European Stroke Journal最新文献

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.

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.

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.

Introduction: Early cognitive screening, although recommended, can be challenging in acute stroke settings. In patients with acute stroke, we aimed to evaluate (1) reasons and predictors of non-applicability of the Montreal Cognitive Assessment (MoCA) and (2) MoCA score performance, focusing on sex-related differences.

Patients and methods: We conducted a single-centre study on patients consecutively admitted to our stroke unit (June 2019-June 2023). Reasons for MoCA non-applicability and MoCA scores were compared between sexes. Univariate and multivariable analyses explored associations between MoCA applicability and sociodemographic/clinical characteristics.

Results: Out of 637 admitted patients (median age 78.8 years; 54.3% male; 81.2% ischemic stroke), 445 (69.8%) completed the MoCA (76.3% of males, 62.2% of females, P <.001). Reasons for non-applicability were acute stroke-related in 63.5% of cases (mainly altered consciousness and aphasia), prestroke conditions-related in 22.9% and other (refusal/unreported) in 13.5%. Stroke-related reasons were more frequent in females (P =.002) and refusal in males (P =.005). Variables associated with MoCA non-applicability were: NIHSS on admission in both females (adjusted odds ratio [adj.OR] 1.25, 95% CI, 1.16-1.34) and males (adj.OR 1.24, 95% CI, 1.14-1.34); pre-stroke mRS in females (adj.OR 1.58, 95% CI, 1.15-2.17) and years of education and left-hemisphere lesion in males (adj.OR 0.91, 95% CI, 0.84-1.00 and adj.OR 2.38, 95% CI, 1.16-4.86, respectively). Among tested patients, females showed lower raw and adjusted MoCA scores (P <.001 and P =.022, respectively).

Conclusion: Sex-specific factors influence feasibility and interpretation of early cognitive screening in the acute stroke phase: recognising these differences might guide future efforts towards more inclusive and individualised protocols.

Introduction: In meta-analyses of large cohorts, a decline in procedural risks after carotid endarterectomy (CEA) was found. It remains unclear whether these trends extent to smaller cohorts, carotid artery stenting (CAS), and how long-term outcomes have evolved.

Patients and methods: PubMed and EMBASE were searched until 18 November 2024, for studies reporting on 100 or more adults undergoing CEA or CAS for symptomatic or asymptomatic carotid stenosis. Primary outcomes were 30-day and long-term risk of stroke or death. We performed separate analyses in smaller cohorts of < 500 patients.

Results: 291 studies reported 475,266 patients undergoing CEA (214,526 symptomatic, 260,740 asymptomatic) and 209,117 undergoing CAS (77,133 symptomatic, 131,984 asymptomatic). Short-term stroke or death after CEA declined 36% (RR = 0.64, 95% CI, 0.63-0.64) per 5-year later treatment midyear in symptomatic and 41% (RR = 0.59, 95% CI, 0.59-0.59) in asymptomatic patients, with consistent trends in smaller cohorts.For CAS, short-term risks declined 44% (RR = 0.56, 95% CI, 0.53-0.58) in symptomatic, and 27% (RR = 0.73, 95% CI, 0.71-0.74) in asymptomatic patients, with consistent trends in smaller cohorts. Long-term death risk after CEA increased 26% (RR = 1.26, 95% CI, 1.20-1.32) and 11% in smaller cohorts. Long-term stroke risk after CAS increased 30% (RR = 1.30, 95% CI, 1.17-1.43) and 44% in smaller cohorts.

Conclusions: Short-term risks after CEA and CAS have decreased over time, also in smaller cohorts. Long-term death after CEA and stroke after CAS have increased. The increased long-term risk of death after CEA and stroke after CAS limits the durability of carotid interventions and warrants further scrutiny.

Introduction: Differentiating true from pseudo-occlusion of the cervical internal carotid artery (ICA) in acute ischemic stroke patients undergoing thrombectomy is crucial but challenging. We aimed to investigate the ability of contrast-enhanced magnetic resonance angiography (CE-MRA) to differentiate true from pseudo-occlusion (defined as an isolated thrombus of the intracranial ICA suppressing ascending blood flow) of the cervical ICA in acute ischemic stroke patients.

Materials and methods: Multicenter, retrospective analysis of acute ischemic stroke patients with true or pseudo-occlusion of the cervical ICA and subsequent thrombectomy. Patients with preprocedural CE-MRA showing a lack of contrast filling in the cervical ICA on the symptomatic side were included. Six readers (three radiology fellows and three board-certified radiologists) independently evaluated the CE-MRA images for true or pseudo-occlusion of the cervical ICA using a rating scheme. Their assessments were compared with DSA results as the reference standard. Diagnostic accuracy measures, as well as inter- and intra-reader reliability for detecting pseudo-occlusion, were calculated and compared between subgroups.

Results: A total of 41 patients were included. The median age was 73 years, and 39% were female. According to the reference standard, 16 of 41 (39%) patients had a pseudo-occlusion of the cervical ICA, while the remainder had a true occlusion. The aggregated sensitivity and specificity from all readers were 72% (95% confidence interval [CI]: 62%-81%) and 86% (95% CI: 79%-91%), respectively. Board-certified radiologists performed better, with a sensitivity of 81% (95% CI: 67%-91%) and specificity of 92% (95% CI: 83%-97%). Overall, inter-reader agreement was moderate (κ = 0.48; 95% CI: 0.31-0.65) and reached substantial agreement within the board-certified radiologists subgroup (κ = 0.65; 95% CI: 0.45-0.85).

Conclusion: Differentiating true occlusion from pseudo-occlusion of the cervical ICA using CE-MRA is feasible but requires training in specific imaging characteristics as well as experience in interpreting them, as evidenced by the higher diagnostic accuracy of board-certified radiologists. Correct distinction help in optimal material selection (e.g. size and type of guiding catheter) prior to endovascular treatment.

Background: Botulinum neurotoxin type A (BoNT-A) is a well-established treatment for post-stroke spasticity. However, its real-world use remains underexplored. This study evaluated BoNT-A use trends among stroke survivors in France from 2015 to 2023.

Methods: A retrospective cohort study was conducted using data from the French National Hospital Discharge Database. We analyzed stroke hospitalizations and BoNT-A treatment rates by age and care pathway. Among patients presenting with stroke between 2017 and 2019 who survived beyond 6 months post-stroke, we estimated the prevalence of patients with coded post-stroke spasticity, BoNT-A use, and time from stroke onset to spasticity coding and the first BoNT-A injection.

Results: Between 2015 and 2023, 1,170,436 hospitalizations for stroke were recorded in France. BoNT-A treatment rates remained low, ranging from 1.4% in 2015 to 1.9% in 2022. BoNT-A treatment rates increased from 3.3% to 3.8% in stroke survivors aged 20-29 and from 1.0% to 1.6% in those aged 70-79 between 2015 and 2022. Patients who, during their care pathway, stayed in a neurovascular or neurorehabilitation unit were more likely to receive BoNT-A treatment-rising from 2.0% in 2015 to 2.6% in 2022 and 7.3% to 9.6%, respectively-than those managed in non-specialized units, where rates increased from 0.9% in 2015 to 1.1% in 2022. Among 287,370 patients presenting with stroke between 2017 and 2019, 37,692 (13.1%) were coded with post-stroke spasticity, 8056 (2.8%) received ⩾1 BoNT-A injection between 2017 and 2023, 4360 (1.5%) received ⩾3 injections, and 1003 (0.35%) received ⩾3 injections spaced ⩽6 months apart. The median time from stroke onset to spasticity coding was 96 days, and to the first BoNT-A injection 258 days.

Conclusion: BoNT-A remains underutilized in the treatment of post-stroke spasticity in France. These results emphasize the need to enhance access to and adherence to BoNT-A therapy to optimize post-stroke spasticity management.