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: 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.

Background: Previously undetected antiphospholipid antibodies (aPLs) potentially provide explanations for early-onset cryptogenic ischemic stroke (CIS). Prior association studies conducted over a decade ago were inconclusive and not focused on patients with CIS.

Methods: SECRETO is a multi-center case-control study enrolling patients aged 18-49 years with imaging-positive acute CIS and 1:1 matched stroke-free controls. Lupus anticoagulant (LA), anticardiolipin (aCL), and anti-beta2-glycoprotein I (aβ2GPI) IgG antibodies were assessed from blood samples taken at two time points (baseline and 12-weeks) from patients and at a single time point from controls. Conditional logistic regression models assessed the association of aPLs, adjusted for age, level of education, and vascular risk factors.

Results: A total of 503 patient-control pairs were analyzed. At either time-point, compared to healthy controls, patients had more frequently positive aβ2GPI (patients 11.9% vs controls 2.0%, p < 0.001). There was no significant difference in the presence of positive LA between patients and controls. In the logistic regression model, at either time-point positive aB2GI and aCL were associated with CIS (odds ratio [OR] 11.22, 95% confidence interval [CI] 4.35-28.95 and OR 20.85, 95% CI 204-213.16, respectively). The frequency of patients with positive aβ2GPI or aCL increased from baseline to 12 weeks (p < 0.001), whereas frequency of positive LA results decreased (p < 0.001).

Conclusions: Positive aβ2GPI and aCL, but not LA, detected either shortly after stroke or after 12 weeks were associated with early-onset CIS. Notably, after the acute phase, frequencies of positive aβ2GPI and aCL increased, whereas LA showed a reverse trend.

Introduction: Despite advances in clinical care and treatment options, recurrent stroke risk remains significant. The unmet needs and challenges in secondary stroke prevention (SSP) after a non-cardioembolic ischaemic stroke are not fully understood, leaving many patients at risk of stroke recurrence. This study summarises expert consensus on the challenges in current SSP treatment and management.

Patients and methods: We conducted a 2-round modified Delphi study with 13 international stroke experts. This multidisciplinary panel included stroke neurologists, a stroke nurse, a dementia care nurse with lived experience and patient advocacy group representatives. The Delphi co-chairs developed 11 statements which were presented to the experts. Agreement was sought through a 2-round, anonymous survey and a final consensus discussion.

Results: All 11 statements achieved consensus after the 2 survey rounds. The statements addressed key areas including the burden of recurrent stroke, treatment and lifestyle interventions, management of stroke care and future needs to enhance SSP.

Conclusion: This is the first Delphi-based global consensus focused specifically on unmet needs in SSP. The experts agreed on several challenges-notably, recurrent stroke risks-and consistently emphasised that the impact of recurrent stroke is underappreciated. This Delphi panel's strong consensus underscores the real-world barriers, clinical inefficiencies and unmet needs that remain in SSP treatment and management. Addressing these challenges will require sustained investment in SSP treatments, education and innovation.

Introduction: Cervical arterial dissections (CeAD) can involve either single (sCeAD) or multiple (mCeAD) arteries. Whether the involvement of a single versus multiple arteries is associated with outcomes remains unclear. We aimed to study associations between the number of affected arteries and clinical, imaging and outcome parameters.

Patients and methods: Patients with CeAD from the STOP-CAD multicenter registry study were included. Clinical, imaging, treatment and outcome parameters were compared between patients with sCeAD and mCeAD. Regression analyses were performed to identify associations with multi-arteries involvement.

Results: Overall, 3858 STOP-CAD patients were included in this analysis and 443 (11.5%) had mCeAD. The presence of mCeAD was associated with age (adjusted odds ratio [aOR] 95% confidence intervals [95% CI] 0.99; (0.98-1.00)), female sex (aOR 1.5; 95% CI 1.17-1.91), recent upper respiratory infection (aOR 2.25; 95% CI 1.55-3.27), presence of connective tissue disease (aOR 3.11; 95% CI 2.32-4.17), severe arterial stenosis (aOR 1.95; 95% CI 1.95-2.58), intracranial extension (aOR 1.47; 95% CI 1.04-2.09), vertebral artery involvement (aOR 2.50; 95% CI 1.94-3.22) and presence of dissecting aneurysm (aOR 2.59; 95% CI 1.95-3.42). In adjusted analyses, mCeAD was not associated with clinical outcomes (ischemic stroke, mortality, and sICH; all p > 0.05).

Conclusions: mCeAD does not appear to increase risk of subsequent stroke as compared to sCAD despite baseline risk factors suggestive of vasculopathy. mCeAD patients who did develop a stroke presented with milder strokes and less often had vessel occlusions compared to those with sCeAD. The presence of mCeAD did not impact outcomes.

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.