European Stroke Journal最新文献

Introduction: To investigate the clinical characteristics in patients without traditional risk factors (TRFs) after transient ischemic attack or minor ischemic stroke, who were recruited in the TIAregistry.org.

Patients and methods: A total of 3847 patients were analyzed. TRFs included hypertension, diabetes, hypercholesterolemia, current smoking, and atrial fibrillation. Background characteristics and outcomes at 1 and 5 years in patients without TRFs were compared to those in patients with TRFs. The primary outcome was major cardiovascular event (MACE), which was non-fatal stroke, non-fatal acute coronary syndrome, or vascular death. To evaluate the causes, we applied the ASCOD (atherosclerosis, small vessel disease, cardiac pathology, other causes or dissection) grading system.

Results: One-year risk of MACE (5.3% vs 6.3%, hazard ratio (HR) 0.84, 95% confidence interval (CI) 0.53-1.31) was comparable between patients without TRFs (n = 402) and those with TRFs (n = 3445). Five-year risk of MACE was significantly lower in patients without TRFs than in those with TRFs (7.9% vs 13.9%, HR 0.57, 95% CI 0.39-0.82). In patients without TRFs, causal atherosclerosis was a potent risk factor (HR 5.67, 95% CI 2.68-12.02) and ipsilateral extra- or intra-cranial arterial stenosis was only significant predictor of MACE (interaction p = 0.0046) at 5 years.

Conclusion and discussion: The 5-year risk of MACE was lower in patients without TRFs than those with TRFs, although a certain level of risk persisted in the absence of TRFs. The most significant predictor of MACE in patients without TRFs was arterial stenosis.

Introduction: Data on safety and efficacy of endovascular thrombectomy (EVT) for acute ischemic stroke in older patients are limited and controversial, and people aged 80 or older were under-represented in randomized trials. Our aim was to assess EVT effect for ischemic stroke patients aged ⩾80 at a nationwide level.

Patients and methods: The cohort included stroke patients undergoing EVT from the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS). Patients were a priori divided into younger and older groups (<80 vs ⩾80). Primary outcome was good functional outcome (modified Rankin scale, mRS, 0-2 at 90 days). Secondary outcomes were symptomatic intracranial hemorrhage (sICH), successful reperfusion, EVT abortion. Propensity score matching (PSM) was performed between age groups for baseline features, functional status, stroke severity and neuroradiological features. Logistic regression was implemented to test the weight of age group on the predefined outcomes.

Results: Overall, 5872 individuals (1:1 matching, n = 2936 aged ⩾80 vs n = 2936 < 80) were matched from 13,922 records. In ⩾80 group 34.1% had good functional outcome, vs 51.2% in <80 group (absolute difference = -17.1%, p < 0.001), with a 4.4% excess in EVT abortion. Age ⩾80 was a negative independent predictor of good functional outcome (aOR = 0.4, 95% CI = 0.3-0.5), but had no impact on sICH.

Discussion and conclusion: Age ⩾80 years represents a consistent predictor of worse functional outcome, independently from successful reperfusion and sICH. Cost-effectiveness studies are needed for tailored and implement sustainable care, and research should focus on strategies to improve functional outcome in older age patient groups.

Introduction: There is an unmet need for improved detection of intracranial aneurysms (IAs) and distinction between stable and unstable (high rupture risk) IAs. Within the IA wall, synthesis and degradation of type I collagen as the main molecular constituent balance each other to maintain IA stability. We hypothesized that collagen breakdown products could serve as molecular markers for IA presence and instability.

Patients and methods: This prospective, cross-sectional, single-center study included patients with unstable (growing/symptomatic/ruptured) and stable IAs and controls. We determined C-telopeptide (CTx) and c-terminal telopeptide (ICTP) as breakdown products of type I collagen in arterial and venous blood.

Results: We included 107 participants with IAs (52 stable/44 unstable) and 41 controls. The correlation between intra-aneurysmal and venous levels was r = 0.63 (p < 0.001) for ICTP, r = 0.55 (p = 0.001) for CTx. The odds of harboring an IA were five times higher for participants with high compared to low venous levels of collagen breakdown products (ICTP: odds ratio (OR) 4.9 (95% CI 1.1-22.7); CTx: OR 5.3 (95% CI 1.4-20.0)). The OR for having an unstable IA was 9.3 (95% CI 2.1-41.5) for patients with high compared to low venous ICTP levels. The area under the curve for ICTP levels as a marker for IA instability was 0.75.

Discussion and conclusion: Increased levels of venous collagen breakdown products, especially ICTP levels, could serve as a biomarker for IA presence and instability and complement current data for management of unruptured IAs on an individual patient level. Future studies with longitudinal data are needed to validate ICTP as a biomarker for high risk IAs.

Introduction: The risk of dementia in patients with stroke-heart syndrome (SHS) remains unexplored.

Patients and methods: Retrospective analysis using the TriNetX network, including patients with ischaemic stroke from 2010 to 2020. These patients were categorised into two groups: those with SHS (heart failure, myocardial infarction, ventricular fibrillation, or Takotsubo cardiomyopathy within 30 days post-stroke) and those without SHS. The primary outcome was the 1-year risk of dementia (vascular dementia, dementia in other disease, unspecified dementia, or Alzheimer's disease). The secondary outcome was the 1-year risk of all-cause death. Cox regression analysis after 1:1 propensity score matching (PSM) was performed to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) for the outcomes.

Results: We included 52,971 patients with SHS (66.6 ± 14.6 years, 42.2% females) and 854,232 patients without SHS (64.7 ± 15.4 years, 48.2% females). Following PSM, 52,970 well-balanced patients were considered in each group. Patients with SHS had a higher risk of incident dementia compared to those without SHS (HR 1.28, 95%CI 1.20-1.36). The risk was the highest during the first 31 days of follow-up (HR 1.51, 95%CI 1.31-1.74) and was mainly driven by vascular and mixed forms. The increased risk of dementia in patients with SHS, was independent of oral anticoagulant use, sex and age but it was the highest in those aged <75 years compared to ⩾75 years.

Discussion and conclusion: SHS is associated with increased risk of dementia. Future studies are needed to develop innovative strategies for preventing complications associated with stroke-heart syndrome and improving the long-term prognosis of these patients.

Introduction: There is a lack of evidence for the optimal type of anesthesia technique in patients ⩾ 90 years with acute ischemic stroke undergoing mechanical thrombectomy (MT) as this subgroup of patients was often excluded or under-represented in previous trials. We aimed to compare outcomes between general anesthesia (GA) and non-GA techniques in patients ⩾ 90 years with large vessel occlusion (LVO) undergoing MT.

Patients and methods: Our study included patients ⩾ 90 years with anterior circulation LVO, NIHSS ⩾ 6, ASPECTS ⩾ 5 consecutively treated with MT within 6 h after stroke onset in three thrombectomy capable centers between January 1st, 2016 and March 30th, 2023. Inverse probability weighting (IPW) was used to reduce bias by indication of the anesthesia type on study outcomes. We used a weighted ordinal robust logistic regression analysis to explore the primary outcome of modified Rankin Scale (mRS) shift at 90 days in GA versus non-GA treated patients. Secondary outcomes included 90-day mortality, symptomatic intracranial hemorrhage (sICH) and TICI score of 2b, 2c, or 3.

Results: We included 139 patients ⩾ 90 years treated with MT, 62 were in GA group and 77 in non-GA group. There was a significant shift for worse mRS scores at 90-day in non-GA treated patients (cOR 3.65, 95% CI 1.77-7.77, p = 0.001). The weighted logistic regression showed that non-GA technique was an independent predictor of 90-day mortality (OR 7.49, 95% CI 2.00-28.09; p = 0.003).

Conclusion: Our study indicated that nonagenarians with acute ischemic stroke treated with MT without GA have a worse prognosis than their counterparts undergoing MT with GA. Further studies in larger cohorts are warranted to evaluate the optimal type of anesthesia in this patient population.

Purpose: Secondhand smoke significantly increases the risk of cerebrovascular diseases, prompting recent public smoking bans. We aimed to ascertain the effects of smoke-free legislation on stroke incidence and mortality.

Methods: We systematically searched Medline, Embase, Cochrane Library, and Scopus up to August 13, 2023, for studies reporting changes in stroke incidence following partial or comprehensive smoking bans. A random-effects meta-analysis was conducted on hospital admissions and mortality for stroke, stratified based on comprehensiveness of the ban ((i) workplaces-only, (ii) workplaces and restaurants, (iii) workplaces, restaurants and bars). The effect of post-ban follow-up duration was assessed visually by a forest plot, while meta-regression was employed to evaluate for any dose-response relationship between ban comprehensiveness and stroke risk.

Findings: Of 3987 records identified, 15 studies analysing bans across a median follow-up time of 24 months (range: 3-67) were included. WRB bans were associated with reductions in the rates of hospital admissions for stroke (nine studies; RR, 0.918; 95% CI, 0.872-0.967) and stroke mortality (three studies; RR, 0.987; 95% CI, 0.952-1.022), although the latter did not reach statistical significance. There was no significant difference in the risk of stroke admissions for studies with increased ban comprehensiveness and no minimum duration for significant post-ban effects to be observed.

Discussion and conclusion: Legislative smoking bans were associated with significant reductions in stroke-related hospital admissions, providing evidence for its utility as a public health intervention.

Introduction: The Modified Rankin Scale (mRS) is the most commonly used functional measure in stroke research but is limited by inter-rater reliability (IRR). Various interventions to improve mRS application have been described. We aimed to compare properties of differing approaches to mRS assessment.

Patients and methods: Multidisciplinary databases (MEDLINE, EMBASE, Health and Psychosocial Instruments [OVID], CINAHL, PsycINFO [EBSCO]) were searched for adult human stroke studies describing psychometric properties of mRS. Two researchers independently screened 20% titles and abstracts, reviewed all full studies, extracted data, and conducted risk of bias (ROB) analysis. Primary outcomes for random-effects meta-analysis were IRR measured by kappa (K) and weighted kappa (KW). Validity and inter-modality reliability measures (Spearman's rho, KW) were also summarised.

Results: From 897 titles, 46 studies were eligible, including twelve differing approaches to mRS, 8608 participants. There was high ROB in 14 (30.4%) studies. Overall, reliability was substantial (n = 29 studies, K = 0.65, 95% CI: 0.58-0.71) but IRR was higher for novel approaches to mRS, for example, the Rankin Focussed Assessment (n = 2 studies, K = 0.94, 95% CI: 0.90-0.98) than standard mRS (n = 13 studies, K = 0.55, 95%CI:0.46-0.64). Reliability improved following the introduction of mRS training (K = 0.56, 95% CI: 0.44-0.67; vs K = 0.69, 95% CI: 0.62-0.77). Validity ranged from poor to excellent, with an excellent overall concurrent validity of novel scales (n = 6 studies, KW = 0.86, 95% CI: 0.75-0.97). The agreement between face-to-face and telephone administration was substantial (n = 5 studies, KW = 0.80, 95% CI: 0.74-0.87).

Discussion: The mRS is a valid measure of function but IRR remains an issue. The present findings are limited by a high ROB and possible publication bias.

Conclusion: Interventions to improve mRS reliability (training, structured interview, adjudication) seem to be beneficial, but single interventions do not completely remove reliability concerns.

Introduction: Prediction scores for hematoma expansion in spontaneous intracerebral hemorrhage (ICH), such as the 9-point and BRAIN scores, were developed predominantly using planimetry to measure hematoma volume. In this study, we aim to investigate whether the ABC/2 formula, which is known to overestimate hematoma volume, can be reliably used as a substitute for planimetry in these prediction scores.

Patients and methods: A total of 429 patients from four hospitals were retrospectively enrolled. CT scan and clinical data at admission and follow-up CT scan were collected. The 9-point and BRAIN scores were calculated using hematoma volume from ABC/2 and planimetry. Hematoma expansion was assessed using hematoma volume from planimetry.

Results: The median hematoma volume measured by ABC/2 was 11.97 ml (interquartile range [IQR], 4.8-30.0), whereas the volume measured by planimetry was 11.70 ml (IQR, 4.9-26.6). The median measurement error between ABC/2 and planimetry was 0.30 ml (IQR, -0.72-2.87). ABC/2 overestimated hematoma volume in 244 patients (56.9%) compared to planimetry. In the 9-point score, the area under the curves (AUCs) for predicting hematoma expansion were 0.735 (95% confidence interval [CI], 0.675-0.796) with ABC/2 and 0.732 (95% CI, 0.672-0.793) with planimetry. In the BRAIN score, the AUCs were 0.753 (95% CI, 0.693-0.813) with ABC/2 and 0.745 (95% CI, 0.688-0.803) with planimetry.

Discussion and conclusion: The 9-point and BRAIN scores using hematoma volume measured by ABC/2 and planimetry showed good performance in predicting hematoma expansion in ICH. ABC/2 volumetric estimation proved to be reliable for these scores.

Background: Adverse cardiac events following ischaemic stroke (stroke-heart syndrome, SHS) pose a clinical challenge. We investigated the association between initial blood pressure at stroke presentation and the risk of SHS.

Methods: We utilised data from the Virtual International Stroke Trials Archive (VISTA). We defined SHS as the incidence of cardiac complications within 30 days post-ischaemic stroke. These presentations included acute coronary syndrome encompassing myocardial injury, heart failure/left ventricular dysfunction, atrial fibrillation/flutter, other arrhythmia/electrocardiogram abnormalities, and cardiorespiratory arrest. Using Cox proportional hazards models, we assessed the risk trajectories for developing SHS and its presentations associated with initial blood pressure. We also explored the risk trajectories for 90-day mortality related to initial blood pressure.

Results: From 16,095 patients with acute ischaemic stroke, 14,965 (mean age 69 ± 12 years; 55% male) were analysed. Of these, 1774 (11.8%) developed SHS. The risk of SHS and initial blood pressure showed a U-shaped relationship. The lowest blood pressures (⩽130 mmHg systolic and ⩽55 mmHg diastolic) were associated with the highest risks (adjusted hazard ratio [95%confidence interval]: 1.40 [1.21-1.63]; p < 0.001, 1.71 [1.39-2.10]; p < 0.001, respectively, compared to referential blood pressure range).Cardiorespiratory arrest posed the greatest risk at higher blood pressure levels (2.34 [1.16-4.73]; p = 0.017 for systolic blood pressure >190 mmHg), whereas other presentations exhibited the highest risk at lower pressures. The 90-day mortality risk also followed a U-shaped distribution, with greater risks observed at high blood pressure thresholds.

Conclusions: There is a U-shaped relationship between initial blood pressure at ischaemic stroke presentation and the risk of subsequent SHS.

Background: Acute intracranial occlusion of the internal carotid artery (ICA) can be distinguished into (a) occlusion of the terminal ICA, involving the proximal segments of the middle or anterior cerebral artery (ICA-L/-T) and (b) non-terminal intracranial occlusions of the ICA with patent circle of Willis (ICA-I). While patients with ICA-L/-T occlusion were included in all randomized controlled trials on endovascular therapy (EVT) in anterior large vessel occlusion, data on EVT in ICA-I occlusion is scarce. We thus aimed to evaluate effectiveness and safety of EVT in ICA-I occlusions in comparison to ICA-L/-T occlusions.

Methods: A large international multicentre cohort was searched for patients with intracranial ICA occlusion treated with EVT between 2014 and 2023. Patients were stratified by ICA occlusion pattern, differentiating ICA-I and ICA-L/-T occlusions. Baseline factors, technical (modified thrombolysis in cerebral infarction (mTICI) scale) and functional outcomes (modified Rankin scale [mRS] at 3 months) as well as rates of (symptomatic) intracranial hemorrhage ([s]ICH) were analyzed.

Results: Of 13,453 patients, 1825 (13.6%) had isolated ICA occlusion. ICA-occlusion pattern was ICA-I in 559 (4.2%) and ICA-L/-T in 1266 (9.4%) patients. Age (years: 74 vs 73), sex (female: 45.8% vs 49.0%) and pre-stroke functional independency (pre-mRS ⩽ 2: 89.9% vs 92.2%) did not differ between the groups. Stroke severity was lower in ICA-I patients (NIHSS at admission: 14 [7-19] vs 17 [13-21] points). EVT was similarly successful with respect to technical (mTICI2b/3: 76.1% (ICA-I) vs 76.6% (ICA-L/-T); aOR 1.01 [0.76-1.35]) and functional outcome (mRS ordinal shift cOR 1.01 [0.83-1.23] in adjusted analyses. Rates of ICH (18.9% vs 34.5%; aOR 0.47 [0.36-0.62] and sICH (4.7% vs 7.3%; aOR 0.58 [0.35-0.97] were lower in ICA-I patients.

Conclusion: EVT might be performed safely and similarly successful in patients with ICA-I occlusions as in patients with ICA-L/-T occlusions.