European Stroke Journal最新文献

Introduction: Right-to-left shunt (RLS) associated with a patent foramen ovale has been related with ischemic stroke. However, its relationship with MRI white matter hyperintensities (WMHs) remains debated. This cross-sectional, single-centre study investigated the prevalence of RLS detected by transcranial Doppler sonography (TCD) and its association with vascular lesions on MRI.

Patients and methods: 502 outpatients (mean age 47.8 ± 13 years; 45% male) with non-specific neurological symptoms underwent brain MRI and TCD with contrast saline. WMH severity was visually graded using the Fazekas scale.

Results: RLS was detected in 39% of the sample. No difference was found in demographics and clinical variables between those with and without RLS. No association was also found between RLS and MRI lesion load. As expected, a significant (P < .001) positive correlation was identified between age and Fazekas scores (ie, higher scores with increasing age). No effect on lesion load was found for sex, hypercholesterolemia, diabetes, obesity and smoking, while a statistically significant association (P = .016) was present for arterial hypertension (odds ratio 1.68, 95% CI, 1.10-2.56; among those with higher Fazekas scores). Finally, no significant association was found between RLS magnitude, both at rest and during the Valsalva manoeuver and the Fazekas scores.

Discussion: Although RLS was frequently detected in this cohort, it was not associated with the presence or severity of WMHs, which were instead driven by age and arterial hypertension. These findings support WMHs as MRI marker of cerebral small vessel disease rather than subclinical paradoxical embolism. This also suggests limited utility of routine TCD screening for RLS in patients with incidental WMHs and no history or sign of embolic features.

Conclusions: In patients with non-specific neurological symptoms, we detected a high occurrence of RLS, although this was not associated with an increased risk or severity of WMHs. As such, paradoxical embolism may not be a major determinant of subclinical WMHs in this population.

Background: Limited data exist on characteristics and patterns associated with patients with atrial fibrillation (AF) who encounter first-ever ischemic stroke (IS) while not on oral anticoagulation (OAC) therapy.

Methods: From a nationwide registry-linkage database including all patients with AF in Finland from 2007 to 2017, we included those with IS after diagnosis of AF and those without IS. Factors associated with non-OAC use among IS patients were examined using logistic regression, with separate models for independent variables and risk scores.

Results: Among 174,094 patients with new-onset AF, 11,680 (6.7%) patients (56.9% female; mean age 79.0 years) experienced IS. A total of 7507 (64.3%) of IS patients were not on OAC at the time of IS (mean age 78.9 years; 57.2% female). The proportion of non-OAC decreased from 77.2% to 45.6% over the study period. In the adjusted logistic regression model, the strongest factor associated with non-OAC was CHA2DS2-VA score of 0 points (OR 4.561; 95% CI, 3.097-6.718), followed by a score of 1 point (OR 2.382; 95% CI, 1.971-2.879). Other significant independent factors associated with non-OAC use were alcohol abuse (OR 2.282; 95% CI, 1.805-2.885), liver dysfunction (OR 2.120; 95% CI, 1.335-3.367), renal dysfunction (OR 1.430; 95% CI, 1.200-1.703), dementia (OR 1.394; 95% CI, 1.227-1.583), prior myocardial infarction (OR 1.346; 95% CI, 1.181-1.535), age <65 years (OR 1.274; 95% CI, 1.034-1.571), lowest income (OR 1.232; 95% CI, 1.104-1.374), female sex (OR 1.177; 95% CI, 1.077-1.287), and antiplatelets/NSAID use (OR 1.133; 95% CI, 1.042-1.231).

Conclusions: Less than 2% of AF patients experienced IS during study period and among these around 63% were without appropriate OAC therapy at the time of the IS. However, decreasing trend of non-OAC use was identified throughout the study period.

Introduction: This multicenter, double-blind, placebo-controlled trial, commissioned by South Korea's Ministry of Food and Drug Safety, evaluated the effect of oxiracetam for preventing post-stroke cognitive impairment (PSCI) and explored potential interaction with physical activity using neuroimaging.

Patients and methods: Patients at high risk of PSCI, reporting subjective cognitive decline ⩾3 months after stroke, were randomized 1:1 to receive oxiracetam or placebo for 36 weeks. Physical activity was tracked via wrist-worn actigraphy. Coprimary endpoints were changes in Mini-Mental State Examination (MMSE) and Clinical Dementia Rating-Sum of Boxes (CDR-SB). Secondary outcomes included neuropsychological assessments and resting-state functional magnetic resonance imaging network metrics.

Results: Of 500 enrolled participants (mean age 68.9 years; median 32 months post-stroke), 457 completed the study. There were no statistically significant differences between groups in changes in MMSE (oxiracetam: +0.13 ± 2.27 vs placebo: +0.27 ± 2.09; p = 0.49) or CDR-SB scores (-0.14 ± 0.70 vs -0.08 ± 0.80; p = 0.38). No evidence of interaction was observed between oxiracetam and physical activity. Exploratory analyses suggested favorable trends in functional segregation and CDR-SB scores among highly active oxiracetam participants.

Discussion and conclusion: Oxiracetam did not demonstrate benefit in preventing PSCI in high-risk patients. These findings support the recent regulatory decision to suspend its use in South Korea.

Background: Left atrial appendage (LAA) thrombus is associated with atrial fibrillation (AF) and can be a marker of atrial cardiomyopathy. We determined the association between computed tomography angiography (CTA) identified LAA thrombus in patients presenting with acute ischaemic stroke or transient ischaemic attack (TIA), and 3-month outcome.

Methods: We undertook a dual-centre, retrospective cohort study from New Zealand and Australia. All consecutive patients presenting with acute ischaemic stroke or TIA during the inclusion period who underwent acute stroke imaging were included. We analysed the association with CTA-LAA thrombus and 3-month outcome on modified Rankin Scale using multivariable logistic regression models adjusted for known predictors of outcome.

Results: Of the 1435 patients included, 1304 (90.9%) had acute ischaemic stroke and 131 (9.1%) had TIA. 582 (41%) had confirmed intracranial medium or large vessel occlusion (MLVO), and 565 (40%) received reperfusion therapies. CTA-LAA thrombus was identified in 58 (4.0%) patients, and these patients were older (median age 85 (IQR 75-88) vs 73 (63-81), p < 0.01), more likely to be female (62% vs 40%, p < 0.01), had higher rates of AF (79% vs 29%, p < 0.01), heart failure (29% vs 9%, p < 0.01), MLVO (53% vs 40%, p = 0.05), and mortality at 3-months (28% vs 11%, p < 0.01). Adjusting for known predictors of poor outcome, LAA thrombus was independently associated with increased 3-month mRS score (OR: 2.02, 95% CI: 1.20-3.40, p < 0.01).

Conclusions: CTA-LAA thrombus detected during the acute stroke imaging protocol in patients with ischemic stroke or TIA is a predictor of worse outcome.

Introduction: Whether patients with acute ischaemic stroke (AIS) and prior antiplatelet therapy (APT) are at higher risk of symptomatic intracranial haemorrhage (sICH) has not been established. This study aimed to determine whether prior APT increases the risk of bleeding.

Methods: 41,113 patients treated for AIS in Switzerland between 2014 and 2022 were analysed. The primary outcome was sICH, and secondary outcomes were recurrent ischaemic stroke (IS), all-cause mortality, functional outcome at discharge and 90 days. Patients grouped by prior APT: no APT (nAPT), single APT (SAPT), and dual APT (DAPT) were analysed using logistic and Cox proportional hazards regression. Confounding variables, including revascularisation treatment, were accounted for using multivariable adjustment and matching, and a time-to-event analysis was performed.

Results: In the adjusted analysis at 90 days, patients with nAPT versus SAPT had a decreased risk of sICH (aOR 0.75 (0.62-0.90), p < 0.01), while these occurred within the first days. There was no difference in the risk of recurrent IS, all-cause mortality, or functional outcome. Patients with DAPT had no higher risk of sICH or mortality than those with SAPT, but a higher occurrence of recurrent IS (aOR 1.41 (1.12-1.77), p < 0.01) and worse functional outcome (aOR 1.18 (1.07-1.31), p < 0.01). The results were consistent after adjusting for revascularisation treatment.

Conclusions: Patients with nAPT had a lower risk of sICH than those with SAPT. Patients with DAPT have a higher risk of recurrent IS and worse functional outcome respectively. The majority of sICH occurred within the first days after admission.

Introduction: Genetic deficiency of factor XI is associated with a reduced risk of ischemic stroke. Asundexian is a direct inhibitor of activated factor XIa (FXIa) with a low risk of bleeding in early trials. We seek to determine its efficacy and safety combined with antiplatelet therapy for prevention of ischemic stroke.

Patients and methods: Oral faCtor Eleven A iNhibitor asundexian as novel antithrombotiC (OCEANIC-STROKE) is a placebo-controlled, double-blind, event-driven randomised trial including participants with stroke (NIHSS ≤ 15) or high-risk TIA (ABCD2 6 or 7) within 72 h of onset. Participants had at least one of the following: atherosclerosis of extra- or intracranial vessels, a medical history of atherosclerosis or an imaged acute non-lacunar infarct. We excluded sources of stroke requiring anticoagulation and active non-trivial bleeding other than hemorrhagic infarction (HI 1 or 2). Participants received asundexian 50 mg daily or placebo stratified by planned concurrent antiplatelet therapy (single vs dual). The primary endpoint is time to ischemic stroke. We present baseline characteristics as of 5 June 2025.

Results: Between January 2023 and February 2025, we randomised 12,327 participants. Participants were 67% male with a mean (SD) age of 68 (11) years. Ischemic stroke was the index event for 95% of whom 27.4% had thrombolysis and/or mechanical thrombectomy. By TOAST classification, 43% of index strokes were LAA, 22% small vessel disease, 30% undetermined and 2% cardioembolic. Dual antiplatelets were planned in 63% as standard initial treatment. Trial completion is anticipated in October 2025.

Conclusion: OCEANIC-STROKE will be the first completed trial of FXIa inhibition for prevention of stroke after non-cardioembolic stroke or TIA.

Trial registration: ClinicalTrials.gov (NCT05686070).

Background: Growing evidence suggests that surgical treatment of ICH may be beneficial, particularly when performed early, with minimally invasive procedures, and in patients with lobar ICH. However, the available evidence is limited by risk of bias, heterogeneity and imprecision, and data supporting a beneficial effect in deep ICH is limited.

Aim: To determine whether early minimally invasive endoscopy-guided surgery in addition to standard medical management improves functional outcome in patients with spontaneous supratentorial ICH, compared with standard medical management alone.

Study design: The Dutch ICH Surgery Trial (DIST) is a multicentre, prospective, randomised trial with open-label treatment and blinded end-point assessment conducted in 11 neurosurgical centres in the Netherlands. Six hundred adult patients with spontaneous supratentorial ICH with a haematoma volume ≥ 10 mL and an NIHSS score ≥2 will be enrolled. Patients will be randomised (1:1) to minimally invasive endoscopy-guided surgery within 8 hours of symptom onset in addition to standard medical management, or to standard medical management alone.

Study endpoints: The primary outcome is the mRS score at 180 days. Secondary outcomes include the mRS at 90 and 365 days, safety and technical efficacy outcomes, quality-of-life measures and health economic evaluations up to 365 days. In addition, DIST will investigate blood and imaging biomarkers of secondary brain injury.

Summary: Dutch ICH Surgery Trial assesses the efficacy of early endoscopy-guided surgery for patients with supratentorial ICH. Recruitment started in November 2022; as of October 2025, 235 participants have been enrolled. Completion of recruitment is expected in 2027.

Trial registration: ClinicalTrials.gov NCT05460793.

Background: The no-reflow phenomenon, characterized by impaired microvascular reperfusion despite successful macrovascular recanalization, has been identified as a potential contributor to poor outcomes in acute ischemic stroke (AIS) treated with endovascular therapy (EVT). This systematic review and meta-analysis aimed to assess the prevalence and clinical impact of no-reflow phenomenon in AIS patients undergoing EVT.

Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies reporting the no-reflow phenomenon after EVT. Databases searched included PubMed, Embase, and CENTRAL (inception to February 9, 2025). Outcomes included no-reflow prevalence, functional outcomes (mRS), early neurological recovery, infarct volume, hemorrhagic complications, and 90-day mortality. Pooled risk ratios (RR) or mean differences (MD) were calculated using random-effects meta-analysis, and heterogeneity was assessed with I2.

Results: Eight studies (n = 1483 patients) were included. The pooled prevalence of no-reflow was 20.5% (95% CI 6.2%-49.9%; I2 = 96.9%). Compared with controls, patients with no-reflow had reduced early neurological recovery (RR 0.76; 95% CI 0.64-0.90) and increased risk of hemorrhagic transformation (RR 1.82; 95% CI 1.18-2.79) and symptomatic intracranial hemorrhage (RR 1.88; 95% CI 1.00-3.56). Differences in functional independence (mRS 0-2) and mortality were not statistically significant. Subgroup analyses based on study design revealed divergent patterns, particularly for infarct volume, which was significantly greater in no-reflow patients in post-hoc RCTs but not in the overall analysis.

Conclusion: No-reflow affects one in five EVT-treated patients and is associated with adverse neurological and hemorrhagic outcomes. Findings highlight the need for standardized definitions and prospective trials to clarify its clinical impact.

Background and objectives: Hemorrhagic transformation (HT) remains an important issue following ischemic stroke. Efforts have been made to identify predictors of HT, especially imaging features. Among them, the infarct growth rate (IGR) remains underexplored. We investigated the influence of IGR on the risk of subsequent HT in the setting of large vessel occlusion stroke (LVOS) intended for endovascular treatment (EVT) and compared IGR to baseline infarct volume as predictors of HT.

Methods: We conducted a secondary analysis of two merged prospectively collected databases (FRAME 2017-2019 and ETIS 2015-2021). Patients presenting with anterior circulation LVOS, a witnessed symptoms onset, baseline MRI within 24 h after symptoms onset and available day 1 imaging (MRI or CT) were included. Posterior circulation LVOS, medium and distal vessel occlusions of the anterior circulation, tandem occlusions and unknown time of stroke onset were excluded. The primary endpoint was the occurrence of any HT detected on day 1 imaging. Secondary endpoint was the occurrence of parenchymal hematoma (defined as PH1 or PH2). Associations between the IGR and the occurrence of any HT and parenchymal hematoma within 24-h after mechanical thrombectomy were assessed using univariable and multivariable logistic regression models.

Results: We included 775 patients (mean age 70.5 years (SD 15.1)). The median of IGR was 8.7 ml per hour (IQR 2.8-24.2). A faster IGR was independently associated with a higher risk of any HT (adjusted OR 1.35; 95% CI 1.16-1.57 per one log unit increase). A faster IGR was also associated with an increased risk of parenchymal hemorrhage in univariate analysis (OR 1.35; 95% CI 1.15-1.58), but the association did not remain significant in multivariable analysis including all the other predictors of parenchymal hemorrhage (adjusted OR 1.16 (95% CI 0.96-1.40) per one log unit increase). ROC analyses revealed that baseline infarct volume significantly better predicted any HT and PH occurrence than the IGR (p = 0.019 and p = 0.029 respectively).

Conclusion: In patients presenting with anterior circulation LVOS and treated with EVT, the IGR was significantly associated with an increased risk of HT. However, the baseline infarct volume was a stronger predictor of HT than IGR.