European Stroke Journal最新文献

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.

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: Whether thrombectomy with or without emergent carotid stenting improves outcomes in patients with large vessel occlusion (LVO) stroke due to carotid artery dissection (CAD) is unknown.

Patients and methods: International multicentre observational study. Patients with LVO due to CAD undergoing thrombectomy with emergent stenting were compared to those without emergent stenting. The primary outcome was functional independence (modified Rankin Scale 0-2) at 3 months, secondary outcomes included early neurological improvement (ENI) within 24-48 h, successful recanalisation, symptomatic intracerebral haemorrhage (sICH) and mortality at 3 months. Inverse probability of treatment weighting and multivariable Poisson regression were used to adjust for group imbalances and to estimate the effect size, respectively.

Results: Of 516 patients (mean age 53.8 years, 76% male) undergoing thrombectomy, 167 (32.4%) and 349 (67.6%) were treated with or without emergent carotid stenting, respectively. After robust adjustment, emergent stenting was not associated with functional independence (adjusted risk ratio [aRR] = 1.01; 95% confidence interval [CI], 0.89-1.15) or ENI (aRR = 1.07; 95% CI, 0.95-1.21) but with successful recanalisation (aRR = 1.29; 95% CI, 1.10-1.50) and reduced mortality at 3 months (aRR = 0.39; 95% CI, 0.15-0.99). Risk of sICH was equivalent (aRR = 1.01; 95% CI, 0.95-1.06).

Conclusion: In patients with LVO secondary to CAD, emergent stenting during endovascular procedure appeared safe, increased odds of successful recanalisation and reduced 3-month mortality rates. However, intraprocedural stenting was not associated with better functional outcome.

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.