European Stroke Journal最新文献

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.

Introduction: CADASIL is a monogenic inherited cerebral small vessel disease (SVD) caused by a mutation affecting the NOTCH3 gene. Mutation location appears to influence disease severity. We investigated the hypothesis that mutation location modifies phenotype by comparing a CADASIL population stratified by mutation site risk with a cohort of older people with sporadic SVD.

Patients and methods: We included adults with CADASIL and control group from the XILO-FIST trial. We recorded age at first stroke, white matter hyperintensity (WMH) volume, lacunes, cerebral microbleeds and other clinical biomarkers. We divided the CADASIL cohort into (1) two groups NOTCH3 mutations affecting epidermal growth factor-like repeat (EGFr) domains 1-6 (proximal) and EGFr domains 7-34 (distal); and (2) three groups; low, medium and high-risk based on a proposed three-tiered risk stratification.

Results: The CADASIL cohort included 129 people, 57 (44.2%) male, mean age 47.5 ± 11.7 years. The sporadic SVD cohort included 460 people, 317 (68.9%) male, mean age 65.7 ± 8.7 years. The CADASIL proximal group were imaged at younger age, but fewer had hypertension (14.3% v 38.1%) compared to distal mutations. Lacune count and WMH volume differed between low, medium and high-risk CADASIL mutations, and sporadic SVD. Percentage progression of WMH volume was higher in proximal CADASIL (0.26%), than distal CADASIL (0.14%) which was higher than sporadic SVD (0.05%), p < 0.001.

Discussion and conclusion: Proximal CADASIL mutations average more extensive WMH, higher lacune count and experienced first stroke at younger age than those with distal mutations. Both groups showed imaging differences compared to sporadic SVD.

Introduction: Whether the risk-benefit profile of once-daily versus twice-daily direct oral anticoagulants (DOAC) differs after atrial fibrillation(AF)-associated ischemic stroke is unclear. We explored this in a post-hoc analysis of ELAN trial data (NCT03148457).

Patients and methods: We compared the risk of the primary outcome (recurrent ischemic stroke, systemic embolism, intracranial hemorrhage (ICH), major extracranial bleeding, vascular death) from treatment initiation to the trial's 90-day follow-up in participants treated with once-daily or twice-daily DOAC after AF-associated stroke using Firth's logistic and Cox proportional hazards regression in unadjusted, inverse-probability-of-treatment-weighted and augmented-inverse-probability-weighted models to address confounding. Secondary outcomes were the primary outcome components and non-major bleeding. We calculated the net clinical benefit (NCB) of twice-daily over once-daily DOAC by subtracting the weighted rate of excess bleeding attributable to twice-daily DOAC from the rate of excess ischemic events possibly prevented by twice-daily DOAC.

Results: We analyzed 1890/2013 (94%) participants (median age 77 years, 45% female), of whom 384 (20%) received once-daily and 1506 (80%) twice-daily DOAC. The primary outcome occurred in 64 (3.4%) participants, and did not differ between DOAC types in logistic (ORunadjusted 0.89 (95% CI 0.50-1.66); ORweighted 1.34 (0.71-2.79); ORaugmented 1.45 (0.81-3.21); twice-daily vs once-daily DOAC) nor in Cox models. We identified no clear differences in any secondary outcome. NCB analysis revealed a near-neutral net effect of twice-daily versus once-daily DOAC (+0.28 to +0.67 weighted events possibly prevented/100 person-months for ICH weights 1.5-3.3).

Discussion and conclusion: The risk-benefit profile of once-daily versus twice-daily DOAC after AF-associated ischemic stroke does not seem to differ.

Introduction: Embolic Stroke of Undetermined Source (ESUS) is a subtype of cryptogenic stroke with no clear etiology despite thorough evaluation. Atrial fibrillation (AF) is detected in only ~40% of cases, and trials of empiric anticoagulation have failed to reduce recurrence, suggesting other mechanisms such as subclinical atherosclerosis may contribute. Coronary artery calcium (CAC) scoring is a validated marker of atherosclerosis, yet its burden in ESUS remains underexplored.

Patients and methods: We conducted a retrospective cohort study of consecutive ESUS patients admitted between April 2019 and December 2023 who underwent cardiac CT angiography (CCTA) during diagnostic work-up. CAC scores were calculated using the Agatston method, and percentiles were derived from the MESA database, adjusted for age, sex, and ethnicity. Patients with prior coronary interventions were excluded.

Results: Among 165 ESUS patients (median age 73.0 [IQR 66.5-82.0]; 47.9% female), the median CAC score was 225 [IQR 41.5-623.5] AU, and the median CAC percentile was 65 [IQR 40.05-85.0], significantly higher than population norms (p < 0.001). Patients ⩽65 years had higher CAC percentiles than older patients (80.0 [58.2-90.7] vs 61.0 [36.0-80.0], p = 0.002), despite similar CAC scores (p = 0.396).

Conclusion: ESUS patients exhibit a high burden of coronary atherosclerosis, particularly notable in younger individuals. Elevated CAC may reflect both subclinical atherosclerosis and a broader cardiovascular risk profile, offering insight into stroke pathophysiology and the limited efficacy of empiric anticoagulation. CAC assessment could improve etiologic classification and inform tailored secondary prevention.

Introduction: Most patients with intracerebral hemorrhage (ICH) are initially evaluated using non-contrast CT (NCCT) alone, which may delay or miss diagnoses of secondary causes and limit opportunities for timely targeted intervention. This review aims to identify NCCT findings suggestive of secondary ICH aetiologies.

Methods: We conducted a systematic literature review. Studies were included if they reported NCCT findings in patients with secondary ICH. We excluded studies focusing exclusively on traumatic ICH or anticoagulation-related ICH. Non-contrast CT findings suggestive of secondary ICH were broadly categorised into 4 domains: (i) intra-parenchymal haemorrhage findings, (ii) extra-parenchymal haemorrhage findings, (iii) non-haemorrhagic findings and (iv) absence of small vessel disease (SVD) findings.

Results: We identified a range of NCCT findings that mark an increased likelihood of being associated with secondary ICH. Intraparenchymal haemorrhage findings included morphological characteristics or atypical morphologies (eg, "cashew nut sign", "flame" shape bleeds, calcifications, fluid levels and disproportionate perihaematomal oedema) as well as unusual anatomical locations (eg, multiple bleeds, location outside the deep supratentorial regions, haemorrhages adjacent to typical arterial aneurysmal sites or venous structures). Extra-parenchymal haemorrhage findings included haemorrhage extension into intraventricular, subdural or subarachnoid spaces, and isolated intraventricular haemorrhage. Non-haemorrhagic findings included concomitant ischaemic lesions and venous hyperdensity. The absence of SVD markers also suggested secondary ICH.

Conclusion: Several NCCT findings can raise suspicion for secondary ICH and may guide early decision-making regarding the need for further imaging beyond NCCT. Recognising these findings is especially valuable in settings with limited access to advanced diagnostics.

Introduction: Cryptogenic stroke (CS) represents a heterogeneous group in terms of etiology. Atrial cardiopathy (AC) has emerged as a relevant underlying substrate for both stroke and atrial fibrillation (AF) in these patients. However, no reliable tools are currently available for the early and accurate identification of AC.

Material and methods: We conducted a prospective study including consecutive patients with cardioembolic stroke due to AF (CES-AF), non-cardioembolic stroke (NCES) and cryptogenic stroke (CS). Left atrial strain (LAS) assessed by speckle-tracking echocardiography, and serum markers of AC were evaluated in CES-AF versus NCES patients using ROC curve analysis. Based on these results, we developed a logistic regression model to calculate the probability of AC in CS patients, aiming to discriminate between cardioembolic and non-cardioembolic etiology. Clinical characteristics were compared between CS patients with high (>0.5) and low (<0.5) predicted probability of AC.

Results: A total of 136 patients were included: 44 with CES-AF, 52 with NCES, and 40 with CS. The combination of N-terminal pro-brain natriuretic peptide (NT-proBNP) levels ⩾ 469 pg/mL and biplanar LAS during the contraction phase (LASct) ⩾ -10.2% demonstrated the best-performing AC biomarker combination among those evaluated for identifying cardioembolic etiology (AUC = 0.995). Based on this combination, 30% of CS patients had a predicted probability > 0.5 for AC. These patients were older (77.3 ± 8 vs 68.8 ± 10 years; p = 0.011), had more severe strokes (NIHSS score 10.1 ± 7.5 vs 4.6 ± 5.2; p = 0.024) and showed a higher incidence of AF during follow-up (6 vs 0 cases; p = 0.029).

Conclusions: The combination of NT-proBNP levels and biplanar LASct provides highly sensitive and specific biomarkers of AC. This multiparametric model allows for individualized estimation of AC probability in CS patients, supporting its potential utility in discriminating cardioembolic from non-cardioembolic etiologies and guiding personalized clinical management.

Introduction: The risk of death increases significantly after stroke as shown in previous studies from the general stroke population; however, specific knowledge regarding survival after wake-up stroke and unknown-onset stroke is lacking. We aimed to report short- and long-term survival after ischaemic stroke, by mode of onset, using data from a high-quality nationwide stroke registry.

Patients and methods: Data from the Norwegian Stroke Registry for the period 2014-2023 were retrieved to assess short- and long-term survival after first-ever ischaemic stroke. Short-term survival was defined as surviving the first 30 days after stroke, and long-term survival was examined in 30-day survivors. Kaplan-Meier survival probabilities were estimated at 30 days, 1, 3 and 5 years after stroke for all patients and stratified by mode of onset: known-onset stroke, wake-up stroke and unknown-onset stroke. The relationship between mode of onset and all-cause mortality was assessed using multivariable regression models.

Results: Of the 68,025 patients included, 45,084 had known-onset stroke, 12,429 wake-up stroke and 10,512 unknown-onset stroke. The 30-day survival rate was 91.3% for known-onset stroke, 92.4% for wake-up stroke and 91.7% for unknown-onset stroke, while 5-year survival rate among 30-day survivors was 65.4%, 67.6% and 60.4%, respectively. For 30-day survivors, using known-onset stroke as reference group, the adjusted HR for all-cause mortality in the total observation period for wake-up stroke was 0.99 (95% CI, 0.95-1.04), P = .778 and for unknown-onset stroke the HR was 1.19 (95% CI, 1.14-1.25), P < .001.

Conclusion: Short-term survival was similar across all modes of onset, while unknown-onset stroke was associated with poorer long-term survival.

Objectives: Implementation of the Stroke Action Plan for Europe (2018-2030) (SAP-E) was initiated in 2019. It is now updated at mid-term to reflect and respond to challenges for stroke care in Europe in 2025.

Methods: The SAP-E covers the entire chain of stroke care. The sections (state of the art, current status and targets) were developed by working groups and finalised based on inputs from the Interim Review Committee and an open online meeting. Targets for 2030 were updated to reflect current knowledge, to prioritise and to increase accountability.

Results: All sections have been updated based on the newest evidence to reflect the state of the art and current status in 2025.

Conclusion: Stroke remains a significant health issue in Europe, with notable incidence and inequities in access to care. Key interventions are strongly evidence-based, cost-effective and supported by World Health Organization and European Union recommendations. Despite improvements, gaps remain across the care pathway but particularly in terms of access to stroke units, rehabilitation and follow-up. To control and reduce the burden of stroke, the main action points are: (1) national stroke plans, which encompass the entire chain of care and are reflected in reimbursement systems, (2) quality and outcome control, where impact is measured at both individual and health care system level, (3) robust and resilient health care organisation covering the entire chain of care that promotes equal access to sustainable, timely and evidence-based stroke care and (4) effective national strategies to promote and facilitate a healthy lifestyle and risk factor control.

Introduction: Elevated blood pressure (BP) in acute hemorrhagic stroke has been associated with adverse clinical outcomes. Limited data from randomized controlled clinical trials (RCTs) indicate that early BP management, in the prehospital setting, may be safe and beneficial. We sought to evaluate the efficacy and safety of prehospital BP-lowering in acute hemorrhagic stroke when compared to usual care.

Patients and methods: We conducted a systematic review and meta-analysis including available RCTs evaluating prehospital BP-lowering among acute hemorrhagic stroke patients. The pooled risk ratio (RR) of a 3-month good functional outcome, defined as modified-Rankin-Scale scores of 0-2 and all-cause 3-month mortality were the primary efficacy and safety outcomes, respectively. Secondary outcomes included the pooled RR of hematoma expansion (HE) and serious adverse events (SAEs).

Results: A total of four RCTs were included, comprising 642 patients treated with prehospital BP-lowering therapies and 617 patients receiving usual care. Prehospital BP-lowering was associated with similar rates of good functional outcome (RR: 1.07; 95% CI, 0.52-2.19) and all-cause mortality (RR: 0.90; 95% CI, 0.60-1.35) at 3 months, compared to usual care. The risk of SAEs (RR: 0.97; 95% CI, 0.74-1.26) and HE (RR: 1.05; 95% CI, 0.45-2.46) did not significantly differ between the two groups. Subgroup analyses revealed the superiority of the α-adrenoreceptor blocker urapidil compared to glyceryl trinitrate in terms of reducing SAE risk and HE.

Conclusion: Our meta-analysis indicates that prehospital BP-lowering in acute hemorrhagic stroke does not improve functional outcome and survival. Future RCTs conducted in mobile stroke units, and exclusively focusing on patients with acute hemorrhagic stroke, are required.

Introduction: Electroencephalography (EEG) features are emerging as valuable prognostic indicators in acute stroke. However, data on the predictive value of interictal epileptiform discharges (IEDs) remain limited. This study aimed to assess the prognostic role of IEDs in predicting functional outcomes in stroke patients without symptomatic seizures who underwent point-of-care EEG within 72 h of admission.

Patients and methods: We retrospectively analysed the clinical, neurophysiological and neuroimaging data of acute stroke patients who underwent point-of-care EEG within 72 h of admission. Interictal epileptiform discharges were identified according to the International Federation of Clinical Neurophysiology criteria. A multivariate logistic regression model identified variables associated with modified Rankin scale (mRS) scores of 3-6 at 3 months.

Results: Among 593 stroke patients (median age 77 years, range 22-98; median National Institutes of Health Stroke Scale [NIHSS] 5, range 0-25), 18.2% exhibited IEDs on EEG within 72 h of admission. At 3-month follow-up, 223 patients (37.6%) demonstrated poor functional outcome (mRS 3-6). The presence of IEDs on EEG (odds ratio [OR] = 1.088, P = .037), along with age (OR = 1.004, P < .001), NIHSS at admission (OR = 1.032, P < .001), premorbid disability (OR = 1.111, P < .001), hemorrhagic stroke (OR = 1.120, P < .001) and lesion extent (OR = 1.070, P < .001), was an independent predictor of poor clinical outcomes at 3 months (mRS 3-6). The logistic regression model, including these factors, achieved 81% accuracy in predicting functional outcomes.

Conclusion: Early IEDs on EEG within 72 h are independent predictors of poor clinical outcomes (mRS 3-6) at 3 months. These findings underscore the importance of EEG monitoring in the acute phase of stroke and suggest that IED detection may serve as an additional prognostic marker.