European Stroke Journal最新文献

Introduction: ICH is a common complication following endovascular therapy (EVT) for ischaemic stroke. While sICH is known to worsen outcomes, the impact of ICH without early neurological deterioration (END), commonly referred to as "asymptomatic" (aICH), remains controversial. This study aimed to assess imaging patterns of aICH and its effect on clinical outcomes.

Patients and methods: This study used data from the prospective, multicentre German Stroke Registry-Endovascular Treatment. Bleedings were assessed on follow-up imaging at 24 hours applying the Heidelberg Bleeding Classification. European Cooperative Acute Stroke Study III (ECASS)-III criteria were used to stratify patients into (1) no ICH, (2) aICH and (3) sICH. The primary outcome was functional independence (mRS ≤ 2) at 3 months. Secondary outcomes included mRS shift and 3-month mortality.

Results: Among 4834 patients with EVT (median age 76, 51% female, median NIHSS 14), ICH occurred in 13.2% (aICH: 9.7%, sICH: 3.5%). Haemorrhage patterns differed, with sICH being more often parenchymal (48.2% vs 34.6%), multicompartmental (34.1% vs 20.2%) and involving the ventricular system (18.8% vs 7.6%), while aICH were predominantly haemorrhagic transformation (34.6% vs 21.8%). Functional independence at 90 days was reached by 40.0% (no ICH), 25.4% (aICH; adjusted odds ratio [aOR] 0.43 [0.32-0.58]) and 6.5% (sICH; aOR 0.06 [0.03-0.14]), respectively. aICH was associated with worse overall recovery (mRS shift adjusted common OR 0.51 [0.41-0.63]) and higher 90-day mortality (35.5% vs 24.9%; aOR 1.90 [1.44-2.51]), when compared to no ICH.

Conclusion: ICH after EVT was associated with worse functional recovery and higher mortality, even in the absence of END. Given these results, the term "asymptomatic ICH" warrants reconsideration.

Introduction: Remote ischaemic conditioning (RIC) initiated pre-hospital did not improve 90-day functional outcomes after acute stroke in the RESIST trial. The duration of treatment pre-reperfusion modifies treatment effect for other neuroprotective therapies. We examined whether the effects of RIC might be modified by the duration of pre-hospital treatment.

Patients and methods: This post-hoc analysis of the RESIST randomised-controlled trial (ClinicalTrials.gov: NCT03481777) included patients who presented with pre-hospital stroke symptoms < 4 hours, randomised to RIC or sham, diagnosed with acute ischaemic stroke (AIS) or ICH (modified intention-to-treat [mITT] cohort). Patients were stratified by time from randomisation to hospital admission (ie, pre-hospital treatment duration). The primary outcome was shift in 90-day mRS; secondary outcomes were 90-day mRS 0-2 and 24-hour neurological improvement (NIHSS).

Results: Among 902 mITT patients (AIS, n = 737; ICH, n = 165), median randomisation-to-admission time was 29.4 minutes (IQR: 19.6-39.4) and median onset-to-admission time was 88 minutes (IQR: 62.4-131.3). Across pre-hospital treatment duration strata, RIC conferred no significant benefit on 90-day mRS, mRS 0-2 or early NIHSS improvement in the combined, AIS or ICH populations. In patients with AIS receiving reperfusion therapy, stratification by transport time likewise revealed no efficacy differences. No significant interaction was observed between RIC and pre-hospital treatment duration for any outcome.

Conclusion: Longer pre-hospital treatment duration was not associated with efficacy of RIC in the RESIST trial including in patients with AIS who received reperfusion therapies. Findings may not apply to settings where RIC could be routinely administered for longer periods. We found no treatment duration-dependent benefit of pre-hospital RIC, at least when durations are under an hour.

Introduction: The efficacy of endovascular treatment (EVT) in ischemic stroke patients with distal-medium vessel occlusion (DMVO) remains unclear. We evaluated whether CT-perfusion target mismatch criteria (TMC) could predict functional independence in patients with M2 non- or codominant middle cerebral artery DMVO.

Materials and methods: This retrospective study analyzed consecutive patients with M2 DMVO receiving EVT and imaged with multimodal CT study protocol within 24 h from onset. A receiver operating characteristic curve analysis was used to identify the infarct core volume cutoff to predict functional independence (modified Rankin Scale 0-2 at 3-months). This parameter was subsequently considered as part of TMC together with penumbra volume ⩾ 10 mL and mismatch ratio ⩾1.2. The association between TMC and functional independence was tested with logistic regression.

Results: A total of 115 patients with M2 were included. Infarct core volume had good discriminative ability for functional independence (AUC 0.75; 95%CI 0.64-0.84) and the best cut-off value was ⩽30 mL (77% sensitivity, 61% specificity, 69% positive predictive value, 70% negative predictive value). TMC were independently associated with functional independence (OR [odds ratio] = 6.50, 95%CI = 2.37-17.77, p < 0.001), excellent outcome (modified Rankin scale 0-1 at 3-months, OR = 3.28, 95%CI = 1.30-8.31, p = 0.012) and final infarct volume (B = -35.52, p = 0.004). After including interaction terms, a significant treatment effect on functional independence was observed between successful recanalization and TMC (OR = 3.82, 95%CI = 1.64-8.89, p = 0.002).

Discussion and conclusion: In patients with M2 non- or codominant DMVO receiving EVT, TMC identified as core volume ⩽30 mL, penumbra volume ⩾ 10 mL, and mismatch ratio ⩾ 1.2, were associated with better functional outcome. Our findings suggest that functional independence after EVT was not directly related to successful recanalization, which is indeed effective only in patients with a favorable baseline imaging profile, including a small infarct core size, and in the presence of small penumbra volumes.

Background: The benefits of endovascular thrombectomy (EVT) over medical treatment for medium vessel occlusion (MeVO) remain uncertain. Understanding how vascular reperfusion leads to favorable outcomes is crucial. This study examines whether penumbra salvage and infarct volume reduction quantify EVT benefits in MeVO patients and assesses their impact on clinical improvement post-reperfusion.

Methods: We conducted a multicenter, observational study analyzing MeVO patients who underwent thrombectomy and received multimodal CT imaging from January 2020 to June 2024. EVT efficacy was evaluated by measuring follow-up infarct volume (FIV) on CT scans 24-48 h post-procedure and calculating the penumbra salvage index (PSI). PSI is the ratio of salvaged tissue volume (difference between baseline delay time (DT) >3 s volume and FIV) to baseline DT >3 s volume. Mediation analysis assessed PSI and FIV's contributions to successful reperfusion and functional outcomes.

Results: Of 338 patients, 241 (72%) achieved successful reperfusion. Median FIV was 21 mL (IQR 12-32 mL), and median PSI was 0.68 (IQR 0.50-0.82). Successful reperfusion was linked to a 0.10 increase in PSI (95% CI: 0.05-0.15, p < 0.001) and a 4.36 mL reduction in FIV (95% CI: 1.31-7.20, p = 0.005). Successful reperfusion predicted improved outcomes, with an adjusted odds ratio (aOR) of 1.92 (95% CI: 1.08-3.47, p = 0.020) for excellent outcomes (modified Rankin Scale (mRS) score 0-1) and an aOR of 1.70 (95% CI: 1.01-2.89, p = 0.024) for functional independence (mRS score 0-2). PSI and FIV accounted for 44% and 16%, respectively, of the effect of reperfusion on excellent outcomes.

Conclusions: In acute MeVO patients, penumbra salvage significantly mediates the beneficial relationship between reperfusion and excellent clinical outcomes, more so than infarct volume reduction.

Introduction: There are few recent studies on trends over time in functional outcome and mortality after stroke, with results separately presented for ischaemic stroke (IS) or ICH. We aimed to determine temporal changes in functional outcome and case-fatality 90 days after IS and ICH in Sweden between 2010 and 2019.

Patients and methods: We included patients (≥18 years) with first-ever IS or ICH registered in the Swedish Stroke Register (Riksstroke) between 2010 and 2019. Functional outcome data were based on the Riksstroke 90-day follow-up surveys and reported as distribution on the mRS. Multiple imputation was used for missing functional status in the survey non-responders (15.2% of total cohort). Mortality data were obtained from the Swedish Cause of Death Register, and "all-cause" mortality within 90 days was used as the outcome. Logistic regression was applied to calculate odds ratios for good functional outcome (mRS 0-2), and Cox regression was used to estimate hazard ratios for death within 90 days, with 2010-2012 as the reference period. Analyses were stratified by age groups (18-64, 65-74, 75-84, ≥ 85 years) and by 3 time periods (2010-2012, 2013-2016, 2017-2019).

Results: Between 2010 and 2019, 153,865 (87.3%) cases of IS and 22,289 (12.7%) cases of ICH were registered in Riksstroke. Good functional outcome (mRS 0-2) after 90 days increased in patients with IS from 49.2% in 2010-2012 to 52.4% in 2017-2019 (adjusted odds ratio [aOR] 1.12; 95% CI, 1.09-1.16) but not in patients with ICH (from 34.2% to 34.3%, aOR 0.96; 95% CI, 0.88-1.06). A significant improvement in functional outcome after IS from 2010-2012 to 2017-2019 was only observed in patients over 75 years. Crude 90-day case-fatality decreased in both IS (from 13.8% to 12.4%) and ICH (from 31.0% to 30.4%) from 2010-2012 to 2017-2019. Adjusted hazard ratios for case-fatality showed no significant changes over time for IS (0.99; 95% CI, 0.95-1.02) or ICH (1.00; 95% CI, 0.94-1.06).

Conclusion: We observed improvements in functional outcome after IS but not after ICH in Sweden between 2010 and 2019. Changes over time in functional outcome were more favourable in patients older than 75 years in both IS and ICH. Case-fatality decreased in IS and ICH, but this reduction was not significant after adjustment for confounding.

Introduction: The pathophysiological basis for lacunar stroke is uncertain. The susceptibility vessel sign (SVS) on magnetic resonance imaging (MRI) is associated with thrombotic large vessel occlusion and has been reported in association with lacunar infarcts using T2* imaging. We investigated the presence of a relevant SVS in acute lacunar stroke with susceptibility-weighted imaging (SWI) and time-of-flight MR angiography (TOF-MRA) at 7 Tesla (T).

Patients and methods: We performed a single-centre prospective observational study in patients with small subcortical infarct confirmed on 1.5 or 3 T MRI. Additional 7 T MRI was acquired and raters independently reviewed 7 T SWI and TOF-MRA sequences blinded to clinical data. Presence of an SVS and any associated occluded vessels were recorded. A SVS was considered present if reported by two or more raters in the relevant hemisphere with agreement confirmed at consensus review.

Results: Twenty people (10 male, 10 female), with median age 67.5 [interquartile range (IQR) 64-81] years and median National Institutes of Health Stroke Scale 3 (IQR 2-4.75), underwent 7 T MRI. Possible SVS was visualized in 7 of 20 scans (35%) on SWI, with 4 considered highly likely (20%). TOF-MRA review showed an occluded small vessel proximal to the infarct in 1 of 20 patients (5%). This was not associated with a positive SVS on SWI.

Conclusion: A possible SVS was observed in up to 7 of 20 (35%) people with recent small subcortical infarcts, but anatomically related vessel occlusion was not confirmed using TOF-MRA. Diagnosis of small vessel SVS appears subjective and confirmation with 3-dimensional vascular imaging may increase reliability.

Introduction: There are limited data regarding the amyloid positron emission tomography (PET) imaging among patients with Cerebral Amyloid Angiopathy (CAA). We sought to assess the amyloid load distribution detected on amyloid-PET among CAA patients compared to patients with Alzheimer's Disease (AD), patients with hypertension (HTN) related hemorrhage (ICH) and healthy controls (HC).

Patients and methods: A systematic review and meta-analysis of published studies with available data on global and regional amyloid-PET uptake was conducted. Comparisons with respect to amyloid load distribution were investigated using random-effects models based on the ratio of mean (RoM) amyloid-PET uptake. RoM < 1 and RoM > 1 indicate lower and higher global or regional amyloid-PET uptake in CAA compared to another population, respectively.

Results: We identified 16 cohorts, comprising 271 CAA patients (mean age: 72 years; women: 46%) versus 130 AD patients (mean age: 73 years; women: 44%), 180 patients with HTN-related ICH (mean age: 66 years; women: 36%) and 61 HC (mean age: 71 years; women: 46%) with available data on amyloid-PET. Global amyloid PET ratio differentiated CAA from AD [RoM: 0.93; 95% CI: 0.90-0.96; p < 0.0001], HTN-related ICH [RoM: 1.25; 95% CI: 1.20-1.31; p < 0.0001], and HC [RoM: 1.26; 95% CI: 1.23-1.29; p < 0.0001]. Occipital amyloid-PET uptake [RoM: 1.20; 95% CI: 1.15-1.26; p < 0.0001] was higher in CAA compared to HTN-related ICH, and Occipital-to-global [RoM: 1.05; 95% CI: 1.03-1.07; p < 0.0001] ratio of amyloid-PET uptake differentiated also CAA from AD.

Conclusions: CAA is characterized by a distinct amyloid-PET burden and distribution compared to AD patients, patients with HTN-related ICH and HC. These findings may contribute to the design and conduct of future randomized controlled clinical trials, aiming to treat CAA at preclinical stages.

Introduction: To summarize carotid near-occlusion (CNO) diagnostics and its consequences on epidemiology and management.

Materials and methods: A systematic search of PubMed using 19 known synonyms for CNO was performed. Diagnostic analyses of CNO were assessed. Epidemiological and management analyses were based on how the CNO diagnostics was conducted, with diagnostics resembling large trials considered "good."

Results: CNO can be diagnosed with several modalities and approaches (interpretation or measurements). Interpretation of angiography is the reference standard but is not feasible for routine use. Of feasible methods, flow measurements with phase-contrast magnetic resonance imaging (PC-MRI) were considerably better than other alternatives when assessed blinded: 90%-100% sensitive and 99%-100% specific and inter-rater kappa 0.98-1.0. CNO was consistently common (30% of ⩾50% stenosis) in studies with "good" CNO diagnostics but was also often described as rare. Symptomatic CNO have no benefit with revascularization in studies with "good" CNO diagnostics, which foremost applies to the moderate subtype (without full collapse). The more severe CNO subtype (with full collapse) seems to have a very high risk of stroke within the first 2 days, but revascularization performed sufficiently early to prevent this has never been assessed.

Discussion: CNO diagnostics is difficult and that CNO is perceived as rare by many is likely due to poor diagnostics. Such poor diagnostics also likely result in unnecessary surgeries for many symptomatic CNOs.

Conclusion: CNO is a common variant of carotid stenosis. New diagnostic methods (especially PC-MRI) should be introduced, possibly after validation of its prognostic impact in a randomized trial.

Introduction: Despite modern secondary prevention the risk of recurrent vascular events in ischemic stroke remains substantial, and high-sensitivity C-reactive protein (hsCRP) and interleukin-6 (IL-6) are associated with vascular recurrence. This study aims to investigate whether other proteins in the inflammatory cascade could serve as better predictive biomarkers.

Patients and methods: The discovery cohort comprised 559 ischemic stroke cases from SAHLSIS (age 18-69, median 58 years) with a median follow-up of 14.7 years. Acute-phase plasma levels of 65 inflammation-related proteins were assessed using the Olink Inflammation panel. Replication was sought using 502 cases from SAHLSIS2 (age 18-98, median 68 years) with a median follow-up of 3.6 years. Associations between proteins and recurrent major adverse cardiovascular events (MACE) and recurrent stroke were explored with Cox regression. For MACE in SAHLSIS, exploratory analyses stratified by etiologic subtype were performed. Analyses were adjusted for vascular risk factors and statin status.

Results: In SAHLSIS, S100A12 was independently associated with recurrent MACE (adjusted hazard ratio (HR), 1.27 [95% confidence interval 1.10-1.45] per doubling of protein level) and stroke (adjusted HR 1.21 [1.01-1.45]). In SAHLSIS2, the associations for S100A12 replicated (adjusted HR, recurrent MACE 1.25 [1.06-1.48] and stroke 1.35 [1.10-1.66]). Results from the exploratory analyses identified several proteins displaying subtype-specific associations.

Discussion: We identified S100A12 as a potential novel blood biomarker of vascular recurrence after ischemic stroke, and the results indicate that there are subtype-specific protein associations to recurrent MACE warranting further investigation.

Introduction: Poor-quality diets promote ischemic stroke. Red blood cell fatty acids (RBC-FAs) are objective, long-term biomarkers of diet. In a case-control study nested in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Spain, we developed a blood-based lipidomic fat quality (LFQ) score considering pre-defined RBC-FA diet-related biomarkers, and examined whether LFQ score relates to the risk of ischemic stroke.

Patients and methods: We determined the RBC-FAs (n = 438 cases of incident ischemic stroke, n = 438 matched controls). For each participant, we scored 1 for each beneficial metric (C15:0+C17:0; C18:2n-6; C18:3n-3; C20:5n-3; C22:6n-3) ⩾the median of the control group; and 1 for each detrimental metric (C16:0; C16:1n-7; C18:0)

Results: In a fully adjusted model, the Odds Ratio (OR) for ischemic stroke was 0.86 (95% confidence interval [CI] = 0.77-0.95) for each 1-unit increase of the LFQ score. Compared to individuals at the lowest category of LFQ score (0-3 points), those at the top category (5-8 points) had lower odds (OR = 0.64, 95% CI = 0.44-0.94). The findings were similar in the Framingham Offspring Study (Hazard Ratio [HR] for each 1-unit increase = 0.83; 95% CI = 0.70-0.99; HR for those at top category = 0.49; 95% CI = 0.29-0.84, compared to those at the lowest category).

Conclusion: Low blood-based LFQ scores relate to a high risk of ischemic stroke.