European Stroke Journal最新文献

Background and aims: Previous observational data indicate that young adults treated with intravenous thrombolysis (IVT) for acute ischemic stroke have more favorable outcomes and less complications when compared to older adults. Given the limited data on this topic, we aimed to provide more evidence on clinical outcomes and safety in such patients, using a large international thrombolysis registry.

Methods: In this prospective multicenter study, we used data from the Thrombolysis in Ischemic Stroke Patients (TRISP) registry from 1998 to 2020. Patients who received endovascular treatment (EVT), as only treatment or in addition to IVT, were not included in this cohort. Using multivariable regression models, we compared thrombolysed young patients aged 18-49 years with those aged ⩾50 years with regards to the following outcomes: favorable outcome in stroke survivors (modified Rankin Scale ⩽2), symptomatic intracranial hemorrhage (sICH) according to European Cooperative Acute Stroke Study II (ECASS II) criteria, and three-months all-cause death.

Results: Of the 16,651 IVT treated patients, 1346 (8.1%) were 18-49 years. Young adults in TRISP were more often male (59.6% vs 54.0%), had a lower median NIHSS score on admission, 7 (4-13) versus 8 (5-15), and had less cardiovascular risk factors except for smoking (42.0% vs 19.0%) when compared to older patients. When compared to thrombolysed patients aged ⩾50 years, a favorable functional outcome was more likely in young adults: 81.9% versus 56.4%, aOR 2.30 (1.80-2.95), whilst sICH 1.6% versus 4.6%, aOR 0.45 (0.23-0.90) and death 2.3% versus 14.2%, aOR 0.21 (0.11-0.39) were less likely.

Conclusions: Intravenous thrombolysis in young adults is independently associated with higher rates of favorable outcomes and lower rates of complications.

Background: There is paucity of data on the long-term outcomes after acute ischemic posterior circulation stroke (PCS). Additionally, the long-term prognostic value of the New England Medical Center-Posterior Circulation Registry (NEMC-PCR) classification of PCS has not been studied.

Patients and methods: All consecutive patients with PCS registered in the Athens Stroke Registry between 01/1993 and 12/2012 were prospectively followed for up to 10 years and included in the analysis. The NEMC-PCR criteria were applied to classify them in relation to topography. The main studied outcomes were all cause mortality, stroke recurrence and major adverse cardiovascular events (MACEs).

Results: A total of 653 patients with PCS (455 men, mean age 68.06 years) were followed up for 52.8 ± 44.0 months. Seventy-four (11.3%), 219 (33.5%), 335 (51.3%), and 25 (3.8%) patients had proximal, middle, distal, and multiple territories PCS, respectively. During the 10-year follow-up period, 217 patients died (7.6 per 100 patient years), 127 developed recurrent stroke (4.2 per 100 patient years), and 209 had a MACE (7.3 per 100 patient years). The cumulative 10-year mortality was higher in distal and multiple territories PCS compared to middle and proximal PCS (55.6%, 58.8%, 40.0%, 35.5%, respectively, p < 0.001 by log-rank test). Patients with distal location PCS had almost twofold increased 10-year risk of mortality compared to proximal location patients after adjusting for all confounding variables (HR 1.99, 95% CI 1.05-3.77). Per TOAST classification, large artery atherosclerosis was associated with almost two-fold increase in risk of mortality, stroke recurrence and MACEs.

Discussion and conclusion: A large proportion of PCS patients experienced 10-year death, stroke and MACE occurrence after PCS. NEMC-PCR topographic classification was found to have significant prognostic value, with distal and middle PCS having worse long-term outcomes than proximal PCS.

Introduction: Scarce data exist on the etiology of recurrent ischemic strokes (ISs) among young adults. We analyzed the etiology of first-ever and recurrent events and the differences between them.

Patients and methods: Patients aged 15-49 years with a first-ever IS in 1994-2007 were included in the Helsinki Young Stroke Registry. In this retrospective cohort study, data on recurrent ISs were identified from Care Register for Health Care until the end of 2017 and Causes of Death Register and from patient records until the end of 2020. All first-ever and recurrent ISs were classified using Atherosclerosis-Small vessel disease-Cardioembolism-Other Cause (A-S-C-O) and Trial of Org 10172 in Acute Stroke Treatment (TOAST) classifications.

Results: A total of 970 patients were included (median age at index IS 46 years, interquartile range 43-48, 33% women), of which 155 (16.0%) patients had recurrent IS, with 8 (5.2%) fatal cases and 5 (3.2%) unverifiable cases. The median follow-up was 17.4 (IQR 13.9-21.7) years. Median time from the index event to the first recurrent event was 4.5 (interquartile range [IQR] 1.6-10.2) years. Recurrence was more often due to definite cardioembolism (10.7% vs 18.0%, p = 0.013), while the proportion of other definite A-S-C-O subgroups remained the same. With TOAST classification, the proportion of true cryptogenic ISs decreased (16.7% vs 6.7%, p = 0.003), while those with incomplete evaluation increased (9.3% vs 19.3%, p = 0.015). Other TOAST phenotypes remained the same.

Conclusion: The proportion of definite cardioembolism increased at recurrence using the A-S-C-O classification and the number of cryptogenic ISs decreased using the TOAST classification, while cases with incomplete evaluation increased. Most etiologies remained the same.

Introduction: This study aimed to report the safety and efficacy of off-label intravenous thrombolysis (IVT) with alteplase after sequentially liberalizing our institutional guidelines allowing IVT for patients under direct oral anticoagulants (DOACs) regardless of plasma levels, time of last intake, and without prior anticoagulation reversal therapy.

Patients and methods: We utilized the target-trial methodology to emulate hypothetical criteria of a randomized controlled trial in our prospective stroke registry. Consecutive DOAC patients (06/2021-11/2023) otherwise qualifying for IVT were included. Safety and efficacy outcomes (symptomatic intracranial hemorrhage [ICH], any radiological ICH, major bleeding, 90-day mortality, 90-day good functional outcome [mRS 0-2 or return to baseline]) were assessed using inverse-probability-weighted regression-adjustment comparing patients with versus without IVT.

Results: Ninety eight patients fulfilled the target-trial criteria. IVT was given in 49/98 (50%) patients at a median of 178 (interquartile range 134-285) min after symptom onset with median DOAC plasma level of 77 ng/ml (15 patients had plasma levels > 100 ng/ml; 25/49 [51%] were treated within 12 h after last DOAC ingestion). Endovascular therapy was more frequent in patients without IVT (73% vs 33%). Symptomatic ICH occurred in 0/49 patients receiving IVT and 2/49 patients without IVT (adjusted difference -2.5%; 95% CI -5.9 to 0.8). The rates of any radiological ICH were comparable. Patients receiving IVT were more likely to have good functional outcomes.

Discussion and conclusion: After liberalizing our approach for IVT regardless of recent DOAC intake, we did not experience any safety concerns. The association of IVT with better functional outcomes warrants prospective randomized controlled trials.

Introduction: Too few patients benefit from endovascular therapy (EVT) in large vessel occlusion acute stroke (LVOS), and various acute stroke care paradigms are currently investigated to reduce these inequalities in health access. We aimed to investigate whether newly set-up thrombectomy-capable stroke centers (TSC) offered a safe, effective and cost-effective procedure.

Patients and methods: This French retrospective study compared the outcomes of LVOS patients with an indication for EVT and treated at the Perpignan hospital before on-site thrombectomy was available (Primary stroke center), and after formation of local radiology team for neurointervention (TSC). Primary endpoints were 3-months functional outcomes, assessed by the modified Rankin scale. Various safety endpoints for ischemic and hemorragic procedural complications were assessed. We conducted a medico-economic analysis to estimate the cost-benefit of becoming a TSC for the hospital.

Results: The differences between 422 patients in the PSC and 266 in the TSC were adjusted by the means of weighted logistic regression. Patients treated in the TSC had higher odds of excellent functional outcome (aOR 1.77 [1.16-2.72], p = 0.008), with no significant differences in the rates of procedural complications. The TSC setting shortened onset-to-reperfusion times by 144 min (95% CI [131-155]; p < 0.0001), and was cost-effective after 21 treated LVOS patients. On-site thrombectomy saves 10.825€ per patient for the hospital.

Discussion: Our results demonstrate that the TSC setting improves functional outcomes and reduces intra-hospital costs in LVOS patients. TSCs could play a major public health role in acute stroke care and access to EVT.

Introduction: The differences in vascular risk factors' and stroke burden across Europe are notable, however there is limited understanding of the influence of socioeconomic environment on the quality of secondary prevention and outcome after acute ischemic stroke.

Patients and methods: In this observational multicenter cohort study, we analyzed baseline characteristics, reperfusion treatment, outcome and secondary prevention in patients with acute ischemic stroke from three tertiary-care teaching hospitals with similar service population size in different socioeconomic environments: Bern/CH/n = 293 (high-income), Gdansk/PL/n = 140 (high-income), and Lutsk/UA/n = 188 (lower-middle-income).

Results: We analyzed 621 patients (43.2% women, median age = 71.4 years), admitted between 07 and 12/2019. Significant differences were observed in median BMI (CH = 26/PL = 27.7/UA = 27.8), stroke severity [(median NIHSS CH = 4(0-40)/PL = 11(0-33)/UA = 7(1-30)], initial neuroimaging (CT:CH = 21.6%/PL = 50.7%/UA = 71.3%), conservative treatment (CH = 34.1%/PL = 38.6%/UA = 95.2%) (each p < 0.001), in arterial hypertension (CH = 63.8%/PL = 72.6%/UA = 87.2%), atrial fibrillation (CH = 28.3%/PL = 41.4%/UA = 39.4%), hyperlipidemia (CH = 84.9%/PL = 76.4%/UA = 17%) (each p < 0.001) and active smoking (CH = 32.2%/PL = 27.3%/UA = 10.2%) (p < 0.007). Three-months favorable outcome (mRS = 0-2) was seen in CH = 63.1%/PL = 50%/UA = 59% (unadjusted-p = 0.01/adjusted-p CH-PL/CH-UA = 0.601/0.981), excellent outcome (mRS = 0-1) in CH = 48.5%/PL = 32.1%/UA = 27% (unadjusted-p < 0.001/adjusted-p CH-PL/CH-UA = 0.201/0.08 and adjusted-OR CH-UA = 2.09). Three-months mortality was similar between groups (CH = 17.2%/PL = 15.7%/UA = 4.8%) (unadjusted-p = 0.71/adjusted-p CH-PL/CH-UA = 0.087/0.24). Three-months recurrent stroke/TIA occurred in CH = 3.1%/PL = 10.7%/UA = 3.1%, adjusted-p/OR CH-PL = 0.04/0.32). Three-months follow-up medication intake rates were the same for antihypertensives. Statin/OAC intake was lowest in UA = 67.1%/25.5% (CH = 87.3%/39.2%/unadjusted-p < 0.001/adjusted-p CH-UA = 0.02/0.012/adjusted-OR CH-UA = 2.33/2.18). Oral intake of antidiabetics was lowest in CH = 10.8% (PL = 15.7%/UA = 16.1%/unadjusted-p = 0.245/adjusted-p CH-PL/CH-UA = 0.061/0.002/adjusted-OR CH-UA = 0.25). Smoking rates decreased in all groups during follow-up.

Discussion and conclusion: Substantial differences in presentation, treatment and secondary prevention measures, are linked to a twofold difference in adjusted 3-months excellent outcome between Switzerland and Ukraine. This underscores the importance of socioeconomic factors that influence stroke outcomes, emphasizing the necessity for targeted interventions to address disparities in treatment and secondary prevention strategies.

Patent foramen ovale (PFO) is frequently identified in young patients with cryptogenic ischaemic stroke. Potential stroke mechanisms include paradoxical embolism from a venous clot which traverses the PFO, in situ clot formation within the PFO, and atrial arrhythmias due to electrical signalling disruption. The purpose of this guideline is to provide recommendations for diagnosing, treating, and long-term managing patients with ischaemic stroke and PFO. Conversely, Transient Ischaemic Attack (TIA) was not considered an index event in this context because only one RCT involved TIA patients. However, this subgroup analysis showed no significant differences between TIA and stroke outcomes. The working group identified questions and outcomes, graded evidence, and developed recommendations following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach and the European Stroke Organisation (ESO) standard operating procedure for guideline development. This document underwent peer-review by independent experts and members of the ESO Guideline Board and Executive Committee. The working group acknowledges the current evidentiary gap in delineating an unequivocal diagnostic algorithm for the detection of PFO. Although transoesophageal echocardiography is conventionally held as the most accurate diagnostic tool for PFO identification, its status as the 'gold standard' remains unsubstantiated by rigorously validated evidence. We found high-quality evidence to recommend PFO closure plus antiplatelet therapy in selected patients aged 18-60 years in whom no other evident cause of stroke is found but a PFO (i.e. PFO-associated stroke). The PASCAL classification system can be used to select such candidates for PFO closure. Patients with both a large right-to-left shunt and an atrial septal aneurysm benefit most from PFO closure. There is insufficient evidence to make an evidence-based recommendation on PFO closure in patients older than 60 and younger than 18 years. We found low quality evidence to suggest against PFO closure in patients with unlikely PFO-related stroke according to the PASCAL classification, except in specific scenarios (Expert Consensus). We suggest against long-term anticoagulation in patients with PFO-associated stroke unless anticoagulation is indicated for other medical reasons. Regarding the long-term AF monitoring after PFO closure, the working group concluded that there remains significant uncertainty regarding the risks and benefits associated with the use of long-term cardiac monitoring, such as implantable loop recorders. This document provides additional guidance, in the form of evidence-based recommendations or expert consensus statements, on diagnostic methods for PFO detection, and medical management after PFO closure.

Introduction: In intracranial medium-vessel occlusions (MeVOs), intravenous thrombolysis (IVT) shows inconsistent effectiveness and endovascular interventions remains unproven. We evaluated a new therapeutic strategy based on a second IVT using tenecteplase for MeVOs without early recanalization post-alteplase.

Patients and methods: This retrospective, comparative study included consecutively low bleeding risk MeVO patients treated with alteplase 0.9 mg/kg at two stroke centers. One center used a conventional single-IVT approach; the other applied a dual-IVT strategy, incorporating a 1-h post-alteplase MRI and additional tenecteplase, 0.25 mg/kg, if occlusion persisted. Primary outcomes were 24-h successful recanalization for efficacy and symptomatic intracranial hemorrhage (sICH) for safety. Secondary outcomes included 3-month excellent outcomes (modified Rankin Scale score of 0-1). Comparisons were conducted in the overall cohort and a propensity score-matched subgroup.

Results: Among 146 patients in the dual-IVT group, 103 failed to achieve recanalization at 1 h and of these 96 met all eligible criteria and received additional tenecteplase. Successful recanalization at 24 h was higher in the 146 dual-IVT cohort patients than in the 148 single-IVT cohort patients (84% vs 61%, p < 0.0001), with similar sICH rate (3 vs 2, p = 0.68). Dual-IVT strategy was an independent predictor of 24-h successful recanalization (OR, 2.7 [95% CI, 1.52-4.88]; p < 0.001). Dual-IVT cohort patients achieved higher rates of excellent outcome (69% vs 44%, p < 0.0001). Propensity score matching analyses supported all these associations.

Conclusion: In this retrospective study, a dual-IVT strategy in selected MeVO patients was associated with higher odds of 24-h recanalization, with no safety concerns. However, potential center-level confounding and biases seriously limit these findings' interpretation.

Trial registration: ClinicalTrials.gov Identifier: NCT05809921.

Introduction: Transient ischemic attack (TIA) is a frequent neurological emergency which management and definition have changed radically over the last 15 years. However, recent epidemiological studies of TIA are scarce. We report here on the impact of the shift from a time-based to a tissue-based definition of TIA on its incidence and risk of recurrence in a new population-based cohort with a high rate of patients investigated by MRI.

Materials and methods: We prospectively included all TIAs that occurred between May 2017 and May 2021 from the Normandy Stroke Study, a population-based registry using multiple overlapping sources for exhaustive case identification in Caen la Mer area. TIAs were classified as either time-based (symptoms <24 h) or tissue-based (<24 h and no lesion on brain imaging). Attack and incidence rates were calculated, as was the 90-day ischemic stroke rate.

Results: Five hundred and sixty-seven TIAs (549 single patients) were included, with 80.6% having a brain MRI. Four hundred and ten (72.3%) met the definition of tissue-based TIA. The age standardized attack (to the 2013 European population) rate was 39.5 (95% CI 35.7-43.5) and the age-standardized incidence rate (first ever cerebrovascular event) was 29.7 (95% CI 27.3-34.2). The overall recurrent stroke rate at 90 days was 2.7%, with no difference between patients with or without ischemic lesions on MRI.

Conclusion: We found that the use of the tissue-based definition of TIA resulted in a 27.5% reduction in incidence as compared to the time-based definition, but had no impact on the 90-day stroke rate. The burden of TIA remains high, and is likely to increase as the population ages.

Background: Thrombus enhancement sign (TES) is associated with cardioembolic stroke and first-pass angiographic failure in anterior ischemic stroke. However, the relationship between TES and stroke subtype and recanalization status after endovascular treatment (EVT) in basilar artery occlusion (BAO) remains unknown.

Methods: This retrospective study included consecutive patients with acute BAO who underwent EVT between January 2020 and September 2023. Each patient underwent baseline non-contrast computed tomography (CT) and CT angiography. Two independent readers assessed the presence of TES. Stroke types were classified according to the Trial of ORG 10172 for Acute Stroke Treatment. Successful recanalization was defined as a modified Thrombolysis in Cerebral Infarction score of 2b-3 after EVT. Clinical and interventional parameters, along with histopathological thrombi examination results, were compared between the TES-positive and TES-negative groups. The associations between TES and stroke subtype and recanalization status were analyzed using univariate and multivariate analyses.

Results: A total of 151 patients were included in the analysis, among whom 116 (77%) exhibited TES. TES showed a significant correlation with cardioembolic and cryptogenic strokes (odds ratio [OR]: 8.56; 95% confidence interval: 3.49-22.4; p < 0.001), whereas the TES-positive thrombi were characterized by a higher fibrin/platelet proportion (p = 0.002) and lower erythrocyte proportion (p = 0.044). The TES-positive group demonstrated favorable outcomes compared to the TES-negative group, including a shorter procedure time (p < 0.001), lower number of thrombectomy attempts (p = 0.010), higher incidence of first pass success (p = 0.022), and lower rate of requiring rescue angioplasty and/or stenting (p < 0.001). In multivariate analysis, TES remained independently associated with successful recanalization (OR: 9.63; 95% CI: 2.33, 47.7; p = 0.003) after adjusting for baseline confounders.

Conclusions: Visualization of TES serves as a reliable and easily accessible marker for identifying cardioembolic and cryptogenic strokes and predicting recanalization success in thrombectomy for basilar artery occlusion.