European Stroke Journal最新文献

Background: Accurate diagnosis of cerebral amyloid angiopathy (CAA) in surviving patients is indispensable for making treatment decisions and conducting clinical trials. We aimed to evaluate the diagnostic value and clinical utility of the simplified Edinburgh computed tomography (CT) criteria for CAA-related hemorrhage in Chinese patients.

Methods: We analyzed 212 patients with lobar hemorrhage who underwent brain CT and magnetic resonance imaging (MRI) from a multicentre cohort. Using the Boston criteria version 2.0 (v2.0) as the gold standard, we assessed the application value of the simplified Edinburgh CT criteria, and investigated whether the Edinburgh CT criteria predict patient outcomes.

Results: Patients with probable CAA accounted for 36.6% according to the Boston criteria v2.0. The Edinburgh CT criteria indicated an area under the receiver operating characteristic curves (AUC) of 0.735 for the diagnosis of probable CAA, and it performed better when there was a high-risk threshold of CAA in the decision curve analysis. Patients with a high risk of CAA based on the Edinburgh CT criteria had poorer outcomes at 90-day after adjusting for confounding factors (p = 0.034). Finger-like projections in the Edinburgh CT criteria were associated with lobar microbleeds, cortical superficial siderosis, and multispot white matter hyperintensity according to the Boston criteria.

Conclusions: Taking the Boston criteria v2.0 as the gold standard, the Edinburgh CT criteria demonstrated good diagnostic value and predicted outcomes well at 90-day in Chinese patients with lobar hemorrhage. Further studies with larger sample sizes are required to confirm these findings.

Purpose: Cerebral small vessel disease (cSVD) is a highly prevalent disorder leading to physical, cognitive and functional decline. We report key barriers in the management of individuals with cSVD, the potential benefit of cSVD-dedicated health services, and evidence from existing models of care for adults with cSVD.

Methods: We examined information from a scientific seminar developed between seven experts in cSVD during the eighth European Stroke Organisation Conference that discussed the optimal health care for adults with cSVD and what health services dedicated to cSVD should include.

Findings: Barriers in cSVD care include unrecognised symptoms and modifiable risk factors, heterogeneity of clinical presentations, inefficient inter/intra-clinical services communication/organisation, and uncertainties regarding what assessments/treatments should be routinely done, when and by whom. However, existing health services and research studies suggest models of care in cSVD. Multi-step approaches can be used for identification and aetiological workup in individuals with cSVD, including basic and selected advanced evaluations, for example, monogenic cSVD testing. Although current guidelines for management of cSVD illlustrate limitations, there are recommendations on risk factors and lifestyle considerations, as well as pharmacological and non-pharmacological interventions for people with cSVD.

Discussion and conclusion: Existing healthcare models do not provide optimal care for individuals with cSVD. Lack of awareness of heterogeneous clinical presentations and uncertainty in threshold of cSVD 'burden' for referral to specialist multidisciplinary services, are key challenges for health services to overcome. Creating cSVD-dedicated services may prevent underdiagnosing and achieve standardised holistic management to improve outcomes in people with cSVD. However, adequate prevention and early management should be offered at all levels of care.

Introduction: The efficacy and safety of statins for secondary prevention in patients who have experienced a cardioembolic stroke are not well-defined. However, previous observational data reported hyperlipidemia as a risk factor for both ischemic and bleeding complications in patients with AF and previous stroke. Based on these premises, we conducted a sub-analysis of the RAF and RAF-NOAC studies to evaluate the efficacy and safety of statins in secondary prevention in patients with acute ischemic stroke and AF.

Materials and methods: We combined patient data from the RAF and RAF-NOAC studies, prospective observational studies conducted across Stroke Units in Europe, the United States, and Asia from January 2012 to June 2016. We included consecutive patients with AF who suffered an acute ischemic stroke with a follow-up of 90 days. Our outcomes were the combined endpoint, including stroke, transient ischemic attack, systemic embolism, symptomatic intracerebral hemorrhage, and major extracranial bleeding. Furthermore, both ischemic and hemorrhagic outcomes were evaluated separately.

Results: A total of 1742 patients were included (46% male), and 898 (52%) received statins after the index event, of whom 436 (48.6%) were already taking statins before the index event, 462 (51.4%) started treatment after. At multivariable analysis, statin use was statistically associated with age (OR 0.92, 95% CI 0.97-0.99, p = 0.001), male sex (OR 1.35, 95% CI 1.07-1.70, p = 0.013), anticoagulation (OR 2.53, 95% CI 1.90-3.36, p < 0.0001), hyperlipidemia (OR 5.52, 95% CI 4.28-7.12, p < 0.0001), paroxysmal AF (OR 1.40, 95% CI 1.12-1.75, p = 0.003), leukoaraiosis (OR 1.39, 95% CI 1.11-1.75, p = 0.004) and heart failure (OR 0.72, 95% CI 0.53-0.98, p = 0.034). Statin use was not associated with the combined outcome event (OR 0.84, 95% CI 0.58-1.23, p = 0.3) and ischemic outcome event (OR 1.17, 95% CI 0.73-1.88, p = 0.5) while was associated with a lower risk of hemorrhagic outcome event (OR 0.51, 95% CI 0.28-0.91, p = 0.02).

Discussion: Statins protect cerebral arterial vessels (particularly small vessels) from subacute damage due to hypertension, diabetes, and other harmful agents (such as reactive oxygen species, proinflammatory cytokines, etc.) due to their systemic anti-inflammatory and endothelium-protective effects.

Conclusions: Our data show that statins seem to protect against global bleeding events in cardioembolic stroke patients; this may be due to the pleiotropic effect of statins. More data are warranted to confirm these findings.

Introduction: The progression of diabetes status in post-stroke patients remains under-investigated, particularly regarding new treatments for type II diabetes mellitus (DM II), like glucagon-like peptide 1 receptor agonists (GLP-1-RA) and sodium-glucose co-transporter-2 (SGLT-2) inhibitors, which have not been studied in the post-stroke setting.

Patients and methods: Eight hundred eighty-four consecutive ischemic stroke patients recruited to our prospective STROKE-CARD Registry were assessed concerning their glycemic status at baseline (normoglycemia, prediabetes, DM II) and change over time within 1 year follow-up. Multivariate logistic regression was performed to identify factors associated with transitioning from normoglycemia to prediabetes or DM II. Additionally, we reviewed ongoing clinical trials for GLP-1-RA and SGLT-2 inhibitors in the context of acute ischemic stroke.

Results: At baseline, 44.6% (n = 394) of individuals had normoglycemia, 33.9% (n = 300) were prediabetic, and 21.5% had DM II (n = 190). After 1 year, normoglycemia decreased by 12.1 percentage points (n = 107), whereas prediabetes and DM II increased by 10.2 percentage (n = 90) points and 1.9 percentage points (n = 17), respectively. Statin therapy was the only significant risk factor for progression. 23.4% (n = 207) of our cohort would have met eligibility criteria for a recent trial on semaglutide in obese non-diabetics with prior cardiovascular disease. However, only one ongoing trial aims at evaluating short-term cardiovascular risk reduction in stroke patients.

Discussion: GPrediabetes and DM II are frequent in ischemic stroke patients. Even within an intensified post-stroke disease management setting, a considerable amount of stroke survivors convert to prediabetes or DM II within the first year. Our results demonstrate a notable proportion of patients qualifying inclusion in studies examining the efficacy of GLP-1-RA agonists and SGLT-2 inhibitors in secondary prevention.

Conclusion: Given the high prevalence and progression of prediabetes and DM II in stroke survivors, there is a need for clinical trials evaluating the use of GLP-1-RA and SGLT-2 inhibitors in this population.

Background: There are limited therapeutic options in cases of failed reperfusion (modified thrombolysis in cerebral infarction [mTICI] score < 2b) after stent-retriever and/or aspiration based endovascular treatment (EVT) for acute ischemic stroke. Despite the absence of data supporting its use, rescue therapy (balloon angioplasty and/or stent implantation) is often utilized in such cases. Studies are limited to large vessel occlusions, while the outcomes and complications after rescue therapy in medium/distal vessel occlusions (MDVOs) have not been reported. This study aims to report the outcomes of rescue therapy in MDVO stroke patients.

Methods: We performed an analysis of the "Blood pressure and Antiplatelet medication management after reScue angioplasty after failed Endovascular treatment in Large and distal vessel occlusions with probable IntraCranial Atherosclerotic Disease" (BASEL ICAD) retrospective registry. All MDVO stroke patients were included in the analysis.

Results: Out of the 718 registry patients, 87 (12.1%) presented with an MDVO. Fifty-six patients (64.4%) showed an occlusion of the M2 segment of the middle cerebral artery. Rescue stenting was performed in 78 patients (89.7%) while balloon angioplasty alone was performed in 9 patients (10.3%). Successful reperfusion (mTICI score ⩾ 2b) was achieved in 73 (83.9%) patients after rescue therapy. Symptomatic intracranial hemorrhage (sICH) occurred in 8 patients (9.2%) and post-treatment stent occlusion in 12 patients (13.8%). Ninety days mortality was 20.7%. Twenty-eight patients (32.2%) achieved functional independence at 90 days (modified Rankin Scale 0-2).

Conclusion: Rescue therapy with stenting and/or balloon angioplasty in patients undergoing EVT for isolated MDVO with suspected underlying intracranial atherosclerotic disease is an effective reperfusion strategy but is associated with complications and poor functional outcomes.

Background: Severe left ventricular (LV) systolic dysfunction (ejection fraction [EF] < 30%) is a known cardiovascular risk factor and a major cause of cardioembolism. However, less severe forms of LV disease (LVD), such as mild-to-moderate LV dysfunction and LV wall motion abnormalities (LVWMAs), are considered potential minor cardiac sources in Embolic Stroke of Undetermined Source (ESUS), but their role is underexplored. This study aims to evaluate the prevalence of LVD in ESUS and its association with adverse vascular events and mortality.

Methods: Retrospective, single-center study including consecutive ESUS patients admitted from January 2016 to May 2024. LVD was defined as either global systolic dysfunction (LV ejection fraction 30%-49%) or regional LVWMAs, unrelated to acute or recent (within 4 weeks) myocardial infarction. Univariate and multivariate Cox regression analyses evaluated the association of LVD with a primary composite outcome (including ischemic stroke recurrence, acute coronary events, and all-cause mortality), and its components separately.

Results: Among the 556 ESUS patients (median age 71 years [IQR 60-80], 44.6% female), 95 (17.1%) had LVD, including 51 (53.7%) with reduced LVEF (30%-49%), and 81 (85.3%) presenting LVWMAs. During follow-up (median 30 months), LVD(+) patients had significantly higher rates of the composite outcome (41.0% vs 21.3%, p < 0.001), ischemic stroke recurrence (13.7% vs 5.9%, p = 0.007), acute coronary events (7.4% vs 2.4%, p = 0.012), and all-cause mortality (28.4% vs 15.2%, p = 0.002), compared to LVD(-) patients. Multivariate Cox regression analysis showed that LVD independently increased the risk of ischemic stroke recurrence (adjusted HR 2.13, 95%CI 1.08-4.24, p = 0.032) and the composite outcome (aHR 1.92, 95%CI 1.27-2.90, p = 0.002), but not acute coronary events (aHR 1.65; 95%CI 0.54-5.01, p = 0.374), or all-cause mortality (aHR 1.62; 95%CI 0.98-2.70, p = 0.062).

Conclusions: LVD is significantly associated with an increased risk of ischemic stroke recurrence and adverse outcomes in ESUS patients. These findings highlight the clinical importance of identifying and optimizing LVD management among ESUS to improve long-term outcomes in this population.

Introduction: The effects of imaging-based intravenous thrombolysis on outcomes based on patient sex remain unclear. We aimed to investigate whether outcomes among patients with stroke with an unknown onset time and treated with imaging-based intravenous thrombolysis are influenced by their sex.

Patients and methods: This study was a pooled analysis of individual patient-level data acquired from the Evaluation of unknown Onset Stroke thrombolysis trials. Patients treated with imaging-based intravenous thrombolysis for stroke with an unknown onset time were included. The primary outcome was a favourable outcome (modified Rankin Scale score 0-1) at 90 days. The sex-based difference in outcomes was studied using mixed-effect logistic or ordinal regression models, considering potential heterogeneity across trials.

Results: Out of 509 patients in total, 204 (40.1%) were women. Compared with men, women were older and more likely to have atrial fibrillation. Baseline National Institutes of Health Stroke Scale score was higher and hours from last-known-well to treatment were longer for women than for men. Favourable outcomes occurred less often among women than among men. However, multivariate adjustment revealed a non-significant association between female sex and favourable outcome (adjusted odds ratio: 1.04 [95% confidence interval: 0.66-1.52], p = 0.98).

Discussion and conclusion: Pooled data from the included clinical trials showed that women with ischaemic stroke with an unknown onset time had worse functional outcomes following imaging-based intravenous thrombolysis than did men. However, this sex-based difference can be explained by the higher age and more severe clinical status at onset among women.

Introduction: Little is known of the long-term prognosis of patients with acute ischaemic stroke in the absence of standard modifiable stroke risk factors (SMoRFs). In acute coronary syndromes, patients without modifiable risk factors have a higher mortality rate. We analysed data from the Swedish Stroke Register to determine survival of patients without SMoRFs following an ischaemic stroke.

Patients and methods: We identified adult patients with first-presentation acute ischaemic stroke between 2010 and 2020. Patients were considered to possess a SMoRF if they had one of: hypertension, diabetes, hyperlipidaemia, atrial fibrillation or an active smoking history. We compared mortality in patients with and without SMoRFs following first-presentation ischaemic stroke using cox regression models. We also assessed the combined endpoint death and dependency (mRS 3-6) at 3 months via logistic regression models.

Results: Of 152,588 patients with ischaemic stroke, hypertension (58.7%) and atrial fibrillation (27.3%) were the most common risk factors. 34,019 patients (22.3%) had no SMoRFs. After a first-presentation ischaemic stroke, patients without SMoRFs had a lower risk of death than patients with one or more SMoRFs (HR 0.58 [95% CI 0.57-0.59]). The absence of SMoRFs was associated with lower odds of death and dependency at 3 months in logistic regression models (OR 0·60 [95% CI 0.58-0.62]).

Conclusion: One in five patients with acute ischaemic stroke had no standard modifiable stroke risk factors. These patients have lower risk of death compared to patients with one or more SMoRFs.

Introduction: The efficacy of intracranial rescue stenting (RS) following failed mechanical thrombectomy (MT) in large-vessel occlusion (LVO) stroke remains uncertain. We aimed to evaluate clinical outcomes of RS in patients with anterior circulation LVO stroke following unsuccessful MT.

Patients and methods: We conducted a retrospective analysis using the Stroke Code Registry of Catalonia (January 2016-March 2022), a prospective, population-based registry including patients treated at 10 comprehensive stroke centers. We compared outcomes between patients who received RS and those who did not after failed MT. The primary outcome was the shift in 90-day functional status, assessed by the modified Rankin Scale (mRS), adjusted for confounders using inverse probability of treatment weighting (IPTW). Secondary outcomes included good (mRS ⩽ 2 or 3 if baseline mRS was 3) and excellent (mRS ⩽ 1) outcomes, ischemic recurrences, hemorrhagic transformation, and 90-day mortality.

Results: Of 601 patients, 69 underwent RS. RS did not significantly impact the 90-day mRS shift (adjusted common odds ratio [acOR] 1.06, [95% CI 0.85-1.32]; p = 0.613). However, RS was associated with higher rates of good (18.8% vs 11.7%; aOR 1.41, [95% CI 1.00-1.99]; p = 0.048) and excellent outcomes (17.4% vs 5.7%; aOR 2.90, [95% CI 1.89-4.43]; p < 0.001). Symptomatic intracranial hemorrhage (9.4% vs 7.4%; p = 0.507) and 90-day mortality (30.4% vs 39.8%; p = 0.135) were similar between groups. Stroke recurrence (4.2% vs 1.7%; p = 0.247) showed no significant difference at 33-month follow-up.

Discussion and conclusion: RS may increase the likelihood of good and excellent outcomes in anterior LVO stroke after failed MT, without increasing long-term risks. Further randomized trials are warranted for comprehensive validation.

Background: Collateral circulation plays a key role in acute ischemic stroke. We sought to determine the association between the arterial collateral status, estimated by the Hypoperfusion Intensity Ratio (HIR) on perfusion MRI, and stroke etiology in anterior circulation large vessel occlusion (LVO).

Methods: We retrospectively analyzed anterior circulation LVO acute stroke patients with a baseline perfusion MRI performed within 24 h from symptom onset. To avoid selection bias, patients were chosen from (1) the prospective registry of one comprehensive stroke center that included both thrombectomy-treated and untreated patients with systematic use of perfusion MRI and (2) one prospective thrombectomy study where perfusion MRI was acquired per protocol, but treatment decisions were made blinded to the results. Stroke etiology was evaluated according to the TOAST classification. HIR, defined as the proportion of time-to-maximum (T_max) > 6 s with T_max > 10 s volume, was measured on perfusion imaging. The relationship between stroke etiology (large artery atherosclerosis [LAA]) versus cardioembolism [CE]) and HIR was assessed by bivariate then multivariable binary logistic regression analyses.

Results: Among the 310 included patients, stroke etiology was CE in 178 (57%) and LAA in 51 (16%). Patients with CE stroke etiology had higher HIR (0.43 vs 0.31, p < 0.001) than those with LAA etiology. Higher HIR, indicating worse collateral circulation, remained independently associated with CE etiology following adjustment for the main confounders (adjusted OR = 1.5 [95%CI 1.24-1.81] per 0.1-point increase, p < 0.001).

Conclusion: CE etiology is associated with worse collateral circulation in LVO-related acute stroke patients.