic data, plaque features and LSA morphology between three groups, and used binary logistic regression models to investigate factors that could potentially be related to END.

Results: Fifty-two patients (49.46 ± 13.94 years, 39 males) were included in final analyses. Patients in three groups did not differ in age or vascular risk factors. Irregular plaque surface (16/16 vs 12/16 vs 11/20 in END vs stable vs TIA groups, P = 0.008) and plaques adjacent to LSA origin (14/16 vs 10/16 vs 7/20, P = 0.006) were more commonly seen in the END group than the other two groups. On TOF-MRA, TIA patients had more LSA branches (6[1,15] vs 5[1,9] vs 7[4,12] in END vs stable vs TIA groups, P = 0.018) and longer total LSA length (95.37 ± 43.98 vs 92.42 ± 33.10 vs 129.61 ± 38.77 mm, P = 0.012). Larger lesion size, higher LDL level and plaques adjacent to LSA origin were significantly associated with END, before and after the adjustment for age and sex.

Conclusion: The 7 T MRA provide precise imaging capabilities for plaque characteristics and LSA in patients with MCA stenosis and END, which could help stratify the risks of END and provide evidence for treatment of ischemic stroke caused by MCA arthrosclerosis.

Purpose: We aimed to clarify the clinical characteristics and outcomes of patients with in-hospital onset ischemic stroke (IOS) compared with those in patients with community-onset ischemic stroke (COS).

Methods: Patients from the Japan Stroke Data Bank, a hospital-based multicenter prospective registry, who were diagnosed with acute ischemic stroke (AIS) within 24 h of onset between January 2001 and December 2020 were included in this study. We assessed favorable outcomes at discharge corresponding to a modified Rankin Scale (mRS) score of 0-2, unfavorable outcomes corresponding to an mRS score of 5-6, and mortality. We also examined trends in these outcomes at 4-year intervals over a period of 20 years.

Results: Of the 100,865 patients analyzed, 2979 had IOS (1416 women, mean age 77 ± 12 years) and were older than those with COS (n = 97,886; 39,110 women, mean age 74 ± 12 years). Multivariate analysis revealed that younger age, higher premorbid mRS score, absence of stroke history, normotension, congestive heart failure, coronary artery disease, chronic kidney disease, liver disease, malignancy, tendency to bleed, and cardioembolic stroke were positively associated with IOS. Compared with COS, IOS was inversely associated with a favorable outcome (42.1% vs 64.8%, adjusted odds ratio [aOR] 0.72 [95% confidence interval (CI) 0.63-0.82]), positively associated with an unfavorable outcome (mRS 5-6 at discharge; 34.3% vs 15.5%, aOR 1.31 [95% CI 1.16-1.48]), and mortality (11.8% vs 4.6%, aOR 1.59 [95% CI 1.37-1.84]). Over 20 years, the mortality rate significantly decreased in both patients with IOS and COS (p < 0.01 both).

Conclusion: IOS is associated with unfavorable outcomes and higher mortality rates during acute hospitalization. The mortality rates in patients with IOS decreased over time, similar to those observed in patients with COS.

Background: Although atrial fibrillation (AF) is a known risk factor for ischemic stroke (IS), few studies have evaluated the risk of AF after IS.

Aim: We evaluated associations between IS and subsequent AF risk in the Korean population.

Methods: We identified 98,076 participants newly diagnosed with IS between 2010 and 2018 who underwent health screening within the 2 years prior to IS diagnosis, and 98,076 propensity score matched controls were included. The risk of AF was estimated using a Fine and Gray model, with death as a competing event.

Results: During the mean follow-up period of 4.7 years, 9611 participants developed AF (6728 with IS and 2883 controls). The IS patients had a greater risk of AF (sub-distribution hazard ratio [sHR] 2.32, 95% confidence interval [CI] 2.22-2.42) than the controls, and this association was more prominent during the first year after IS (sHR 7.32, 95% CI 6.59-8.13). After 1 year, the increased risk of AF was attenuated but remained elevated (sHR 1.64, 95% CI 1.56-1.73). While IS patients with severe disability had the greatest risk of AF during the first year after IS (sHR 8.92, 95% CI 7.23-11.01), this finding was not evident after more than 1 year.

Conclusions: The IS patients were at significantly greater risk of AF during the first year following IS diagnosis. Although the risk was attenuated after 1 year, it remained elevated. Physicians should be aware of the elevated risk of AF in IS patients and take appropriate measures to identify and treat AF.

Background: Anticoagulation is the mainstay acute therapy for cerebral venous thrombosis (CVT). Decompressive surgery is required in a small minority of patients with large parenchymal lesions and impending herniation, which requires a temporary suspension of anticoagulation.

Aim: The objective of this study was to identify the optimal timing for starting or resuming anticoagulation following decompressive surgery.

Methods: Data were collected from the Decompressive Surgery for CVT Study 2 (DECOMPRESS2), a prospective multinational cohort observational study of 118 patients with severe CVT treated by decompressive surgery. We assessed the frequency of new hemorrhagic and venous thrombotic events from admission to discharge in patients who started or resumed anticoagulation <24 h (early) and ⩾24 (late) following surgery, using propensity score matching and logistic regression. Death and disability were evaluated by the modified Rankin scale (mRS > 2) at discharge and at 1 year follow-up and compared between the two groups.

Results: Of the 90 patients available for analysis, 35 (39%) started or resumed anticoagulation within the first 24 h after surgery while 55 (61%) did so later than 24 h. Overall frequency of patients with new hemorrhagic or venous thrombotic events from admission to discharge was 26.7% (24 patients), without crude or adjusted for the propensity score statistically significant difference between the early and late anticoagulation groups (<24 h, 11 patients, 31%, vs ⩾24 h, 13 patients, 24%; odds ratio (OR): 0.86; 95% confidence interval (CI): 0.24 to 3.04; χ² = 0.33, p = 0.57). The distribution of major hemorrhagic events was also comparable: 8 (23%) bleedings in the <24 h, and 9 (16%) in the ⩾24 h (χ² = 0.24, p = 0.62). No CVT recurred. Two venous thrombotic events occurred in <24 h (6%) and 5 in the ⩾24 h (9%) group. There was no association between anticoagulation timing and death or dependence (mRS 3-6) at discharge (OR: 1.65. 95% CI: 0.30 to 9.01, p = 0.56), or at 1 year follow-up (OR: 2.19, 95% CI: 0.78 to 6.10, p = 0.14).

Conclusions: The results of this cohort study suggest that the timing of anticoagulation therapy following decompressive surgery for CVT does not significantly influence the risk of new bleeding or venous thrombotic events or disability.

Background: Little is known about early major neurological improvement (EMNI) after intracerebral hemorrhage (ICH).

Aims: We performed a post hoc analysis of the Intracerebral Hemorrhage-Deferoxamine trial (i-DEF; NCT02175225) to comprehensively evaluate EMNI and assess whether deferoxamine treatment affects it.

Methods: Comparing repeated assessments of National Institutes of Health Stroke Scale (NIHSS) on days 2, 3, 4, and 7 (or discharge, if it was earlier) versus NIHSS score at presentation, and defining EMNI as an NIHSS score decrement of an absolute ⩾4 points from presentation, we determined its presence or absence on day 2, day 3, day 4, and day 7(/discharge). Using adjusted generalized linear mixed-effects or logistic models as appropriate, we examined the association of deferoxamine with EMNI as repeated measure, as well as EMNI's overall frequency, time course, determinants, and association with favorable long-term outcome (modified Rankin Scale 0-2).

Results: Among 291 i-DEF participants in the modified intention-to-treat population (median age 61 years, 38.5% female, median NIHSS score 13, 144 randomized to deferoxamine and 147 to placebo), the proportion of participants with EMNI continuously increased from 20% on day 2 to 36% on day 7(/discharge). Deferoxamine was associated with an average twofold higher odds of EMNI (odds ratio (OR): 2.30, 95% confidence interval (CI): 1.07 to 4.95, p = 0.033 after adjustment for the prespecified trial covariates onset-to-treatment time, baseline ICH volume, and presenting NIHSS score), without clear evidence for treatment-by-time interaction (p_interaction = 0.092). Secondary and sensitivity analyses using alternative EMNI definitions (as relative ⩾20% or ⩾30% NIHSS score decrement) and additional covariate adjustment yielded consistent findings. Race, ICH volume and location were also associated with EMNI. EMNI was independently associated with twofold to sixfold higher odds of favorable 90-day and 180-day outcome, regardless of assessment timepoint.

Conclusion: In a post hoc analysis of the i-DEF trial, the likelihood of EMNI over the first week following ICH was higher with deferoxamine. EMNI showed a continuous upward trajectory and strong association with favorable long-term functional outcome.

Background: Lumbar drainage (LD) and external ventricular drainage (EVD) are used in patients with aneurysmal subarachnoid hemorrhage (aSAH) for cerebrospinal fluid diversion and blood clearance. While both have potential benefits, the relative efficacy and safety of LD versus EVD remain unclear, particularly given their use in differing clinical contexts. This study aims to provide a crude comparison of LD and EVD in the context of aSAH using the most updated and comprehensive meta-analysis.

Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we performed a systematic review and pair-wise meta-analyses of 28 studies (4390 patients). Cohorts were analyzed across three contrasts-LD versus non-LD, EVD versus non-EVD, and LD versus EVD-using random-effects models. Outcomes included rebleeding, clinical vasospasm, delayed ischemic neurological deficit (DIND)/ischemic stroke, functional status (mRS 0-2 early and late; Glasgow Outcome Scale (GOS) ⩽ 2), mortality, infection, and shunt dependency.

Results: Compared with non-LD, LD lowered the odds of vasospasm (odds ratio (OR): 0.51, 95% confidence interval (CI): 0.33 to 0.78), DIND/ischemic stroke (OR: 0.55, 0.37 to 0.83), severe disability/vegetative state (GOS ⩽ 2) (OR: 0.28, 0.17 to 0.46), and mortality (OR: 0.59, 0.41 to 0.85) without affecting rebleeding rates. Versus non-EVD, EVD reduced ischemic complications (OR: 0.39, 0.16 to 0.96) but increased infection risk (OR: 11.58, 1.45 to 92.71); vasospasm and rebleeding were similar. Direct comparison showed LD superior to EVD for early functional independence (OR: 1.92, 1.06 to 3.50) and mortality (OR: 0.49, 0.30 to 0.81), while rebleeding, vasospasm, infections, and shunt dependency were similar.

Conclusion: LD was associated with lower rates of vasospasm, ischemic complications, severe disability, and mortality compared to non-LD, without increasing rebleeding risk. EVD reduced ischemic complications but was linked to higher infection rates. When directly compared, LD was favored for early functional recovery and survival. These findings should be interpreted in light of differing clinical indications and baseline severity. Further studies are needed.

Background: The effect of Ayurvedic Rehabilitation therapy (ART) in improving the sensorimotor recovery of patients with ischemic stroke is unclear irrespective of the fact that ayurveda is a commonly practiced alternate system of medicine in India and south Asia. The trial hypothesized that ayurvedic treatment is superior to physiotherapy (PT) in recovery of ischemic stroke patients.

Methods: We performed investigator-initiated, multi-center prospective, parallel arm randomized controlled trial (RCT) with blinded outcome assessment across four comprehensive stroke centers in India. Participants were randomly assigned in a 1:1 ratio to the ART arm (intervention group) or on to the PT arm (control group). The primary outcome was sensory motor recovery of upper extremity assessed using Fugl Meyer Assessment-upper extremity (FMA-UE) and secondary outcome, a composite of functional disability, activities of daily living, postural balance and quality of life at 1- and 3-month follow-up. The safety outcomes were serious adverse events during the study duration.

Results: Of 403 participants screened, 140 patients were enrolled, 70 in intervention (ART) and 70 in control (PT) group. At 3 months, compared with ayurveda group, the sensory motor impairment (FMA-UE) score was significantly better in the PT group (71.97 ± 23.88 vs. 81.97 ± 24.57, p = 0.023) but after adjusting for age, stroke severity, baseline FMA-UE scale and risk factors, the group differences were not significant (p = 0.057). None of the secondary outcomes were significantly better in the ayurveda group. During the trial, no major serious adverse events were reported.

Conclusion: This pragmatic first-ever RCT of ayurveda in stroke looked into the benefit of ayurveda treatment in first ever stroke survivors. The current intervention protocol of ART was not superior to PT in improving the sensorimotor recovery of patients with ischemic stroke. This is the first RCT of its kind.

Background: Survivors of aneurysmal subarachnoid hemorrhage (aSAH) often have cognitive impairment, which may be caused by long-term inflammation. We aimed to determine whether long-term neuroinflammation or microstructural brain damage is associated with cognitive impairment after aSAH.

Methods: In this prospective cohort study, we included patients >3 years after aSAH between 2020 and 2022. Patients underwent neuropsychological evaluation, translocator protein 18 kDA (TSPO) positron emission tomography (PET) imaging using [¹⁸F]DPA-714 to determine neuroinflammation, and brain diffusion kurtosis imaging (DKI) to determine microstructural damage. We compared TSPO PET binding potential, mean kurtosis (MK), kurtosis anisotropy (KA), axial kurtosis (AK), and radial kurtosis (RA) between groups and determined which metric was correlated with individual cognitive tests.

Results: We included 27 patients with aSAH; 14 with and 13 without cognitive impairment. Whole-brain TSPO binding potential was similar between groups (mean BP_ND: -0.046 [95% confidence interval (CI): -0.105; 0.013] vs -0.047 [95% CI -0.108; 0.014], p = 0.98) and there were no regional differences. Those with cognitive impairment had a lower whole-brain MK (mean MK 0.70 [95% CI: 0.69-0.72] vs 0.73 [95% CI: 0.72-0.74], p = 0.03) and whole-brain AK (mean AK 0.81 [95% CI: 0.78-0.83] vs 0.86 [0.84-0.87], p = 0.04). Left thalamic MK and AK were correlated with tests of verbal memory (r = 0.60-0.67, p < 0.01), while other correlation tests were non-significant.

Conclusion: Our results do not support the hypothesis that long-term cognitive impairment after aSAH is caused by long-term neuroinflammation. Instead, microstructural damage may play a role.