International Journal of Stroke最新文献

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.

Background and aim: Cerebral venous thrombosis (CVT) is an uncommon but increasingly recognized cause of stroke.Despite its lower incidence than arterial stroke, CVT can cause substantial functional disability and mortality and mainly affects younger adults. This review summarizes current treatment strategies, recent advances, and potential future directions.

Recent advances: Anticoagulation remains the cornerstone of CVT treatment. While vitamin K antagonists (VKAs) have long been the standard, direct oral anticoagulants (DOACs) have recently been demonstrated to be equally safe and effective, and are increasingly used in routine practice. Endovascular therapy is reserved for selected severe cases unresponsive to anticoagulation, although data from randomized trials remain limited. The recently completed DECOMPRESS2 study has provided high-quality data on the outcomes of patients with severe CVT that underwent decompressive surgery. Novel scoring systems, such as DIAS3 and SI(2)NCAL(2)C, have helped facilitate individualized prediction of seizures and long-term outcomes.

Future directions: The diagnostic work-up of CVT could be further improved if clinical decision rules, in combination with biomarkers, are developed and validated. Similarly, Artificial Intelligence algorithms that are able to detect signs of CVT on imaging, even when CVT is not suspected, could help to speed up diagnosis of CVT, allowing faster treatment. Novel anticoagulant and fibrinolytic treatments hold promise to rapidly and safely achieve recanalization of the venous system. Finally, multicenter studies should address novel ways to measure outcome after CVT, beyond the modified Rankin Scale. As with all CVT research, international collaboration through academic consortia will be the key to produce evidence-based answers to the burning clinical questions, with the ultimate goal to reduce the global burden of this condition.

Background: Randomized studies have demonstrated the efficacy of endovascular therapy (EVT) for acute large vessel occlusion with large infarction. However, the impact of the occlusion site on EVT outcomes remains underexplored.

Methods: We conducted this prespecified subgroup analysis of the Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core (ANGEL-ASPECT) trial. Participants were enrolled within 24 h of symptom onset and had an Alberta Stroke Program Early Computed Tomography Score of 3 to 5 or an infarct core volume of 70-100 mL and were randomly assigned to undergo EVT or standard medical management (MM). All 455 patients were included and categorized into 2 subgroups by whether there was an internal carotid artery occlusion (ICAO) or middle cerebral artery occlusion (MCAO). The primary outcome was functional outcome (modified Rankin Scale) at 90 days. We further assessed the association between onset-to-puncture time (OPT) and outcome in both groups using ordinal logistic regression and tested for an interaction between occlusion site and the effect of EVT.

Results: A total of 164 patients (36.0%) had ICAO, while 291 patients (64.0%) had MCAO. The baseline characteristics of patients treated with EVT and MM were comparable in either the ICAO or MCAO groups. EVT benefit was observed in both groups without significant heterogeneity (p for interaction = 0.891). A significant statistic interaction between occlusion site and treatment on any intracranial hemorrhage (ICH) within 48 h was observed (p for interaction = 0.002), with ICAO significantly increasing the risk of ICH compared to MCAO in patients undergoing EVT (ICAO: common OR, 6.34; 95% CI, 2.84-14.16; MCAO: common OR, 2.19; 95% CI, 1.56-3.09). However, the risk of symptomatic ICH was not increased significantly in both groups. For patients with ICAO, when OPT exceeds about 10 h and 10 min, the benefit of EVT compared to MM is not significant.

Conclusions: Although both ICAO and MCAO patients with large infarction could benefit from EVT, EVT increased the risk of any ICH in ICAO patients without increasing the risk of sICH. Longer OPT was associated with poorer EVT efficacy in patients with ICAO.Data access statement:The data supporting the findings of this study are available from the corresponding author upon reasonable request.Registration: URL: https://www.

Clinicaltrials: gov; Unique identifier: NCT04551664.

Background: Pregnancy and delivery are known to increase the risk of cerebrovascular events (CVEs) in patients with moyamoya disease (MMD). This study determined the frequency, risk factors, and outcome of CVEs during pregnancy in MMD.

Methods: We conducted a multicenter study involving 171 MMD patients with 196 deliveries across four Korean tertiary institutions between 1990 and 2023. Data on MMD-related clinical, imaging, and operative findings were collected. We analyzed CVEs and pregnancy outcomes, including delivery mode and anesthesia. Univariate and multivariate analyses were performed to identify risk factors for peripartum CVEs.

Results: Peripartum CVEs occurred in 5.6% of pregnancies, with intracerebral hemorrhage being the most common, followed by cerebral infarction. CVEs were more common in women diagnosed with MMD during pregnancy (85.7% vs. 2.6% in women diagnosed before pregnancy) and in women who had not completed revascularization before pregnancy or were hemodynamically unstable: 55.6% versus 1.1%. Delivery mode and anesthesia showed no significant association with the occurrence of CVEs. Multivariate analysis revealed that the "non-revascularized or hemodynamically unstable" group remained a significant risk factor for peripartum CVEs (adjusted odds ratio (OR) = 353.23, P < 0.001). CVEs resulted in maternal functional impairment in 4 of 11 affected cases (36.4%) and fetal loss in 2 of 11 cases (18.2%).

Conclusion: This study highlights the protective effect of revascularization on peripartum CVEs and proposes a structured clinical protocol, recommending prepregnancy hemodynamic assessment and neurosurgical consultation. Women diagnosed with MMD during pregnancy and those in the "non-revascularized or hemodynamically unstable" group should be considered a high-risk group for peripartum CVEs.

Background: Management of large cerebellar infarctions with potential malignant evolution is highly heterogeneous across physicians, and recommendations rely on low-evidence studies.

Aim: We aimed to perform a systematic review and meta-analysis on patients with large cerebellar infarction undergoing neurosurgery, to study mortality and functional outcome, according to neurosurgical technique.

Summary of review: We searched on PubMed and Embase according to pre-defined selection criteria and we assessed their quality according to a predefined risk of bias scale. Our primary outcomes were mortality and functional outcome rates. Favorable outcome was defined as a modified Rankin scale of 0-2, a Glasgow Outcome Scale of 4-5, or a Barthel Index > 90%. Pooled rates were obtained using random effect model and heterogeneity was quantified using I² statistics. Among 27 included studies (including 1173 patients), we studied the 662 patients undergoing neurosurgery. All studies were retrospective and observational; there was no randomized clinical trial (RCT). The median selection bias score was 5 (IQR, 4-6). Mortality rate was estimated at 18% [95% CI, 13-24%], I² 58%. Among survivors, 64% achieved a favorable functional outcome [95% CI, 51-77%], I² 82%. Study design and heterogeneity in patients' characteristics limited a meaningful comparison of mortality and functional outcome according to neurosurgical techniques.

Conclusion: High-quality evidence on neurosurgical treatment for large cerebellar infarctions remains limited. Our systematic review and meta-analysis, despite moderate risk of bias, suggest that neurosurgery may reduce mortality and improve functional outcomes. These findings support its potential benefit, but RCTs are needed to confirm effectiveness and evaluate best surgical technique.

Background: The clinical utility of implantable cardiac monitors (ICMs) for atrial fibrillation (AF) detection following cryptogenic stroke or embolic stroke of undetermined source (ESUS) is well established. However, the optimal timing for ICM implantation to maximize diagnostic yield remains uncertain.

Aims: To systematically review the literature and conduct a meta-analysis to determine whether earlier ICM implantation after cryptogenic stroke or ESUS ischemic stroke improves detection rates and reduces the time to AF diagnosis.

Summary of review: A comprehensive search of PubMed, Embase, and Cochrane CENTRAL was conducted from inception to June 2025, without language restrictions. References of retrieved articles and relevant reviews were manually searched. We included observational studies or randomized trials reporting ICM use in patients with ESUS or cryptogenic stroke/transient ischemic attack (TIA), providing data on AF detection rates and/or timing metrics (stroke-to-ICM interval, ICM-to-AF interval). Two reviewers independently screened studies and extracted data. Disagreements were resolved by consensus or third-party adjudication. Data were extracted following Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Study-level AF detection rates were modeled using logit-transformed proportions and pooled using random-effects models (REML). Mixed-effects meta-regressions assessed the effect of timing (stroke-to-ICM interval) on AF detection and diagnostic delay, adjusting for ICM monitoring duration. The primary outcomes were pooled AF detection rate and mean time from ICM implantation to AF diagnosis. Timing of implantation was assessed as a continuous and categorical (early, intermediate, delayed) variable. Forty-seven studies (N = 6918 patients) were included. The pooled AF detection rate was 27.3% (95% CI: 24.6-30.2), with substantial heterogeneity (I² = 80.8%). Early ICM implantation (<31.5 days from index event) was associated with a higher AF detection rate compared with delayed implantation (30.0% vs 23.7%; p = 0.0017), independent of monitoring duration. Stratified meta-regression confirmed that delayed implantation was associated with lower AF detection even after adjusting for ICM duration. For each additional day of delay in ICM implantation, the time from AF diagnosis increased by an additional 0.32 days on average, even after accounting for monitoring duration (p = 0.0007).

Conclusion: These findings suggest that earlier ICM implantation enhances AF detection after ESUS or cryptogenic stroke and shortens diagnostic delay. Optimizing timing of post-stroke monitoring may improve patient selection for anticoagulation and reduce recurrent stroke risk.CRD 420251064227.

Background: Decreased cardiorespiratory fitness (CRF) is prevalent in stroke patients, and aerobic training can improve CRF in this population. Protein supplementation has been proposed as a strategy to enhance exercise adaptations by promoting muscle protein synthesis, reducing muscle loss, and improving physical function. However, the potential of protein supplementation to further improve CRF during aerobic training among stroke patients remains unclear. This study aims to evaluate the effect of protein supplementation on CRF and physical performance in patients with chronic stroke undergoing aerobic training.

Methods: This multicenter, participant- and assessor-blinded, randomized clinical trial enrolled 114 ambulatory adults with chronic stroke at four teaching hospitals. Participants were randomized to receive protein supplementation (n = 58) or an isocaloric carbohydrate placebo (n = 56) during 30 supervised aerobic training sessions over 10 weeks. The primary outcome was the change in peak oxygen consumption (V̇O₂peak, mL/kg/min) at 11 weeks. Secondary outcomes included CRF-related measures, body composition (total lean and fat mass), and physical performance (Short Physical Performance Battery (SPPB), Physical Performance Test, Berg Balance Scale, and Timed Up-and-Go test).

Results: Participants had a mean age of 57.2 years, 30% were women, and 87% completed the primary outcome assessment. At the 11-week follow-up, V̇O₂peak increased by 1.7 mL/kg/min (95% CI: 1.0-2.4) in the protein group and 1.6 mL/kg/min (95% CI: 0.9-2.3) in the placebo group, with no between-group difference (mean difference, 0.1 mL/kg/min; 95% CI: -0.8 to 1.1; p = 0.43). Both groups showed improvements in most CRF-related and physical performance measures. At 20 weeks, the protein group demonstrated greater SPPB improvement (mean difference, 0.7 points; 95% CI: 0.1-1.3; p = 0.03) and lower fat mass at 11 weeks (mean difference, -0.6 kg; 95% CI: -1.2 to -0.06; p = 0.04).

Conclusions: Protein supplementation during aerobic training did not significantly enhance CRF compared with an isocaloric placebo. These findings warrant further investigation in populations with a broader range of baseline protein intake.