Stroke最新文献

Background: This study compared the effects of contralaterally controlled functional electrical stimulation (CCFES) to cyclic neuromuscular electrical stimulation (cNMES) and task-oriented training (TOT) without electrical stimulation (TOT) on the recovery of hand function in stroke survivors with chronic hand hemiparesis.

Methods: In this assessor-blinded randomized controlled trial conducted at 4 sites in the United States, individuals 6 to 24 months poststroke with moderate-to-severe hand weakness were randomly assigned 1:1:1 to CCFES, cNMES, or TOT and prescribed 10 sessions/week of treatment-specific exercise at home plus 22 sessions of treatment-specific functional task practice in the laboratory over 12 weeks. The primary outcome was the change in the box and blocks test score at 6 months after treatment. Secondary measures included the upper extremity Fugl-Meyer, the action research arm test, and responder rates. Mixed effects analyses and differences of least square means were used to evaluate treatment effects.

Results: Between February 15, 2019, and January 24, 2024, 132 patients were randomized; 113 completed the treatment phase (36 CCFES, 39 cNMES, and 38 TOT) and were included in the analysis (modified intention-to-treat). There were no significant between-group differences in the change in the box and blocks test score at 6 months after treatment. CCFES improved upper extremity Fugl-Meyer scores more than cNMES and TOT, CCFES versus cNMES difference of 4.4 (95% CI, 1.5-7.3; P=0.003), and CCFES versus TOT difference of 3.7 (95% CI, 0.8-6.5; P=0.012). CCFES improved action research arm test scores more than TOT, CCFES versus TOT difference of 4.1 (95% CI, 1.1-7.1; P=0.008). The responder rate based on an increase in upper extremity Fugl-Meyer ≥5.25 points at 6 months after treatment was greater for CCFES than cNMES (67% versus 42%; P=0.047) and TOT (67% versus 38%; P=0.020). There were no between-group differences in responder rates based on the box and blocks test (27% CCFES, 32% cNMES, and 21% TOT) or action research arm test (42% CCFES, 32% cNMES, and 26% TOT). There were no serious treatment-related adverse events.

Conclusions: By 6 months after 12 weeks of treatment, CCFES did not improve dexterity more than cNMES or TOT. CCFES reduced upper extremity impairment more than cNMES and TOT and improved upper limb function more than TOT.

Registration: URL: https://www.clinicaltrials.gov; Unique Identifier: NCT03574623.

Background: We tested the Stroke Preparedness in the Emergency Department Intervention, an emergency department-based intervention that teaches stroke symptoms and the importance of calling 911, in a racially diverse community.

Methods: This was a National Institutes of Health-funded, single-center, participant-blinded parallel-group trial of adult emergency department patients randomized 1:1 to a brief pamphlet and video stroke preparedness intervention versus a general cardiovascular health control condition (Life's Simple 7; from February 2022 to August 2023). The primary outcome was intent to call 911 in response to 4 video vignettes (Video STAT instrument) depicting an actor having an acute stroke (stroke action score, range 0-8) at 1 month (delayed posttest). Secondary outcomes were recognition of the 4 videos depicting an acute stroke (stroke recognition score; range, 0-4) and the stroke action score immediately after treatment. Linear mixed models evaluated the association between intervention groups and each outcome, with adjustment for baseline characteristics, in a prespecified per-protocol analysis.

Results: Of the 353 participants randomized, 330 participants were included (159 in the intervention group, 171 in the control group, 61% female, 49% Black adults). The intervention group had a higher intent to call 911 than the control group on the immediate posttest (adjusted mean stroke action score difference, 1.14 points higher [95% CI, 0.78-1.50]; P<0.001) and on the delayed posttest (1.12 points higher [95% CI, 0.64-1.59]; P<0.001). The intervention group had higher stroke recognition than the control group on the immediate posttest (adjusted mean stroke recognition score difference, 0.40 points higher [95% CI, 0.23-0.56]; P<0.001) and on the delayed posttest (0.51 points higher [95% CI, 0.30-0.72]; P<0.001). Treatment effects did not differ by sex or race (P>0.05).

Conclusions: Among an adult emergency department population, a brief intervention increased intent to call 911 for stroke and increased recognition of stroke symptoms.

Background: Clinical decision support systems hold promise for improving adherence to guidelines and reducing decision-making time in acute ischemic stroke management. We developed a stroke-specific clinical decision support system smartphone app termed cerebri and assessed its efficacy in reducing imaging-to-decision time and enhancing guideline adherence in a real-world clinical setting.

Methods: We conducted a prospective, single-center, calendar-day-randomized pilot study at the Emergency Department of Campus Bio-Medico University Hospital in Rome, Italy, from December 1, 2024, to March 30, 2025 (80 effective study days). Eligible participants were adult patients (≥18 years) with suspected ischemic stroke presenting within 24 hours of symptom onset. Randomization occurred by day, assigning patients to either the cerebri group (app providing clinical decision support plus a timer function) or the control group (timer function only, without decision support). The app was used by the neurologist on-call that workday. Primary outcomes were imaging-to-decision time (imaging to decision time: the time from imaging completion to therapeutic decision, in minutes) and adherence to European Stroke Organization guidelines. Guideline adherence was expressed as the percentage of cases compliant, and assessed separately for diagnostic decisions (appropriate imaging modality), therapeutic decisions (appropriate treatment choice), and overall adherence (compliance with both diagnostic and therapeutic domains). Multivariable linear and logistic regression analyses adjusted for age, National Institutes of Health Stroke Scale, and revascularization therapies were performed.

Results: Fifty patients (mean age, 73.1±13.3 years; 64% female) were enrolled (25 cerebri, 25 control). Patients in the cerebri group had significantly reduced median imaging to decision time (6 versus 22 minutes; adjusted difference: -18.8 minutes [95% CI, -37.4 to -3.5]; P=0.009). Overall guideline adherence was significantly higher in the cerebri group (96% versus 73.9%; adjusted odds ratio, 11.6 [95% CI, 1.12-121.16]; P=0.040). Therapeutic guideline adherence was 100% in the cerebri group versus 86.9% in the control (P=0.062).

Conclusions: Cerebri significantly improved decision-making speed and adherence to stroke guidelines in the hyperacute management of ischemic stroke. The app demonstrated feasibility and efficacy even in nontertiary stroke centers, suggesting its potential for broader implementation to enhance stroke care quality and equity.

Background: The influence of socioeconomic deprivation on outcomes in ischemic stroke patients treated with thrombectomy remains unclear.

Methods: We analyzed 6219 patients with ischemic stroke treated with thrombectomy between 2016 and 2023 in Catalonia, Spain. Socioeconomic deprivation was defined at the health care service area level (n=378) as the proportion of inhabitants with an annual income below $21 000. The adjusted absolute difference in the proportion of patients achieving good functional outcome (90-day modified Rankin Scale score of 0-2) between the least and most deprived areas (fifth versus 95th percentile) was estimated based on mixed effects modeling. Secondary outcomes included mortality at 90 days, 24-hour National Institutes of Health Stroke Scale score, complete reperfusion, and onset to arterial puncture time. Analyses were stratified by reference center location-Barcelona metropolitan region (fully covered by thrombectomy-capable centers) and Catalonia provincial region (dispersed population with varying center capabilities, including 3 thrombectomy-capable centers). The contribution of deprivation to between-center variance was estimated using a between-within effects model.

Results: Patients from most deprived areas were less likely to achieve functional independence in metropolitan (adjusted absolute difference, 7.4% [95% CI, 2.1%-12.7%]; P<0.01) than provincial (adjusted absolute difference, 10% [95% CI, 2.8%-17.2%]; P<0.01) regions. Mortality rate, complete reperfusion, and 24-hour National Institutes of Health Stroke Scale score did not differ between areas, whereas time from onset to thrombectomy was delayed in most deprived areas of the provincial region (least deprived 226 minutes [95% CI, 196-256] versus most deprived 272 minutes [95% CI, 247-298], difference 46 minutes [95% CI, 3-90]; P=0.02). Average center-level socioeconomic deprivation explained a substantial proportion of between-center variability in good functional outcomes, particularly in the metropolitan region.

Conclusions: Socioeconomic deprivation is a major determinant of poor functional outcomes in patients with stroke undergoing endovascular thrombectomy in Catalonia, Spain, explaining a substantial proportion of between-center differences in outcomes. This disparity may be partially attributed to delays in acute treatment; however, postacute care factors should be evaluated as key contributors.

Background: Primary aldosteronism, the most common endocrine cause of hypertension, is associated with an increased risk of stroke compared with essential hypertension. Targeted treatment with mineralocorticoid receptor antagonists, or surgical resection of an aldosterone-producing adrenal adenoma, can effectively reduce blood pressure and mitigate cardiovascular risk. However, despite being a highly modifiable cardiovascular risk factor, primary aldosteronism is grossly underdiagnosed, even in high-risk populations.

Methods: We conducted a multicenter retrospective cohort study to assess the frequency of primary aldosteronism testing among patients admitted between January 2019 to January 2020 with stroke or transient ischemic attack. Data, including blood pressure, antihypertensive medication use, serum potassium, and adrenal imaging, were collected from the medical records of patients admitted for stroke or transient ischemic attack at 2 large tertiary hospitals in Victoria, Australia.

Results: Among 400 patients (mean age, 73.9±13.4 years; 42.1% female), 30% (n=120) had a clinical indication for primary aldosteronism testing, yet only 2% (n=8) were tested.

Conclusions: These findings highlight a missed opportunity to identify a treatable cause of hypertension in patients at high risk of recurrent cerebrovascular events. Routine testing for primary aldosteronism in stroke care pathways may improve long-term outcomes through targeted intervention.

Background: Preeclampsia, a serious hypertensive disorder of pregnancy, is associated with increased long-term risk of cardiovascular disease in adult offspring, particularly stroke. Although low-dose aspirin (LDA) is used prophylactically to prevent preeclampsia, its impact on offspring is unclear. This study investigated the effect of maternal LDA treatment during experimental preeclampsia (ePE) on adult first-generation (F1) offspring, including stroke outcome.

Methods: ePE was induced in pregnant Sprague-Dawley rats via a high-cholesterol diet starting on gestational day 7 and treated with LDA (1.5 mg/kg) or vehicle. Offspring were weaned and fed standard chow until transient middle cerebral artery occlusion at 12 to 18 weeks (3-hour ischemia and 1-hour reperfusion). Fetal and juvenile weights were taken at gestational day 20 and from weeks 10 to 13. Infarct and edema were quantified using 2,3,5-triphenyltetrazolium chloride staining. Multisite laser Doppler was used to measure cerebral hemodynamics, including cerebral blood flow autoregulation and collateral flow. Circulating proinflammatory and anti-inflammatory factors were measured via multiplex immunoassay.

Results: Male offspring from ePE dams (ePE-F1) had larger infarction and edema versus male offspring from normal pregnant dams (NormP-F1, 48%±6 versus 11%±4; P<0.01) and all female offspring. Maternal treatment with LDA was protective of male offspring (ePE+Asp-F1) that had reduced infarct and edema. Increased infarction in ePE-F1 males was associated with greater collateral perfusion deficit and elevated levels of TNF-α (tumor necrosis factor-alpha) and IL (interleukin)-1β that were prevented by maternal LDA treatment. There were no differences in infarct, edema, or perfusion deficit in female offspring.

Conclusions: Prenatal exposure to ePE worsened stroke severity and inflammation in male but not female offspring, which was largely mitigated by maternal LDA treatment, potentially due to an improved intrauterine environment. These findings highlight a sex-specific impact of prenatal preeclampsia exposure on long-term cerebrovascular health and suggest that maternal LDA may confer long-lasting protection to the offspring in addition to the mother.

Background: Pregnancy-associated stroke may present with nonfocal symptoms, leading to missed diagnostic opportunities (MDO).

Methods: We conducted a retrospective study including patients aged 18 to 50 years and pregnant or within 1 year of delivery, treated at 5 US comprehensive stroke centers from 2012 to 2021 for confirmed arterial ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, or cerebral venous thrombosis. Vascular neurologists at each site reviewed cases using a validated tool, Safer Stroke-Dx. We determined the proportion of cases with MDO and estimated 95% CIs based on a binomial distribution.

Results: We identified 135 patients with pregnancy-related stroke (mean age, 32.4 [SD, 6.0] years), of whom 37 (27%) had MDO (95% CI, 20.6%-35.5%). Presenting symptoms included focal neurological deficits (57%; n=77), headache (53%; n=71), systemic symptoms (26%; n=35), and altered mental status (19%; n=25). More patients with MDO had hemorrhagic strokes (22 of 37 [59%] versus 34 of 79 [43%] patients with no MDO, and 10 of 19 [53%] with insufficient information to determine [P=0.05]). Among patients with MDO, 34 of 37 (92%) had ≥1 documented medical encounter in the month preceding stroke diagnosis compared with 47 of 79 (59%) individuals without MDO and 9 of 19 (47%) with insufficient information to determine (P<0.001). Of the 86 patients with prestroke encounters, most were evaluated by obstetricians (49%; n=42) or emergency medicine clinicians (29%; n=25). Among patients with MDO, contributing factors included failure to recognize symptoms (84%; n=31) and omission of appropriate neuroimaging studies (81%; n=30), despite that the clinical presentation was judged typical of the final stroke diagnosis in 35 of the 37 (95%) patients.

Conclusions: In this retrospective cohort, >1 in 4 pregnant or postpartum patients with acute stroke experienced MDO. Our results suggest a need for enhanced clinician education, particularly for nonneurologists, in diagnosing stroke during pregnancy and the postpartum period.

Background: Maternal ischemic stroke (IS) might affect the course of subsequent pregnancies. We aimed to study stroke recurrence, other complications, and the implementation of secondary prevention in subsequent pregnancies of women with a prior maternal IS.

Methods: Women diagnosed with IS during pregnancy or puerperium in Finland during the years 1987 to 2016, and the data of subsequent pregnancies were collected from the Medical Birth Register and Hospital Discharge Register. Diagnoses were verified from medical records. Three matched controls without a maternal stroke were identified for each case.

Results: Data on subsequent pregnancies were available for 90 patients with maternal IS after excluding patients who died within 1 year. Patients with maternal IS less frequently had at least 1 subsequent pregnancy (38.9% versus 51.7%; age-adjusted odds ratio, 0.55 [95% CI, 0.32-0.93]), and more frequently, multiple induced abortions (adjusted odds ratio, 6.24 [95% CI, 1.12-34.88]) than controls. Three women had a recurrent maternal IS or transient ischemic attack (8.6%). Patients with maternal IS more commonly had diabetes during pregnancy (29.1% versus 13.6%; adjusted odds ratio, 2.77 [95% CI, 1.17-6.59]) and hypertensive disorders of pregnancy than controls (12.7% versus 4.5%; adjusted odds ratio, 3.57 [95% CI, 1.02-12.51]). In the first subsequent pregnancy, perinatal deaths were more common in patients with maternal IS compared with controls (5.9% versus 0%; P=0.042). Most women used antithrombotic medication (87.9%) in the first subsequent pregnancy, but this declined in later pregnancies. The use of other secondary preventive medications was uncommon both before and during pregnancy.

Conclusions: Although most pregnancies proceed without complications, the subsequent pregnancies of women with a prior maternal IS are high-risk pregnancies that require careful planning and surveillance. They are frequently complicated with diabetes and hypertensive disorders of pregnancy, and the recurrence of IS or transient ischemic attack is notable.

Background: Subarachnoid hemorrhage (SAH) following aneurysmal rupture remains a devastating cerebrovascular event with limited predictive biomarkers. Accurate prediction of aneurysm rupture risk remains a clinical priority, as it could improve risk prediction and reveal potential therapeutic targets. Leveraging UK Biobank proteomic data, we aimed to identify protein markers associated with SAH risk using observational and genetic analyses.

Methods: We analyzed data from 52 916 participants enrolled in the UK Biobank. The analysis involved 3 steps: (1) Longitudinal cox proportional hazards analyses between normalized circulating levels of 2923 proteins and incident nontraumatic SAH (aneurysmal or nonaneurysmal) adjusting for age, sex, ancestry, smoking status, hypertension, hyperlipidemia, and diabetes; (2) Proteins identified in step 1 (false discovery rate-adjusted P<0.05) underwent Mendelian randomization using cis-protein quantitative trait loci; (3) cellular expression profile of significant proteins were examined using single-cell transcriptomic from immunophenotypic atlas of human hematopoietic progenitors.

Results: We identified 123 incident SAH cases; the mean follow-up was 7.06 years (SD, 3.53), the mean age was 59.28 (SD, 7.13), and 62% were females. SLAMF1 (signaling lymphocytic activation molecule family member 1) and NINJ1 (Ninjurin 1) were significantly associated (SLAMF1: HR per SD increase, 2.18 [95% CI, 1.49-3.18]; adjusted P<0.001; for NINJ1: HR, 1.85 [95% CI, 1.43-2.40]; adjusted P=0.004). Mendelian randomization confirmed the association for SLAMF1 (Inverse Variance Weighted approach OR, 1.73 [95% CI, 1.26-2.38]), with directionality supported through reverse Mendelian randomization (P>0.05). Single-cell transcriptomic analysis demonstrated high SLAMF1 expression in CD4-CTM, CD4-activated, and CD4-naive cells, indicating a possible immunologic role in SAH pathophysiology.

Conclusions: Our combined analytical approach identified SLAMF1 as a protein associated with increased SAH risk. SLAMF1, a receptor involved in modulating innate and adaptive immune responses, has been implicated in inflammatory and autoimmune diseases. SLAMF1 and related proteins represent promising biomarkers for SAH risk, potentially enhancing risk stratification, guiding preventive strategies, and informing future therapeutic development. Further research is necessary to explore its mechanistic role in SAH development.