International Journal of Stroke最新文献

Background: Mobile stroke units (MSUs) improve outcomes in acute ischemic stroke (AIS), but their effectiveness is constrained by limited service radii. Integrating a rendezvous strategy with emergency medical services (EMS) may extend the operational reach of MSUs in rural areas.

Aim: We evaluated whether a novel rendezvous approach between MSUs and EMS could enhance thrombolysis efficiency for rural AIS patients in a larger service area.

Methods: We conducted a single-center, pragmatic, non-randomized, operationally allocated comparative study in Suzhou, Anhui, from 1 January to 31 December 2024. When a suspected stroke call originated from a remote location, a nearby conventional ambulance was dispatched. Subsequently, the MSU was dispatched via an EMS call, met the EMS at a predetermined midway point en route to the stroke center, and treated the patient when MSU was available. Inclusion criteria were: age ⩾ 18 years; onset location ⩾ 20 km from the MSU center; and onset-to-call time ⩽ 4 h. Patients with a final diagnosis of cerebral ischemia were analyzed based on transport method (MSU rendezvous vs EMS only). The primary outcome was the thrombolysis rate; secondary outcomes included time metrics, 90-day functional prognosis, and incidence of symptomatic intracranial hemorrhage (sICH). Propensity score matching (PSM) was used to balance baseline characteristics.

Results: A total of 307 patients with AIS were included; the median age was 72 years (IQR, 63-79), and 192 (62.50%) were male. One hundred ninety-three patients were transferred through rendezvous transport, and 114 patients were transferred through EMS-only. The median distance from onset location to hospital in the rendezvous transport group was 39.00 km (24.23 miles) (IQR 30.00-47.00 km), with a maximum of 68.00 km (42.25 miles). Compared with EMS-only transfers, patients transferred through rendezvous transport had a nearly 3-fold increase in thrombolysis rates (68.90% vs 17.50%, p < 0.001), reduced dispatch-to-door time by 12.5 min, door-to-needle time by 46 min, and onset-to-needle time by 60 min (all p < 0.001). In addition, in terms of clinical outcomes, patients in the rendezvous group had lower median 90-day modified Rankin Scale scores (2.0 (1.0-3.0) vs 3.0 (1.5-5.0), p < 0.001). These findings remained consistent after PSM.

Conclusion: Our study demonstrates that the novel MSU-EMS rendezvous approach significantly improves thrombolysis rates and functional outcomes, serving as a viable strategy to expand acute stroke care to remote populations.Data access statement:Data collected for the study may be made available from the corresponding author to others upon reasonable request.

BackgroundMoyamoya disease (MMD) is a rare cerebrovascular disorder for which nationwide epidemiological data on the pediatric population are limited. In Korea, the majority of published epidemiologic data on MMD entailed brief study periods and were published many years ago. Moreover, the majority of prior epidemiological studies on MMD have not examined the clinical outcomes associated with cerebral revascularization.AimsTo provide a comprehensive analysis of the recent epidemiological trends and cerebrovascular outcomes associated with pediatric moyamoya disease in Republic of Korea.MethodsA retrospective cohort study was conducted using the Korean National Health Insurance Database, analyzing 4,323 pediatric patients diagnosed with MMD between 2006 and 2021. Prevalence and incidence were assessed in all 4,323 patients, and cerebrovascular outcomes were analyzed in 3,656 of these patients. Patients were categorized into surgical and non-surgical groups, with surgical techniques including indirect bypass (IB), direct bypass (DB), and combined bypass (CB). To evaluate year-to-year variations, linear regression analyses were performed to identify and quantify temporal trends for all measured outcomes.ResultsThe mean observation period for the subjects was 10.3 years, with 12.1 years for the non-surgical group and 9.7 years for the surgical group. The prevalence of pediatric MMD increased from 9.3 to 24.8 per 100,000 between 2006 and 2021. Concurrently, the incidence rate has remained stable at approximately 2.0 per 100,000 since 2010. The surgical rate among prevalent cases has exhibited a gradual increase and has remained at approximately 88% since 2018. Furthermore, the case event rate for stroke has exhibited a downward trend over time, and a statistically significant reduction in hemorrhagic stroke was observed.ConclusionsIn Korea, the prevalence rate of MMD continues to rise, while the incidence rate remains stable despite a reduction in absolute case numbers, reflecting demographic shifts and improved survival. The mortality rate among pediatric MMD patients remained unchanged; however, the incidence of hemorrhagic stroke was found to have decreased. Further multi-institution-based cohort studies are needed to clarify long-term cerebrovascular outcomes in this population.

Background and aims: There is limited data regarding the association between thrombocytopenia and outcomes of patients with intracerebral hemorrhage (ICH). We investigated whether thrombocytopenia predicts hematoma expansion and hospital mortality in ICH.

Methods: This was a retrospective cohort analysis of consecutive patients with spontaneous ICH admitted to a tertiary hospital from 2010 to 2024. We tested the association between baseline thrombocytopenia (platelet count < 150 × 10⁹/L) at the time of the index ICH and both hematoma expansion (absolute increase > 6 mL or relative increase > 33%) and hospital mortality using multivariable logistic regression. Secondary analyses were undertaken to compare outcomes between patients with moderate-to-severe thrombocytopenia (platelet count < 100 × 10⁹/L) and mild thrombocytopenia (platelet count 100-149 × 10⁹/L) and between patients with thrombocytopenia who received platelet transfusion vs no transfusion.

Results: We included 1002 patients (median (IQR) age, 73 (61-82); 448 females (44.7%) of whom 168 (16.8%) had thrombocytopenia). At baseline, patients with thrombocytopenia had lower Glasgow Coma Scale (GCS) scores (12 (6-15) vs 14 (9-15) P < 0.001), larger median hematoma volumes (21.4 mL (7.8-56.1) vs 15.3 mL (4.9-43.9), P = 0.004), more intraventricular hemorrhage (IVH) (84/168 (50.0%) vs 320 (38.4%), P = 0.005), and higher ICH scores (2 (1-3) vs 1 (0-3), P < 0.001) compared to those without thrombocytopenia. Hematoma expansion was more frequent in patients with thrombocytopenia (62/136 (45.6%) vs 233/738 (31.5%), P = 0.002); however, no association was present in adjusted analysis (adjusted odds ratio (OR) 1.28 (95% CI, 0.82-2.00), P = 0.269). With exclusion of platelet transfusion as a covariate from the adjusted model, thrombocytopenia was associated with hematoma expansion (OR 1.77 (95% CI, 1.20-2.59), P = 0.004). Thrombocytopenia was independently associated with hospital mortality (77/168 (45.8%) vs 199/834 (23.9%); OR 2.09 (95% CI, 1.24-3.53), P = 0.006). Among patients with thrombocytopenia, a platelet count < 100 × 10⁹/L was associated with more hematoma expansion in univariable (26/44 (59.1%) vs 36/92 (39.1%), P = 0.030) but not multivariable analysis (OR 1.66 (95% CI, 0.58-4.80), P = 0.348). Platelet transfusion predicted hematoma expansion in univariable (23/33 (66.7%) vs 40/103 (38.8%), P = 0.006) but not multivariable analysis (OR 2.74 (95% CI, 0.86-8.75), P = 0.090).

Conclusions: Our findings suggest that both thrombocytopenia and platelet transfusions may be risk factors for hematoma expansion in ICH. Further study is needed to clarify the independent contributions of thrombocytopenia and platelet transfusions toward hematoma expansion and clinical outcome.Data access statement:Data available upon reasonable request.

Objective: To determine associations between cerebral microbleeds (CMBs) and intracerebral hemorrhage (ICH) as well as functional recovery after thrombolysis in participants of the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED).

Methods: ENCHANTED recruited acute ischemic stroke (AIS) patients eligible for thrombolytic therapy from 111 clinical centers in 13 countries. We included those with T2*-weighted or susceptibility-weighted brain magnetic resonance imaging within 6 h after AIS. Associations between CMB (primary predictor), burden (0, 1, 2-4, or ⩾5 CMBs), and location (deep, lobar, mixed) and any ICH (primary outcome), symptomatic intracerebral hemorrhage (sICH), 90-day disability or death (modified Rankin scale (mRS) score 2-6), and other unfavorable functional outcomes (mRS 3-6, 6, and shift) were explored in logistic regression models and in a stratification by alteplase dose.

Results: Of 311 eligible AIS participants, 111 (35.7%) had CMB(s) and this was not associated with an increase in any ICH (adjusted odds ratio = 1.49, 95% confidence interval (CI) = 0.87-2.54) or sICH (2.05, 0.92-4.56). However, the presence of CMB(s) was associated with 90-day disability or death (1.75, 1.04-2.94) and other unfavorable functional outcomes. Comparable associations were seen between CMB burden (defined as ordinally categorical; any ICH 1.16 (0.90-1.50), mRS 2-6 1.44 (1.11-1.87)) or mixed deep-lobar distribution (any ICH 1.42 (0.61-3.29), mRS 2-6 3.66 (1.48-9.05)) and these outcomes. There were no differences in associations between CMB presence/burden/distribution and outcomes between two different alteplase doses (P_interaction > 0.087).

Conclusion: In ENCHANTED, CMB(s) was associated with 90-day unfavorable function recovery but not with a significantly increased likelihood of ICH in post-intravenous thrombolytic AIS. Low-dose alteplase may not offer a better profile for AIS with CMB(s).Data access statement:Individual de-identified participant data used in this analysis will be shared by request from any qualified investigator via the Research Office of The George Institute for Global Health.

This World Stroke Organization Scientific Statement highlights how sex and gender differences shape stroke risk, treatment, care, and research. Estrogen confers a relative protection before menopause, with risk increasing thereafter. Beyond shared cardiovascular determinants (hypertension, atrial fibrillation, and diabetes), women face sex-specific risks-hypertensive disorders of pregnancy, menopause, and hormone therapy, with clear implications for stroke prevention and management. Despite comparable efficacy of acute and secondary stroke therapies in women and men, women are less likely to receive timely acute treatment and often experience delays in recognition and access. The statement recommends gender-responsive prevention and care pathways; systematic consideration of pregnancy-related and menopausal factors; and public and professional education to improve stroke symptom recognition and purposeful inclusion of women across the research continuum. By integrating evidence from epidemiology, acute care, and secondary prevention, this statement provides clear and timely guidance for reducing inequities and shaping future research and policy to achieve equitable stroke care globally.

Background: Research on long-term functional recovery after stroke remains limited. This study aims to investigate the long-term functional recovery among ischemic stroke patients with functional disabilities in China.

Methods: This prospective cohort study used data from the China National Stroke Registry III, which had 15,166 patients consecutively enrolled across 201 hospitals in China between August 2015 and March 2018. We included 4086 patients with disabling ischemic stroke at discharge (the modified Rankin Scale (mRS) score of ⩾2) after excluding 19 patients (0.47%) lost to follow-up by the 5-year endpoint, and our final cohort included 4067 patients. The main outcome was 5-year functional recovery, defined as a ⩾1-point reduction in the mRS score between discharge and 5-year follow-up. Multivariable Cox proportional hazards regression models were used to determine the factors of recovery.

Results: Among 4067 patients, the mean ± SD age was 63.3 ± 11.5 years, and 1416 (34.8%) were female. The functional recovery rate was 86.8% within 5 years (n = 3531/4067). In multivariable analysis, older age (adjusted hazard ratio (aHR) 0.86, (95% CI 0.84-0.89)), current alcohol use (aHR 0.91, (95% CI 0.83-0.99)), history of stroke (aHR 0.88, (95% CI 0.81-0.95)), higher National Institutes of Health Stroke Scale score at discharge (aHR 0.96, (95% CI 0.95-0.97)), and stroke recurrence (aHR 0.88, (95% CI 0.81-0.96)) were independently associated with reduced likelihood of 5-year functional recovery. Patients with small artery occlusion (aHR 1.11, (95% CI 1.01-1.22)), without atrial fibrillation (aHR 1.31, (95% CI 1.09-1.58)), and discharged with anticoagulant medication (aHR 1.35, (95% CI 1.06-1.71)) were independently associated with increased likelihood of 5-year functional recovery.

Conclusion: In this cohort study of patients with disabling ischemic stroke, long-term functional recovery rates were high, and key factors associated with recovery outcomes were identified, which may help guide personalized rehabilitation strategies.

Background and purpose: The pathophysiological mechanisms underlying cognitive changes following recent small subcortical infarcts (RSSIs) remain incompletely understood. In this study, we aimed to investigate alterations in brain fluid dynamics-including interstitial fluid (ISF) and perivascular space (PVS) abnormalities-using magnetic resonance imaging (MRI)-based markers, and examined their associations with cognitive outcomes.

Methods: In this prospective single-center study, patients with RSSIs underwent comprehensive neuropsychological evaluations and multimodal MRI assessments at 3-7 days, 3-6 months, and 1, 2, and 3 years post-stroke. Three MRI-derived proxies of brain fluid dynamics were assessed: free water (FW) fraction, reflecting the ISF fraction; and PVS volume and diffusion tensor imaging analysis along the PVS (DTI-ALPS), both reflecting PVS dynamics. Relative metrics (FW, PVS, and DTI-ALPS) were calculated as (ipsilesional - contralesional)/contralesional values, to quantify hemisphere-specific changes associated with RSSI. Comparative analyses of MRI-derived proxies of brain fluid dynamics were performed between ipsilesional and contralesional hemispheres both cross-sectionally and longitudinally. The associations between these markers and cognitive performance were examined using linear regression and mixed-effects models, with false discovery rate (FDR) corrections for multiple comparisons.

Results: The study included 66 RSSI patients (mean age: 57.15 ± 7.35 years; 80.3% male). Baseline comparisons revealed significantly higher PVS volume (p = 0.004) and lower DTI-ALPS (p = 0.018) in the ipsilesional hemisphere compared with the contralesional side. While FW did not differ significantly between hemispheres (p = 0.858), the perilesional regions showed significantly higher FW compared with the corresponding contralesional regions (p < 0.05). Furthermore, baseline lower relative PVS was associated with attention improvement (β = 0.513, P_FDR = 0.004). Longitudinal analysis revealed bilateral FW increase (p = 0.025) and DTI-ALPS decline (p = 0.016), with no significant interhemispheric differences. However, no significant correlations were observed between relative FW, PVS, and DTI-ALPS slopes and cognitive trajectories (all P_FDR > 0.05).

Conclusion: Our findings demonstrate RSSIs are associated with disrupted MRI-derived proxies of brain fluid dynamics, characterized by increased ISF and PVS dysfunction in the ipsilesional hemisphere. Baseline PVS volume is correlated with cognitive changes in RSSI patients, highlighting the potential of early PVS-targeted interventions to prevent post-stroke cognitive impairment.

Background: Stroke is the second leading cause of death and third leading cause of disability globally. The dose-response relationship between physical activity (PA), particularly moderate-to-vigorous physical activity (MVPA), and stroke risk remains unclear, with limited sex-specific evidence.

Aims: To examine the dose-response associations of total PA and MVPA with stroke risk, considering sex and subtype differences.

Methods: A systematic review and dose-response meta-analysis of prospective cohort studies published between 2013 and 2024, with follow-up durations ranging from 4.9 to 17.9 years, were conducted. PA exposures were standardized to MET-hours per week (MET-h/wk), and incident stroke was the primary outcome. Study-specific hazard ratios (HRs) and 95% confidence intervals (CIs) were pooled using random-effects models. Dose-response associations were assessed using restricted cubic spline models. Analyses stratified by sex and subtype were performed when available.

Results: Fourteen cohorts (n = 2,639,086) were included. Total PA showed a nonlinear inverse association with stroke risk: each 10 MET-h/wk increment reduced risk by 1% up to 130 MET-h/wk, corresponding to a 13% maximum reduction, after which benefits plateaued. MVPA exhibited an L-shaped association (P < 0.001), with the greatest benefit (19% reduction) at 19 MET-h/wk, followed by a gradual increase in risk. Sex-stratified analysis revealed a J-shaped pattern in females (optimal 10-15 MET-h/wk; 18% reduction). For males, the HR was 0.89 (95% CI: 0.70-1.13), and a nonlinear model could not be established due to limited data. In ischemic stroke, dose-response patterns paralleled those for total stroke.

Conclusions: The study found a significant dose-response relationship between total PA and MVPA with stroke risk. Optimal prevention was observed at 130 MET-h/wk for total PA and 19 MET-h/wk for MVPA. Evidence in males and for hemorrhagic stroke remains limited and warrants further study.

Background: In younger patients (<60 years) with cryptogenic stroke (CS) presumed to be patent foramen ovale (PFO)-related, the standard approach involves transcatheter PFO closure combined with antithrombotic therapy. However, due to their exclusion from randomized clinical trials (RCTs), no formal recommendations exist for patients ⩾60 years. This study had two objectives (1) to compare the efficacy and safety of PFO closure versus antithrombotic therapy alone (ATA) exclusively in older patients (⩾60 years) and (2) to assess the outcomes of PFO closure in patients ⩾ 60 years versus < 60 years.

Methods: We searched PubMed, Embase, Web of Science, and ScienceDirect databases to obtain articles in all languages from January 2004 until July 2025. The primary outcome was risk of recurrent stroke during follow-up. Secondary outcomes were risk of new-onset atrial fibrillation (AF), all-cause mortality, and in-hospital complications. PROSPERO registration ID: CRD420250652870.

Results: Only one RCT (post hoc evaluation of the DEFENSE-PFO trial) and 11 observational studies were included. In patients aged ⩾ 60 years, risk of recurrent stroke was lower when PFO was closed compared with ATA (5.48% vs 10.05%, respectively, hazard ratio (HR) = 0.56, 95% confidence interval (CI) = 0.45-0.80, p < 0.001, I² = 45.6%). All-cause mortality was also lower for PFO closure versus ATA (1.73% vs 7.59%, respectively, HR = 0.41; 95% CI = 0.19-0.90, p = 0.02; I² = 43.8%). There was no difference between PFO closure and ATA in risk of new-onset AF (HR = 1.13, 95% CI = 0.53-2.44, p = 0.74). Compared with patients < 60 years, individuals ⩾ 60 years who underwent PFO closure had a higher risk of recurrent stroke (2.94% vs 1.04%, respectively, HR = 3.47; 95% CI = 1.61-7.48; p = 0.001), new-onset AF (4.86% vs 1.01%, respectively, HR = 4.12; 95% CI = 1.90-8.95; p < 0.001), and all-cause mortality during follow-up (8.32% vs 0.39%, respectively, HR = 8.24; 95% CI = 3.49-19.46; p < 0.0001). In-hospital complications after PFO closure were comparable between two age groups. Due to insufficient data, we were not able to perform a subgroup analysis based on anatomic features of PFO, antithrombotic regimen, or occluder devices.

Conclusion: Based on available data, which is predominantly derived from observational studies, PFO closure is associated with a reduced risk of recurrent stroke compared to ATA in patients over 60 years. However, these findings are subjected to limitations, including the potential for selection bias, unmeasured confounding, and insufficient long-term follow-up. Furthermore, long-term randomized trials are essential to definitively confirm efficacy and establish clinical guidelines for PFO closure in this older population.

Background: Both patients with migraine with aura (MA) and patients with ischemic stroke have an increased risk of white matter hyperintensities (WMH) indicating structural microvascular brain damage. It is unclear whether other signs of microvascular damage are also more abundant in these patients, and whether patients with both conditions are more severely affected.

Methods: We included middle-aged women with a history of MA, ischemic stroke, or both, as well as age-matched female control participants without any neurological disease, from two cross-sectional MRI studies (CREW and WHISPER). We assessed WMH, enlarged perivascular spaces, cerebral microbleeds, lacunes, cortical superficial siderosis, parenchymal volume, and cortical atrophy, according to STRIVE criteria. A total small vessel disease (SVD) burden score was determined. We performed regression analyses to assess the association between a history of MA, stroke, or both and the different MRI markers, adjusted for vascular risk factors.

Results: We included 207 women (mean age: 51 years): 39 with MA, 67 with stroke, 62 with both MA and stroke, and 39 controls. MA was not associated with increased microvascular damage compared with controls. Stroke patients had more cerebellar WMH (OR = 7.9, 95% CI = 0.9-73.6), more cortical atrophy (β = 0.2, 95% CI = 0.0-0.4), and a lower parenchymal volume (β = -16.1, 95% CI = -30.7 to -1.4) than controls. There was no difference in the frequency of any of the SVD markers on 3 Tesla (3T)-MRI in patients with stroke with or without migraine.

Conclusion: In our study, markers of microvascular cerebral damage were infrequent in middle-aged women with MA and healthy controls, while stroke was associated with more cerebellar WMH, decreased parenchymal volume, and cortical atrophy. We found no (supra-)additive effect of a history of migraine on the extent of microvascular brain damage in women with stroke.