International Journal of Stroke最新文献

Background: Surgical clipping and endovascular coiling are well-established treatments for acutely ruptured intracranial aneurysms leading to acute subarachnoid hemorrhage (aSAH). However, these modalities have limitations, particularly in cases involving wide-necked, bifurcating, or dissecting aneurysms. Flow diverter (FD) devices, initially used for unruptured aneurysms, have emerged as an alternative treatment for ruptured aneurysms despite concerns about hemorrhagic complications.

Aims: This study aimed to perform a comprehensive systematic review and meta-analysis to assess the efficacy and safety of parental artery FD devices in treating ruptured intracranial aneurysms.

Methods: A systematic search was conducted in Medline, Embase, and Cochrane databases from inception to July 2024. The inclusion criteria focused on studies involving patients with acutely ruptured aneurysms treated with parental artery FDs, with or without adjunctive coiling. Studies were required to report clear, stratified data specific to the population of interest, and include more than five patients. Exclusion criteria included studies on non-ruptured aneurysms, intrasaccular flow diversion devices, or previously clipped aneurysms treated with FD. Data extraction was performed independently by two authors, and statistical analysis included single proportion analysis with 95% confidence intervals under a random-effects model, using R Studio. The primary outcome was the rate of aneurysm occlusion at follow-up.

Summary of review: A total of 60 studies encompassing 1300 patients were included. The primary outcome analysis revealed a 90% (95% CI: 87-92%; I² = 51%) rate of total occlusion at follow-up. Subgroup analysis indicated an occlusion rate of 89% for anterior circulation aneurysms and 96% for posterior circulation aneurysms. Intraoperative complications occurred in 6% of cases, while postoperative complications were observed in 13%. Rebleeding rates were low at 1%, with a 2% need for retreatment. Good functional outcomes (mRS ⩽ 2) were achieved in 82% of patients, and the overall mortality rate was 4%.

Conclusions: FD devices demonstrated high rates of aneurysm occlusion and favorable functional outcomes in patients with acutely ruptured intracranial aneurysms. However, the low mortality rate and favorable outcomes observed may reflect selection bias toward patients with less severe SAH. Despite a modest complication rate, the overall safety and efficacy of FD devices suggest they may be a viable alternative to traditional treatments for specific aneurysm types. Further studies, including a broader spectrum of SAH severities, are warranted to optimize their use in clinical practice.

Background: Cerebral venous thrombosis (CVT) accounts for 0.5-1% of all strokes. The role of endovascular therapy (EVT) in the management of CVT remains controversial and variations in practice patterns are not well known.

Aims: Here, we present a comprehensive, international characterization of practice patterns and perspectives on the use of EVT for CVT.

Methods: A comprehensive 42-question survey was distributed to stroke clinicians globally from May to October 2023, asking about practice patterns and perspectives on the use of EVT for CVT.

Results: The overall response rate was 31% (863 respondents of 2744 invited) across 61 countries. The majority of respondents (74%) supported the use of EVT for CVT in certain clinical situations. Key considerations for decision-making in using EVT favored clinical over radiographic/procedural factors and included worsening level of consciousness (86%) and worsening neurological deficits (76%). In the past 3 years, 56% of respondents used EVT for the treatment of CVT, with most (49.5%) involved in two to five cases. Among interventionalists, significant variability existed in the techniques used for EVT (p < 0.001), with aspiration thrombectomy (56%) and stent retriever (51%) being the most used overall. Regionally, interventionalists from China predominantly used intra-sinus heparin (56%), while this technique was most commonly ranked as "never indicated" throughout the rest of the world (23%). Post-procedure, low molecular weight heparin was the most used anticoagulant (83%), although North American respondents favored unfractionated heparin (37%), while imaging was primarily split between magnetic resonance (71.8%) and computed tomography (65.9%) arteriography or venography.

Conclusion: Our survey reveals significant heterogeneity in approaches to EVT for CVT, and provides a comprehensive characterization of indications, techniques, and long-term management used by clinicians internationally. This resource will aid in optimizing patient selection and endovascular treatments for future trials.

Background: Post-stroke dementia (PSD) is a common and disabling sequela of stroke. However, the long-term incidence of PSD after an ischemic stroke and factors which predict its occurrence are incompletely understood. Linkage of large health datasets is being increasing used to study long term outcomes after disease. We used large scale linked data from Korea to determine the long-term incidence of PSD after ischemic stroke, and identify which factors predicted it occurrence.

Methods: From January 2008 to December 2014, patients with ischemic stroke (n=37,553) without a history of dementia were included in a linked dataset comprising the claims database of the Health Insurance Review and Assessment Service and the Clinical Research Center for Stroke registry data. The outcome measure was PSD after ischemic stroke. Clinical factors evaluated included vascular risk factors, acute stroke management including reperfusion therapy, antithrombotics, and statins, stroke severity, and educational levels, were evaluated. Results: Among 37,553 patients with ischemic stroke without a history of dementia (mean age: 64.9 years; 61.9% males), 6,052 (16.1%) experienced PSD during a median follow-up period of 5 (interquartile range 3.4-7.0) years. The 10 year estimated cumulative incidence of dementia was 23.5%. Age [hazard ratio (HR) 1.82 per 10 years, 95% confidence interval (CI) 1.75-1.88] and a lower educational level [illiteracy or no education HR 1.65 (CI, 1.44-1.88), 0-3 years 1.53 (CI, 1.31-1.79), 4-6 years 1.60 (CI, 1.43-1.80), 7-9 years 1.32 (CI, 1.16-1.49), 10-12 years 1.17 (CI, 1.04-1.32)] were independently associated with an elevated risk of PSD. Male sex was associated with a significantly lower risk of PSD (HR 0.86, CI 0.79-0.92). Diabetes mellitus (HR 1.21, CI 1.14-1.29), a history of stroke before index stroke (HR 1.31, CI 1.21-1.41), and initial National Institutes of Health Stroke Scale (HR 1.03, CI 1.03-1.04) were independent risk factors for PSD. Regarding medications, the use of anticoagulation and antipsychotic medications after stroke appeared to be associated with increased PSD risk whereas statin therapy was associated with a reduced risk.

Conclusions: PSD is common with a 5 and 10 year incidence in patients with ischemic stroke without a history of dementia of 16.1% and 23.5% respectively. Factors associated with PSD include age, female sex, lower educational level, diabetes mellitus, initial stroke severity, antipsychotics and anticoagulants. Further studies are required to determine whether reducing those risk factors which are treatable reduces the incidence of PSD.

Background: Although tube feeding modes have been shown to influence psychological status, the specific mechanism of action and differences between intermittent oro-esophageal tube feeding (IOE) and nasogastric tube feeding (NGT) have yet to be uncovered. This study explored the effect of IOE versus NGT on anxiety in patients with dysphagia after ischemic stroke.

Methods: This longitudinal observational study included patients with dysphagia after ischemic stroke who were treated in the Department of Rehabilitation Medicine between February 2022 and June 2024. Questionnaires, scales, and medical records were used to collect data regarding anxiety symptoms, basic information, treatment details, and self-perception on the 1st and 10th day of hospitalization. Propensity Score Matching (PSM) was used to balance potential confounding factors and analyze the association between IOE versus NGT and anxiety symptoms. Path analysis was conducted to explore the specific mechanisms of action.

Results: Totally, 2459 participants (55.51% IOE users) were recruited. The IOE users had significantly lower moderate-to-severe anxiety rates than the NGT users (25.88% and 44.42%, p < 0.001). PSM analysis revealed an 8.56% difference in moderate-to-severe anxiety rates between IOE and NGT users. Self-perception of comfort, reflux, dietary schedule, social activity, self-esteem, and daily exercise showed significance as intermediate variables between tube feeding modes and anxiety symptoms in path analysis (all p < 0.001).

Conclusions: Compared to NGT, IOE can alleviate anxiety symptoms in patients with dysphagia after ischemic stroke who were treated in the Department of Rehabilitation Medicine. The relationship between tube feeding modes and anxiety symptoms was mediated by the self-perception of comfort, reflux, dietary schedule, social activity, self-esteem, and daily exercise.

Background: According to the literature, about one third of patients with brain ischemic symptoms lasting <24 h, which are classified as Transient ischemic attacks (TIAs) according to the traditional "time-based" definition, show the presence of acute ischemic lesions at neuroimaging. Recent evidence has shown that the presence of acute ischemic lesions at neuroimaging may impact on the outcome of patients with transient ischemic symptoms treated with dual antiplatelet treatment (DAPT). This uncertainty is even more compelling in recent years as short-term DAPT has become the standard treatment for any non-cardioembolic TIA or minor ischemic stroke.

Methods: This is a pre-specified subgroup analysis from a prospective multicenter real-world study (READAPT). The analysis included patients with time-based TIA-that is, those with ischemic symptoms lasting <24 h-who started DAPT. In the whole population, we assessed the presence of acute brain ischemic lesions at neuroimaging and their association with the ABCD² score. To assess the impact of acute brain ischemic lesions on 90-day prognosis, we performed a propensity score matching of patients with and without those lesions. We adopted a primary effectiveness outcome which was a composite of new stroke/TIA events and death due to vascular causes at 90 days.

Results: We included 517 patients-324 (62.7%) male-with a median (interquartile range-IQR) age of 74 (IQR = 65-81) years; 144 patients (27.9%) had acute brain ischemic lesions at neuroimaging. The proportion of patients with brain ischemic lesions did not vary according to the ABCD² score. At follow-up, 4 patients with brain ischemic lesions (2.8%) and 21 patients without lesions (5.6%) reported the primary effectiveness outcome, which was similar between the groups before (p = 0.178) and after matching (p = 0.518).

Conclusions: In our population, patients with transient ischemic symptoms and acute ischemic lesions at brain magnetic resonance imaging (MRI) had a risk of recurrent ischemic events similar to those without lesions. The risk of recurrent ischemic events was low in both groups.

Background: Short-term dual antiplatelet treatment (DAPT) is superior to single antiplatelet treatment (SAPT) for secondary prevention in non-cardioembolic minor ischemic stroke and high-risk transient ischemic attack (TIA). As the real-world use of DAPT is broader than in trials, it is important to clarify its benefit/risk profile in a diverse population.

Methods: Post hoc analysis of prospectively collected data from the READAPT cohort and three prospective stroke registries including patients with mild-to-moderate (National Institute of Health Stroke Scale (NIHSS) score 0-10) ischemic stroke receiving early DAPT or SAPT. The primary effectiveness outcome was 90-day return to pre-stroke neurological functioning using modified Rankin Scale (mRS) score. Secondary effectiveness outcomes were 90-day mRS shift, new ischemic stroke/TIA, vascular and all-cause death, 24 h early neurological improvement or deterioration. The safety outcome was 90-day intracranial hemorrhage.

Results: We matched 1008 patients treated with DAPT and 1008 treated with SAPT. Compared to SAPT, patients treated with DAPT showed higher likelihood of 90-day primary effectiveness outcome (87.5% vs. 84.4%, risk difference 3.1% (95% confidence interval (CI): 0.1%-6.1%); p = 0.047, risk ratio 1.03 (95% CI: 1.01-1.07); p = 0.043) and higher rate of 24-h early neurological improvement (25.3% vs. 15.4%, risk difference 9.9% (95% CI: 6.4%-13.4%); p < 0.001, risk ratio 1.65 (95% CI: 1.37-1.97); p < 0.001). No differences were observed for other study outcomes. Subgroup analysis confirmed benefit of DAPT over SAPT for primary effectiveness outcome in patients with moderate stroke, those treated with intravenous thrombolysis, and those who received antiplatelet loading dose.

Conclusion: Our findings suggest that DAPT use might be safe and more effective than SAPT even in the real world and in patients who do not strictly fulfill the criteria of landmark large clinical trials.

Background: The recurrence rate of strokes associated with atrial fibrillation (AF) can be substantially reduced through the administration of oral anticoagulants. However, previous studies have not demonstrated a clear benefit from the universal application of oral anticoagulants in patients with embolic stroke of undetermined source. Timely detection of AF remains a challenge in patients with stroke.

Aim: This study aims to develop a convolutional neural network (CNN) model to accurately identify patients with AF using a 12-lead sinus-rhythm electrocardiogram (ECG) recorded around the time of the first ischemic stroke. In addition, this study also evaluates the model's ability to predict future occurrence of AF.

Methods: A CNN model was trained with ECG data from patients at Taipei Veterans General Hospital. External validation was performed on ischemic stroke patients from National Taiwan University Hospital. The model's performance was assessed for detecting AF at the stroke event and predicting future AF occurrences.

Results: The model demonstrated an area under curve (AUC) of 0.91 for internal validation and 0.69 for external validation in identifying AF at the stroke event, with sensitivity and negative predictive value both achieving 97%. Kaplan-Meier survival analysis of patients without a prior diagnosis of AF revealed a significant increase in future AF incidence among the high-risk group identified by the model (adjusted hazard ratio: 4.06; 95% confidence interval: 2.74-6.00).

Conclusions: The CNN model effectively identifies AF in stroke patients using 12-lead ECGs and predicts future AF events, facilitating early anticoagulation therapy and potentially reducing recurrent stroke risk. Further prospective studies are warranted to confirm these findings.

Rationale: The benefit of tenecteplase in the treatment of large vessel occlusion (LVO) patients presenting within 24 hours of symptom onset remains unclear.

Aim: To assess the effectiveness and safety of tenecteplase, compared to standard of care, in patients presenting within the first 24 hours of symptom onset with a LVO and target mismatch on perfusion CT.

Methods and design: The "Extending the time window for Tenecteplase by Effective Reperfusion of peNumbrAL tissue in patients with Large Vessel Occlusion" (ETERNAL-LVO) trial is a prospective, randomized, open-label, blinded endpoint, phase 3, parallel-group, superiority trial with covariate-adjusted 1:1 randomization, and adaptive sample size re-estimation. Patients with an anterior circulation LVO stroke, who present within 24 hours of stroke onset or last known well with a target mismatch on CTP or MRI, will be randomized to tenecteplase (0.25 mg/kg) or standard of care (alteplase 0.90 mg/kg or conservative management at clinician discretion) prior to undergoing endovascular therapy.

Study outcomes: The primary outcome is the proportion of patients with a modified Rankin Scale (mRS) of 0-1 (no disability) or return to baseline mRS at 3 months. Secondary and safety outcomes include the proportion of patients with a mRS of 0-2 at 3 months, an ordinal analysis of the mRS at 3 months, the proportion of patients with symptomatic intracerebral haemorrhage (sICH), the proportion of patients with death due to any cause, and the proportion of patients with mRS 5-6 at 3 months (severe disability or death).

Discussion: The ETERNAL-LVO trial will build upon the current evidence for tenecteplase in the >4.5-hour window. Specifically, this trial will evaluate tenecteplase in a patient population who have access to endovascular therapy but may incur delays to endovascular therapy commencement or require transfer from a primary to a comprehensive stroke center.

Trials registration: ClincialTrials.gov: NCT04454788.

Background: Microcalcification and macrocalcification are critical processes in atherosclerotic plaque progression, though how these processes relate to the risk of stroke recurrence in symptomatic carotid atherosclerosis is poorly understood.

Methods: We performed a post hoc analysis of data from the ICARUSS (Imaging Carotid Atherosclerosis in the Recovery and Understanding of Stroke Severity) study, where individuals with acute ischemic stroke originating from ipsilateral carotid stenosis of ⩾ 50% underwent ¹⁸F-sodium fluoride positron emission tomography (NaF-PET) to measure microcalcification. Tracer uptake was quantified using maximum tissue-to-background ratio (TBR_max). Macrocalcification was measured on computed tomography (CT) using Agatston scoring. Patients were followed up for 6 months for recurrent ipsilateral neurovascular events.

Results: Five (27.8%) of 18 individuals had a recurrent ischemic stroke or transient ischemic attack. Ipsilateral carotid plaque NaF uptake at baseline was higher in those with recurrent events compared to those without, and this association remained after adjustment for other vascular risk factors (adjusted odds ratio (aOR) = 1.24, 1.03-1.50). Macrocalcification score in the symptomatic artery was also significantly independently associated with ipsilateral recurrence, but the effect size was relatively smaller (aOR = 1.12, 1.06-1.17 for each 100 unit increase).

Conclusions: Our findings indicate that microcalcification in symptomatic carotid plaques is independently associated with ipsilateral ischemic stroke recurrence. Furthermore, differences in the extent of active microcalcification in macrocalcified plaques may help explain variation in the relationship between calcified carotid plaques and stroke recurrence reported in the literature. Our pilot study indicates that evaluation of carotid artery microcalcification using NaF-PET may be a useful method for risk-stratification of carotid atherosclerosis, though our findings require confirmation in larger cohorts.

Background: There is yet no randomized controlled evidence that mechanical thrombectomy (MT) is superior to best medical treatment in patients with large vessel occlusion but minor stroke symptoms (National Institutes of Health Stroke Scale (NIHSS) <6). Prior studies of patients with admission NIHSS scores ≥6 observed unfavorable functional outcomes despite successful recanalization, commonly termed as futile recanalization (FR), in up to 50% of cases.

Aim: The aim of this study is to determine the prevalence of FR in patients with minor stroke and identify associated patient-specific risk factors.

Methods: Our multicenter cohort study screened all patients prospectively enrolled in the German Stroke Registry Endovascular Treatment from 2015 to 2021 (n = 13,082). Included were patients who underwent MT for anterior circulation vessel occlusion with a baseline NIHSS score of <6 and successful recanalization (modified Thrombolysis in Cerebral Infarction (mTICI) scores of 2b-3). FR was defined by modified Rankin Scale (mRS) scores of 2-6 at 90 days. Multivariable logistic regression analysis was conducted to explore factors associated with FR.

Results: A total of 674 patients met the inclusion criteria. FR occurred in 268 (40%) patients. Multivariable logistic regression analysis indicates that higher age (adjusted odds ratio (aOR) = 1.04 (95% confidence interval (CI) = 1.02-1.06)), pre-stroke mRS 1 (aOR = 2.70 (95% CI = 1.51-4.84)), transfer from admission hospital to comprehensive stroke center (aOR = 1.67 (95% CI = 1.08-2.56)), longer time from symptom onset/last seen well to admission (aOR = 1.02 (95% CI = 1.00-1.04)), MT under general anesthesia (aOR = 1.78 (95% CI = 1.13-2.82)), higher NIHSS after 24 h (aOR = 1.09 (95% CI = 1.05-1.14)), and symptomatic intracranial hemorrhage (aOR = 16.88 (95% CI = 2.03-140.14)) increased the odds of FR. There was no significant difference in primary outcome between achieving mTICI score of 2b or 3.

Conclusions: Unfavorable functional outcomes despite successful vessel recanalization were frequent in acute ischemic stroke patients with low NIHSS scores on admission. We provide patient-specific risk factors that indicate an increased risk of FR and should be considered when treating patients with minor stroke.

Data accessibility statement: The data that support the findings of our study are available on reasonable request after approval of the German Stroke Registry (GSR) steering committee.