European Stroke Journal最新文献

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.

Introduction: Non-aneurysmal, non-traumatic subarachnoid hemorrhage (nSAH) refers to cases where a causative aneurysm cannot be identified. We studied 6-months' outcomes in nSAH patients.

Patients and methods: From a prospective SAH registry of all nSAH patients admitted between 2012 and 2023, relevant complications and outcomes were collected. Functional outcome and return-to-work at 6 months were assessed using the modified Rankin Scale (mRS), quality of life with the EuroQol-5Dimensions (EQ-5D) and Hospital Anxiety and Depression Scale (HADS), and an institutional 14-item questionnaire for assessment of residual symptoms.

Results: 325 consecutive nSAH patients were included (192 non-perimesencephalic, non-aneurysmal subarachnoid hemorrhage (NPSAH); 133 perimesencephalic subarachnoid hemorrhage (PMSAH)). 303 (93%; 180 NPSAH and 123 PMSAH) were available at follow-up (7 patients died). Favorable functional outcome (mRS-score 0-2) was reported in 271 (89%) patients and did not differ between NPSAH- and PMSAH. One hundred forty-one (77%) patients returned to work, whereas only 71 (39%) patients reached their previous level of work. PMSAH patients were more likely to return to work (68/96 (71%) NPSAH and 73/87 (84%) PMSAH, respectively, p = 0.036). Furthermore, PMSAH patients were more likely to fully return to work (p = 0.028). The mean (SD) EQ-5D and EQ-VAS scores were 0.827 (0.184) and 74 (16), respectively. The HADS-A and -D scores were deviant (score > 7 points) in 53 (23%) and 48 (21%) patients, respectively. Only 39 patients (16%) denied experiencing residual symptoms. Increased fatigue (n = 164; 68%), increased concentration difficulties (n = 130; 54%), and increased forgetfulness (n = 121; 50%) were the most frequently reported residual symptoms.

Discussion and conclusion: This study reveals that the majority of nSAH patients reports residual symptoms and did not return to their previous level of work at 6 months follow-up, despite a favorable functional outcome. These findings nuance the perception of a good outcome, as suggested in previous studies, warranting further research on possible rehabilitative interventions and counseling in these patients.

Introduction: Endovascular thrombectomy (EVT) is an effective treatment for basilar artery occlusion (BAO) stroke in select patients. While there is a growing body of literature suggesting that advanced imaging modalities such as computed tomography perfusion (CTP) and magnetic resonance (MR) may not be necessary for selecting anterior circulation large vessel occlusion stroke patients for EVT, whether advanced imaging may be superior to conventional imaging (non-contrast CT and CT angiography) in identifying good treatment candidates among BAO patients is less clear.

Patients and methods: This was a multicenter retrospective cohort study of BAO EVT patients treated from 2013 to 2022 in the Stroke Thrombectomy and Aneurysm Registry. Patients selected for EVT by advanced imaging (CTP or MR) were matched with those selected by conventional imaging using propensity score matching (PSM) accounting for possible confounders. Primary outcome was functional independence at 90 days. Other outcomes include bedridden state or death at 90-days and symptomatic intracranial hemorrhage (sICH).

Results: 268 patients were included. 150 patients were selected for BAO EVT by conventional imaging, 86 by CTP, and 32 by MR. Patients selected by advanced imaging were significantly older than those selected by conventional imaging (median age 71 vs 64 years, p = 0.001); patient characteristics were otherwise similar between cohorts. After PSM, 90-day outcomes were similar between the two cohorts (p = 0.56), with similar rates of functional independence (39.4% vs 35.1%, p = 0.65), bedridden state or death (40.4% vs 44.7%, p = 0.66), and sICH (3.3% vs 5.7%, p = 0.49) for conventional and advanced imaging groups, respectively. Results were similar across treatment time windows (all p > 0.05).

Conclusions: Selecting patients for basilar EVT using conventional versus advanced imaging did not result in different clinical outcomes, regardless of treatment time windows. Conventional imaging appears sufficient as a first-line tool for selecting basilar EVT patients in routine clinical practice.

Introduction: Complications may secondarily impair functional outcome after stroke and transient ischemic attack (TIA). Here, we estimated the population-level impact of complications on long-term functional outcome to describe their combined impact and identify the most impactful complications.

Patients and methods: Patients admitted for acute ischemic stroke or TIA (ABCD2 score ⩾ 3) and discharged without severe disability were followed-up for occurence of 12 in-hospital and 26 post-discharge complications. Population-level impact of complications on the primary endpoint of non-excellent functional outcome (modified Rankin Scale (mRS) > 1) at end of follow-up 12 months after stroke was assessed by population attributable fraction (PAF). This cohort study was performed at a single European comprehensive stroke center and nested within a randomized controlled trial of intensified post-stroke care, STROKE-CARD.

Results: Among 1705 patients aged 69.4 ± 13.6 years (59.8% male), 36.8% (95% confidence interval: 34.5, 39.2) had non-excellent outcome at 12 months, 21.3% (19.4, 23.3) had unfavorable outcome (mRS > 2), and functional worsening occurred in-hospital in 2.6% (2.0, 3.6) and post-discharge in 20.3% (18.4, 22.3). Non-excellent 1-year functional outcome was predicted in-hospital by occurrence of recurrent stroke, neurological worsening, and infections (PAF: 0.6%-3.2%). Post-discharge, 12 complications significantly predicted outcome, and pain, severe fatigue, falls, and depression were most impactful (PAF: 5.4%-13.0%). Together, in-hospital complications accounted for 7.6% and post-discharge complications for 31.8% of non-excellent outcome, whereas acute therapy (thrombolysis and/or thrombectomy) and STROKE-CARD care accounted for 8.0% and 14.5% of excellent outcomes. In moderate and severe stroke (NIHSS > 5), acute therapy was the strongest predictor of excellent outcome (PAF: 29.1%). Results were consistent or stronger in patients with TIA, without prestroke disability, or in the regional catchment area, and when focusing on unfavorable outcome or worsening in mRS.

Discussion: Complications were responsible for more than one third of non-excellent 1-year functional outcome with pain, severe fatigue, depression, and falls most impactful. Complications rivaled the impact of acute therapy and determined functional outcome after TIA as well as after stroke.

Conclusion: Effective prevention and treatment of complications may substantially improve long-term functional outcomes after stroke and TIA.

Introduction: Covert brain infarctions (CBIs) are associated with cardiovascular risk factors (cvRFs). We aimed to evaluate the presence and therapeutic implications of modifiable cvRFs in patients with incidentally discovered CBI on routine neuroimaging.

Patients and methods: The SILENT cohort (NCT05685069) is a prospective, multicentred European cohort recruiting patients with incidentally detected focal CBIs on routine MRI, without prior clinical stroke. Modifiable cvRFs and their control were assessed using applicable international guidelines during a dedicated outpatient visit, including a clinical examination and laboratory work-up. Associations between cvRF profiles and the number of CBIs were analysed using linear regression.

Results: We included 231 patients (mean age 65 years, n = 130 [56%] male) with a total of 445 CBI lesions. Most CBIs were of lacunar type (n = 226; 51%) and the most common location was the cerebellum (n = 220; 50%). One hundred and fifty (65%) patients had at least 1, 112 (49%) at least 2 and 56 (24%) at least 3 known modifiable cvRFs. Among hypertensive patients, 69 (53%) had uncontrolled hypertension; 22 (65%) of diabetics were insufficiently controlled and 74 (58%) patients with dyslipidaemia had poorly controlled low-density lipoprotein cholesterol. Therapeutic measures were made for 144 patients (62%), including antiplatelet initiation in 107 (46%) and a statin in 69 (30%). The number of cvRFs per patient was significantly associated with the number of CBIs, rate ratio 1.08 (95% Confidence Interval (CI), 1.04-1.13).

Conclusion: In patients with incidentally discovered CBI, we found a high burden of poorly controlled cvRFs. Our findings highlight the importance and yield of a dedicated clinical and laboratory assessment of cvRFs in patients with CBIs.

Background: Recent trials have furthered uncertainty regarding the endovascular benefit for medium vessel occlusions (MeVO). Stent retrievers (SR) were employed in the first attempt in most interventional arm participants. We sought to compare outcomes in acute MCA M2 occlusions between frontline aspiration and SR, and to delineate procedural and anatomical covariates associated with differential treatment effect.

Methods: Retrospective analysis of a multicenter stroke thrombectomy cohort identified cases of MT for M2 occlusions. Unmatched and propensity score-matched (PSM) cohorts were generated comparing frontline aspiration to standalone and combined SR. The primary outcome was functional independence (mRS 0-2) at 90 days. Recanalization, symptomatic intracranial hemorrhage (sICH), mortality, and the effect of M2 laterality, division occlusion and procedure time were assessed.

Results: About 1734 patients with M2 occlusions underwent either frontline aspiration (n = 711) or SR/combined (n = 958) thrombectomy between 2013 and 2024. PSM analysis favored aspiration for functional independence (49.9% vs 44.0%, OR 1.27 (1.03-1.57)), complete recanalization (61.2% vs 48.7%, OR 1.66 (1.34-2.05)), complete first pass effect (35.0% vs 27.6%, OR 1.42 (1.13-1.78)), and sICH (3.5% vs 6.2%, OR 0.55 (0.33-0.91)), with no difference in mortality. Frontline aspiration had significantly shorter procedural times (median 28 [IQR 15-49.5] vs 51 [IQR 35-78] minutes; p < 0.001). For every minute increase in procedure time, the probability of functional independence decreased significantly (p < 0.001) less with frontline aspiration (0.35%) compared to SR/combined (1.61%).

Conclusion: Frontline aspiration for M2 occlusions resulted in better clinical and angiographic outcomes compared to SRs. Future trials for MeVO with a focus on contact aspiration thrombectomy may succeed where recent trials have failed.

Introduction: Non-invasive convective head cooling is a promising putative neuroprotective therapy for ischemic stroke patients as it may portably, non-invasively, and selectively cool the ischemic penumbra. We aimed to investigate the feasibility of utilizing non-invasive convective head cooling in ischemic stroke patients before and during endovascular thrombectomy (EVT).

Patients and methods: We conducted a multi-center, prospective, non-randomized, open-label trial at two comprehensive stroke centers in ischemic stroke patients where EVT was planned. Patients were assessed for eligibility in the emergency department (ED) and had a cooling cap fitted that circulated coolant between -5°C and 0°C until EVT completion. The primary feasibility endpoint was adherence, defined as tolerating cooling for ⩾50% of the time from cooling cap application until EVT completion.

Results: Between July and November 2024, 40 EVT patients (19 (47.5%) female, mean ± SD age 71.6 ± 12.6 years) underwent a median (IQR) duration of convective head cooling of 86 (58-106) min. Thirty-nine (97.5%) participants met the primary feasibility endpoint. The enrollment rate was five participants per site per month. Median (IQR) time from comprehensive stroke center arrival to cooling start was 10 (5-51) min. Thirty-two (80%) patients received general anesthesia. eTICI 2b-3 reperfusion was achieved in 38 (95.0%) participants. Median (IQR) 24-h infarct volume was 14.3 (5.5-29.1) mL. Median (IQR) 3-month modified Rankin Scale score was 2 (1-5). Three-month mortality occurred in 8/38 (21.1%) participants. Nine serious adverse events occurred in 8 (20.0%) participants, none of which were attributed to head cooling.

Conclusions: Convective head cooling is feasible in patients undergoing EVT and warrants further investigation in larger randomized controlled trials.