Journal of Stroke最新文献

Background and purpose: Disparities in stroke care exist globally. While reperfusion therapy is a standard treatment for acute ischemic stroke, variations in its implementation may exist across hospitals.

Methods: We analyzed data from 75,870 patients admitted to 247 acute stroke care hospitals across South Korea, sourced from the Acute Stroke Quality Assessment Program (2013-2018) by the Health Insurance Review and Assessment Service. The primary metric of interest was the hospital reperfusion therapy rate (RTR)-the proportion of patients who received intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT) among those potentially eligible for these therapies and had onset-to-arrival times ≤6 hours and initial National Institutes of Health Stroke Scale scores ≥4. We analyzed correlations between hospital RTRs, adjusted for age, sex, onset-to-arrival time, initial stroke severity, and hospital characteristics.

Results: Of the 10,513 patients eligible for reperfusion therapy, the overall RTR was 52.9%. The average hospital RTR was 34.8% with a median (interquartile range) of 37.5% (9.8-56.2). Hospitals with a greater number of beds and higher monthly stroke volume exhibited higher hospital RTRs. Factors such as monthly stroke volume, stroke unit availability, and monthly IVT and EVT case volume independently influenced hospital RTRs. Notably, hospitals with higher RTRs demonstrated reduced 1-year mortality, irrespective of stroke volume.

Conclusion: In a large national sample of acute stroke care hospitals, there was significant variability in hospital RTRs, with those having higher stroke volumes typically showing higher hospital RTRs. Additionally, an inverse correlation between hospital RTRs and 1-year mortality highlights the clinical importance of improving RTRs.

Numerous randomized controlled trials have demonstrated that glucagon-like peptide-1 receptor agonists (GLP-1RAs) can reduce the risk of stroke across various populations, likely because of their effectiveness in lowering the incidence of ischemic stroke events. This review aimed to consolidate recent advancements in clinical research on the role of GLP-1RAs in preventing ischemic stroke and examine the mechanisms involved. GLP-1RAs have been shown to significantly improve several risk factors associated with ischemic stroke, such as elevated body mass index, hyperglycemia, and renal dysfunction, while potentially mitigating hypertension and dyslipidemia. Additionally, GLP-1RAs play a role in modulating the initiation of inflammation, endothelial dysfunction, and vascular inflammation in atherosclerosis, which may contribute to their protective effects against ischemic stroke. Nevertheless, further investigations are required to substantiate the efficacy of GLP-1RAs in ischemic stroke prevention and comprehensively elucidate the underlying mechanisms.

Background and purpose: Atrial cardiopathy (AC) has been studied for its significance in embolic stroke of undetermined source (ESUS). This real-world study examines the relevance of AC in ESUS and its impact on stroke severity, recurrence, and major adverse cardiovascular events (MACEs).

Methods: We analyzed patients from stroke registries of South Korean centers (2014-2019) aged ≥20 years with acute ESUS or cardiogenic stroke without a definite embolic source. AC was defined by left atrial (LA) enlargement (diameter >40 mm in men and >38 mm in women; or LA volume index >34 mL/m2) or elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP, ≥250 pg/mL) levels. Patients were classified based on AC presence and stratified by the number of factors (AC groups 0, 1, and 2). Survival analysis in original and propensity score (PS)-matched cohorts assessed the impact of AC on stroke severity and vascular outcomes.

Results: Among 5,787 patients (65.9±13.9 years; female: 39.8%), 45.0% met the AC criteria (group 1: 40.3%, group 2: 4.7%). In the original cohort, AC group 2 was associated with increased stroke recurrence (hazard ratio [HR]: 1.76, 95% confidence interval [CI]: 1.06-2.92, P=0.03). After PS-matching, stroke recurrence remained significantly increased for AC (HR: 1.37, 95% CI: 1.04-1.79, P=0.02) and group 2 (HR: 1.94, 95% CI: 1.16-3.26, P=0.01). MACE outcomes increased in the group 2 patients (HR: 1.70, 95% CI: 1.07-2.70, P=0.02). NT-proBNP (HR: 0.97, 95% CI: 0.84-1.12, P=0.69) or LA enlargement (HR: 1.15, 95% CI: 0.89-1.49, P=0.28) alone were not predictive. AC correlated with longer hospital stays, and AC stratification with higher severity.

Conclusion: Especially with multiple factors, AC was associated with adverse clinical outcome in patients with ESUS. These findings underscore the importance of AC stratification in the management of ESUS patients.

Acute ischemic stroke patients with mild deficits (National Institutes of Health Stroke Scale [NIHSS] of 0-5) but confirmed large vessel occlusions (LVO) present a clinical challenge for endovascular thrombectomy (EVT) decisions due to limited evidence and the absence of clear guidelines. A Delphi consensus was conducted at the 2024 5T (Teamwork, Training, Technology, Technique, Transport) Think Tank conference with 40 international stroke experts. Following a systematic literature review, three iterative Delphi rounds were employed to explore EVT decision-making in strokes due to LVO with low NIHSS. Data were collected through surveys and in-person discussions, focusing on disability evaluation, imaging markers, procedural risk, and outcome scales. Consensus was achieved on key factors influencing EVT decisions. Experts emphasized the importance of symptom-specific disability (e.g., aphasia, vision loss) over NIHSS scores alone. Early neurological deterioration (END) was perceived as main concern in this patient population. Imaging markers such as proximal occlusion, poor collaterals, and large penumbra were expected to be predictors of END. The anticipated technical difficulty and patient-specific factors, such as independence and quality of life, also guided decisions. The Potential of rtPA for Ischemic Strokes With Mild Symptoms (PRISMS) trial definition of disabling deficits and the 9-level modified Rankin Scale were favored as outcome measures for future studies. EVT decisions for acute ischemic strokes with mild deficit but proven LVO require nuanced, individualized approaches beyond NIHSS thresholds. Disability assessment, imaging-based risk evaluation, and patient-centered discussions are critical for optimizing outcomes, emphasizing the need for further research and standardized guidelines.

Background and purpose: This study aims to investigate the effects of previous antiplatelet therapy on the efficacy and safety of ticagrelor-aspirin versus clopidogrel-aspirin among patients with and without intracranial artery stenosis (ICAS) using data from the Ticagrelor or Clopidogrel with Aspirin in High-Risk Patients with Acute Nondisabling Cerebrovascular Events-II (CHANCE-2) trial.

Methods: In this post-hoc analysis of the CHANCE-2 trial, patients who underwent intracranial artery imaging were included. The primary efficacy and safety outcomes were recurrent stroke and severe or moderate bleeding within 90 days.

Results: Among the 5,920 patients included, the median age was 64.8 years (interquartile range, 57.0-71.4), 2,004 (33.9%) were females, 2,385 (40.3%) had ICAS, and 701 (11.8%) had previous antiplatelet therapy before enrollment. There were significant interaction effects between previous antiplatelet therapy and dual-antiplatelet therapy regimens on the risk of recurrent stroke (P=0.003) in patients without ICAS but not in those with ICAS (P=0.557). Only in patients without ICAS without previous antiplatelet therapy, ticagrelor-aspirin therapy reduced the risk of stroke recurrence compared with clopidogrel-aspirin therapy (adjusted hazard ratio 0.47, 95% confidence interval 0.34-0.66, P<0.001). Similar effects were observed for the outcomes of composite vascular events and ischemic stroke at 3 months and 1 year. No significant differences in severe or moderate bleeding were observed between the groups.

Conclusion: In patients with minor stroke or high-risk transient ischemic attack carrying CYP2C19 loss-of-function alleles, those without ICAS and no history of previous antiplatelet therapy may have a better response to ticagrelor-aspirin therapy for reducing new stroke and composite vascular events.

Ischemic brain injury (IBI), including stroke and cardiac arrest-induced global cerebral injury, presents a significant clinical challenge due to its high morbidity and incidence of neurological deficits. Currently, effective strategies for neurological repair remain limited. Extracellular vesicles (EVs) are a diverse group of cell-derived, lipid-bound nanoparticles that encapsulate RNAs, proteins, lipids, metabolites, growth factors, and cytokines. EVs play an essential role in intercellular communication and are involved in various physiological and pathological processes. Stem cell-derived EVs (SC-EVs) have been studied in the context of IBI, demonstrating regenerative and angiogenic effects that resemble those of their parent stem cells, holding promise for improved cell-free treatment of IBI. This review provides comprehensive insights into the therapeutic application of SC-EVs in IBI, including an SC-EV source comparison with their distinct advantages and limitations, and dissects the multifaceted mechanisms of SC-EVs including immunomodulation, neurogenesis, mitochondrial transfer, and myelin repair. Furthermore, it highlights recent advances in engineering SC-EV cargo and surfaces for enhanced targeting and efficacy in IBI treatment. It also emphasizes strategies to improve the reproducibility of in vivo studies through standardized protocols and bridges the gap between preclinical findings and early clinical trials. Finally, the review critically addresses ethical challenges and equity considerations, providing a roadmap for the responsible translation of SC-EV therapies into clinical practice.