European Stroke Journal最新文献

Background: Despite international recognition of stroke as a significant health priority, discrepancies persist between the target values for stroke quality measures and the actual values that are achieved in clinical practice, referred to as gaps. This study aimed to reach consensus among international experts on prioritizing gaps in stroke care.

Methods: A two-round Delphi process was conducted, surveying an international expert panel in the field of stroke care and cerebrovascular medicine, including patient representatives, healthcare professionals, researchers, policymakers, and medical directors. Experts scored the importance and required effort to close 13 gaps throughout the stroke care continuum and proposed potential solutions. Data were analyzed using descriptive statistics and qualitative analysis methods.

Results: In the first and second Delphi rounds, 35 and 30 experts participated, respectively. Expert consensus was reached on the high importance of closing 11 out of 13 gaps. Two out of 13 gaps were considered moderately important to close, with expert consensus for one of these two gaps. Expert consensus indicated that only one gap, related to the prevention of complications after stroke, requires moderate effort to close, whereas the others were considered to require high effort to close. Key focus areas for potential solutions included: "Care infrastructure," "Geographic disparities," "Interdisciplinary collaboration," and "Advocacy and funding."

Conclusions: While closing gaps in stroke care primarily requires high effort and substantial resources, targeted interventions in the identified key focus areas may provide feasible and clinically meaningful improvements.

Introduction: Intraventricular hematoma (IVH) occurs in approximately 40% of acute intracerebral hemorrhage (ICH) patients and is significantly associated with worse clinical outcomes. According to cerebrospinal fluid dynamics, some blood within the ventricles may circulate through the subarachnoid spaces, leading to its apparent "disappearance" on follow-up imaging. We aim to investigate the association between initial IVH involvement and significant early ICH retraction at follow-up imaging.

Methods: Data are from the MCAHP (Multiphase CT Angiography Hematoma Prediction) Study, which included consecutive patients with acute ICH investigated with multimodal CT imaging. Patients who underwent surgery before follow-up imaging were excluded. IVH severity was assessed using the IVH score. The primary outcome was significant early ICH retraction, defined as volume decrease (⩾3 ml or ⩾15%) between the initial and follow-up scans. Secondary outcomes included early absolute and relative ICH decrease. Associations between outcomes and initial IVH involvement or IVH score were assessed with logistic regression adjusted for age, baseline NIHSS, initial ICH volume, and onset-to-CT time.

Results: Overall, 177 ICH patients were included. The median age was 71 years (IQR = 59-80), 71 (40.1%) patients were female, and 64 (36.2%) presented with initial IVH involvement. Patients with initial IVH, compared to those without, had a larger initial ICH volume (28.5 ml [IQR = 12.7-52.5] vs. 18.9 ml [IQR = 8.1-30.6], p < 0.001) and different ICH location (deep = 54.7% vs 47.8%; lobar = 35.9% vs 46.0%; infratentorial = 7.3% vs 6.2%; p < 0.001). Early ICH retraction was observed in 33 (18.6%) patients: 21 (32.8%) with initial IVH and 10 (10.6%) without initial IVH. There was a significant association between early ICH retraction and initial IVH involvement (adjusted odds ratio [aOR] 4.02 [95% CI = 1.72-9.41]) and IVH score (aOR 1.14 [95% CI = 1.05-1.23] per 1-point increase). Similar results were observed for secondary outcomes.

Conclusion: Initial IVH involvement is associated with early ICH retraction - "intraventricular washout." This might result in an underestimation of hematoma expansion occurrence and severity in these patients, with potential implications when evaluating the predictive performance of hematoma expansion markers/scores and the radiological efficacy of hemostatic treatments.

Introduction: A Mobile Stroke Unit (MSU) enables prehospital acute stroke assessment, which leads to increased treatment rates and improved patient outcomes. However, for optimal utilization of the specialized resource, identifying the proper location for the MSU is crucial. Motivated by this, our goal was to find the optimal placement of an MSU in the greater Oslo area using geospatial mapping, and to explore how the location may influence acute stroke treatment.

Methods: Historical data on suspected and confirmed strokes with the respective geospatial data and calculated travel times were analyzed using a mathematical optimization model based on the Maximum Coverage Location Problem (MCLP) and solved with the Gurobi solver. The model is universal and may be adapted to other regions and countries.

Results: The optimal base location for a single MSU in the greater Oslo area would increase the coverage of stroke patients by 17%. The rendez-vous approach would further improve the coverage by approximately 300% for confirmed stroke patients. In the optimal location, the MSU has the potential to reduce time to thrombolysis by 27 minutes (25%) and time to thrombectomy by around 35 minutes (20%).

Conclusion: Strategic placement of an MSU in the greater Oslo area significantly increases patient coverage and may reduce treatment times in acute stroke. Geospatial analyses have the potential to aid decision making on MSU location, optimize prehospital acute stroke assessment and improve patient outcomes.

Introduction: Data is limited on the safety of early initiation of direct oral anticoagulation (DOAC) treatment after acute ischemic stroke (AIS) receiving reperfusion therapy in patients with atrial fibrillation (AF). We investigated the timing of DOAC initiation and its association with safety and outcomes.

Materials and methods: We included AIS patients receiving reperfusion therapy with AF diagnosis (prevalent or new) registered in the Safe Implementation of Treatments in Stroke international registry during 2013-2024. Safety outcomes were hemorrhage and death. Secondary outcomes were recurrent AIS, any embolism and functional independence (modified Rankin Scale [mRS] 0-2) at 3 months. We performed descriptive statistics and multivariable analysis for DOAC initiation time as an ordinal variable (0-3, 4-7, and 8-100 days after stroke onset) and its association with outcomes. Explorative analyses were performed to investigate factors associated with DOAC initiation time, as a continuous or ordinal variable.

Results: In total, 13,389 patients had data on DOAC initiation time, and 7861 patients had new event data by 3-month follow-up. We observed 0.1% intracranial hemorrhage, 0.4% major extracranial hemorrhage, 1.1% recurrent ischemic stroke, and 0.2% systemic embolism. At 3 months, 4.8% patients had died, and functional independence was seen in 60.9%. In multivariable analyses, DOAC initiation after stroke onset was not associated with any outcomes. Higher 24 h NIHSS and lower pre-stroke mRS score were associated with delayed DOAC initiation.

Conclusion: DOAC initiation time was not associated with any outcomes in AIS patients who received reperfusion therapy. Severe stroke symptoms at 24 h were associated with delayed DOAC initiation. The low incidence of safety outcomes and missing data in this study should lead to cautious interpretations of these results.

Introduction: A better understanding of who will develop dementia can inform patient care. Although MRI offers prognostic insights, access is limited globally, whereas CT-imaging is readily available in acute stroke. We explored the prognostic utility of acute CT-imaging for predicting dementia.

Patients and methods: We included stroke or transient ischaemic attack (TIA) survivors from participating stroke centres in Scotland. Acute CT-scans were rated using ordinal scales for neurodegenerative and cerebrovascular changes (old infarcts, white matter lesions (WMLs), medial temporal lobe atrophy (MTA), and global atrophy (GA)) and combined together to a 'brain-frailty' score. Dementia status was established at 18-months following stroke or TIA.

Results: Among 195 participants, 33% had dementia after 3 years of follow-up. High brain-frailty score (⩾2/4) correlated with higher risk of dementia (HR (95% CI) 6.02 (1.89-19.21)). As individual predictor, severe MTA was most strongly associated with dementia (adjusted HR (95% CI) 2.09 (1.07-4.08)). Other predictors associated with dementia included older age, higher prestroke morbidity (mRS), WMLs, and GA. Integrated in a prediction model with clinical parameters, prestroke mRS, cardiovascular disease, GA, MTA and Abbreviated-Mental-Test were the strongest predictors of dementia (c-statistic: 0.77).

Discussion and conclusion: Increased brain-frailty, and its individual components (WMLs, MTA, and GA) are associated with a higher risk of dementia in participants with stroke. Combining clinical and brain-frailty parameters created a moderate dementia prediction model but added little value over clinical parameters in combination with cognitive testing. CT-based brain-frailty may provide better prognostic insights when cognitive testing isn't feasible and for identifying highest-risk individuals for dementia prevention trials to increase trial efficiency.

Introduction: Evidence on endovascular therapy (EVT) for symptomatic intracranial stenosis (sICAS) from randomized-controlled clinical trials (RCTs) is conflicting. While prior RCTs on percutaneous transluminal angioplasty and stenting (PTAS) demonstrated harm or no benefit over best medical treatment (BMT), recent data suggest that submaximal balloon angioplasty with BMT may be superior to BMT alone.

Patients and methods: A systematic review and meta-analysis of RCTs was conducted to evaluate the safety and efficacy of elective EVT plus BMT compared to BMT alone for sICAS.

Results: Six RCTs (5 on PTAS and 1 on balloon-angioplasty) comprising 1606 patients were included. EVT increased the risk of any stroke or death (RR = 2.68; 95% CI: 1.72-4.19; I² = 0%), ischemic stroke within the territory of the qualifying artery (RR = 2.51; 95% CI: 1.36-4.61; I² = 0%), any ischemic stroke (RR = 1.99; 95% CI: 1.17-3.38; I² = 0%), intracranial hemorrhage (RR = 6.23; 95% CI: 1.92-20.2; I² = 0%), and mortality (RR = 3.52; 95% CI: 1.04-11.88; I² = 0%) within 30 days. No significant benefit from EVT was detected regarding the risk of any stroke or death (RR = 0.29, 95% CI: 0.06-1.38; I² = 68%), ischemic stroke in the territory of the qualifying artery (RR = 0.44, 95% CI: 0.14-1.33; I² = 59%) and mortality (RR = 0.49, 95% CI: 0.16-1.55; I² = 0%) beyond 30 days through 1 year.

Discussion and conclusion: EVT is associated with adverse early outcomes, without reducing the risk of long-term stroke recurrence or mortality compared to BMT. Further research is warranted to identify high-risk subgroups who may benefit from EVT for sICAS and refine interventions to minimize periprocedural risks.

Introduction: Post-stroke cognitive impairment is associated with impaired quality of life. Remote testing provides a potential avenue to measure cognitive outcomes efficiently.

Patients and methods: Prospective cognitive outcomes were collected at 90-180 days using both telephone MoCA (T-MoCA; range 0-22; <17 impairment) and Creyos, a computerized cognitive battery. Key variables associated with completion were assessed using logistic regressions. Mixed methods brief structured interviews and exit survey were performed to explore barriers to completing computer testing.

Results: Of 791 potentially eligible patients (mean age 70 ± 14 years), there was low feasibility of remote cognitive testing, with only 401 (51%) completing the T-MoCA, and 242 (31%) completing Creyos. Our regression models show that age (OR_T-MoCA: 0.95 (95% Confidence Interval (CI): 0.94-0.97); OR_Creyos: 0.95 (95% CI: 0.94-0.96)), functional impairment (mRS 2-5; OR_T-MoCA: 0.55 (95% CI: 0.37-0.81); OR_Creyos: 0.66 (95% CI: 0.44-0.98)), quality of life (EQ-VAS; OR_T-MoCA: 1.02 (95% CI: 1.01-1.03); OR_Creyos: OR:1.02 (95% CI: 1.01-1.03)) and length of hospital stay (OR_T-MoCA: 0.98 (95% CI: 0.96-0.99); OR_Creyos: 0.97 (95% CI: 0.94-0.99)) predicted both telephone and computer cognitive test completion; computer literacy predicted computer test completion (OR_Creyos: 1.12 (95% CI: 1.04-1.21)). In interviews, a preference for accessibility of computerized testing was reported.

Discussion: Remote cognitive testing has limited feasibility as a secondary outcome in large acute stroke trials. Patients who are older, with worse quality of life, or severe functional impairment post-stroke are less likely to complete remote cognitive outcomes.

Conclusion: Innovative approaches to post-stroke cognitive outcomes in acute stroke trials are needed.Data AccessData available upon request.

Introduction: Limited data exist on cognitive performance and return to work after ischemic stroke, especially in patients under 50 years. We investigated whether cognitive performance in the subacute phase after ischemic stroke in young adults was associated with unemployment and the inability to retain their jobs among those who returned to work.

Patients and methods: We conducted a multicenter prospective cohort study between 2013 and 2021, enrolling patients aged 18-49 years with first-ever ischemic stroke. Cognitive assessments were performed within 6 months following the index event, covering seven cognitive domains. We categorized patients with cognitive impairment (Z-score < -1.5 on a domain) and as no/mild or major vascular cognitive disorder (VCD; Z-score < -2.0 in one or more domains). Cognitive performance and other predefined characteristics were chosen to identify factors associated with unemployment and, among patients who returned to work, the inability to maintain employment.

Results: Of 525 patients (median age 44.3 [IQR 38.0-47.4] years; 243 women [46.3%]); median follow-up of 6.6 [IQR 4.5-8.2] years), 426 patients (81.1%) returned to work. Sixty-five patients (15.3%) were unable to maintain employment. In multivariable logistic regression analysis, major VCD (OR = 2.0; 95% CI 1.3-3.0; p = 0.002) and cognitive impairment in processing speed (OR = 2.0; 95% CI 1.3-3.3; p = 0.004) were associated with unemployment, but not with the inability to maintain employment.

Discussion and conclusion: In young patients after a first-ever ischemic stroke, major VCD and impaired processing speed in the subacute phase after stroke were independently associated with unemployment, but not with the inability to maintain employment.

Introduction: Evidence regarding the benefit of endovascular therapy (EVT) in patients with acute ischemic stroke (AIS) due to isolated cervical internal carotid artery occlusion (c-ICA-O) is lacking. We assessed the outcomes and safety of EVT in patients with isolated c-ICA-O.

Methods: Retrospective multicenter cohort study of patients with an AIS due to isolated c-ICA-O, within 24-h since last-seen-well. Comparisons were made between EVT and best medical therapy (BMT). The primary outcome was 3-months modified Rankin Scale (mRS) ordinal shift. Secondary outcomes included 3-month favorable outcome (mRS 0-2, or return to pre-stroke mRS), symptomatic intracranial hemorrhage (sICH) and any parenchymal hemorrhage. Outcomes were compared combining inverse probability of treatment weighting with regression models and propensity score matching (PSM) as sensitivity analysis.

Results: We analyzed 998 patients (66.2% male, mean age 71.1 ± 13.2 years). 487 (48.8%) patients received EVT and 511 (51.2%) received BMT. Patients receiving EVT had a higher admission NIHSS [13 (7-18) vs 5 (2-13)] compared to BMT. There was no difference between EVT and BMT groups in 3-month mRS shift (adjusted common odds ratio [OR], 1.01 [95% CI 0.76-1.34]) and favorable outcome (adjusted OR [aOR] 1.16 [95% CI 0.84-1.60]). No patient (0%) in the BMT group had sICH versus 1.6% in the EVT group. Parenchymal hemorrhage was numerically higher in EVT patients (2.7% vs 0.6%; aOR 3.85 [95% CI 0.98-15.23]). PSM analysis revealed similar results.

Discussion and conclusion: In patients with isolated c-ICA-O, EVT was associated with similar odds of disability and intracranial bleeding compared to BMT. Randomized-controlled clinical trials in patients with isolated c-ICA-O are warranted.

Up to 20% of patients with cryptogenic ischemic stroke have an occult malignancy at the time of stroke presentation, providing an opportunity for early cancer detection. Despite this significant association, there is currently no consensus in international guidelines on how to systematically screen for malignancy in ischemic stroke patients. This review aims to summarize recent evidence on clinical features and scores, and predictive laboratory tests, that can guide malignancy screening in ischemic stroke patients. Our systemic search included PubMed, MEDLINE and Cochrane databases and yielded a total of 12 studies meeting the inclusion criteria for review. Elevated D-dimer levels and multiple infarcts in different cerebral circulations emerged as key markers. Based on the summarized data, we propose a flowchart for clinical decision-making regarding malignancy screening in patients with ischemic stroke. As the initial steps, we recommend using D-dimers cut-offs and stroke pattern on brain imaging to classify patients according to their risk profile. Based on the identified risk, we recommend a subsequent diagnostic workup addressing the most prevalent cancer types, including gastrointestinal tract, lung adenocarcinoma and gender-related cancer. The clinical implications of early malignancy screening and the need for evidence-based guidelines in cryptogenic stroke are discussed.