European Stroke Journal最新文献

Introduction: Infective endocarditis (IE) is a life-threatening condition and a rare cause of ischemic stroke (IS). This study aimed to evaluate the utility of analyzing cerebral thrombi, obtained through endovascular thrombectomy in IS, for the pathological diagnosis of IE.

Patients and methods: Cerebral thrombi from three groups of IS patients were compared: definite IE (n = 10), cardioembolic stroke without and with concomitant infection (CE-I^-: n = 30, CE-I⁺: n = 10). We performed histological examination, molecular biology, and microbiological tests on cerebral thrombi, to detect microorganisms and assess their composition.

Results: Median age of included patients was 73 years and 50% were females. Hematoxylin & Eosin and Grocott-Gomori Methenamine Silver stains detected microorganisms in all IE cerebral thrombi, and none in the control groups. Thrombus PCR detected relevant microorganism in n = 2/7 IE. Compared to control groups, IE thrombi were characterized by significant lower content of red blood cells (median [IQR]: IE = 7.4 [4.2-26.7], CE-I^- = 49.3 [17-62.6], CE-I⁺ = 57.5 [40.7-60.8], % over thrombus section area [%TSA], p = 0.001), increased von Willebrand Factor (IE = 23.9 [19.1-32], CE-I^- = 11.2 [8.2-12.8], CE-I⁺ = 12.9 [10.7-18.3], %TSA, p = 0.001), cell-dominant pattern of Neutrophil Extracellular Traps (IE = 100%, CE-I^- = 69%, CE-I⁺ = 70%, p ⩽ 0.001), and more frequent sub-acute or chronic thrombus age classification (p ⩽ 0.001). These latter thrombus features displayed good discriminative ability between IE and controls, with AUC values between 0.84 and 0.95.

Discussion: Multimodal analysis of cerebral thrombi in IS with suspected IE supports early and definite pathological diagnosis by detecting pathogens and assessing changes in thrombus composition.

Introduction: The degree of culprit artery stenosis affects the risk of early neurological deterioration (END) after acute ischemic stroke (AIS). The TREND trial demonstrated the efficacy of tirofiban in preventing END in patients with AIS. We aimed to investigate whether the degree of intracranial artery stenosis affects the efficacy of tirofiban in preventing END in patients with AIS.

Patients and methods: We conducted a post hoc analysis of the TREND trial, which enrolled patients within 24 h of onset and randomly allocated to receive intravenous tirofiban or oral aspirin. We stratified the stenosis degrees into three subgroups: no stenosis, mild-to-moderate stenosis (stenosis <70%), and severe stenosis or occlusion (stenosis ⩾70%). The primary endpoint is END₄ defined as an increase of the NIHSS ⩾4 within 72 h after randomization. Secondary outcomes include END₂ (defined as an increase of NIHSS ⩾2) within 72 h after randomization, the proportion of mRS 0-1 and 0-2 at 90 days.

Results: A total of 296 patients were analyzed. In patients with severe stenosis or occlusion, tirofiban significantly reduced the incidence of END₄ (5.7% vs 30.8%, adjusted OR 0.156, 95% CI 0.028-0.873, adjusted p = 0.034), whereas its effects in preventing END₄ were similar to those of aspirin in patients with no stenosis (2.4% vs 4.6%, adjusted OR 0.193, 95% CI 0.018-2.083, adjusted p = 0.175) or mild-to-moderate stenosis (2.9% vs 10.0%, adjusted OR 0.171, 95% CI 0.015-1.943, adjusted p = 0.155). The p value for interaction between stenosis subgroups and treatment was 0.513. Furthermore, tirofiban significantly reduced the incidence of END₂ in patients with mild-to-moderate stenosis (5.9% vs 22.5%, OR 0.146, 95% CI 0.022-0.951, adjusted p = 0.044) and severe stenosis or occlusion (11.4% vs 43.6%, adjusted OR 0.140, 95% CI 0.036-0.540, adjusted p = 0.004). A significant improvement in favorable outcomes with a 90-day mRS of 0-1 was observed only in patients with mild-to-moderate stenosis (85.3% vs 70.0%, adjusted OR 4.617, 95% CI 1.077-19.798, adjusted p = 0.039).

Discussion and conclusion: Tirofiban may significantly reduce the incidence of END in patients with severe arterial stenosis or occlusion. Further studies are required to confirm the effects of intracranial artery stenosis on the benefits of intravenous tirofiban.

Trial registration: ClinicalTrials.gov; identifier: NCT04491695.

Introduction: A better understanding of who will develop dementia can inform patient care. Although MRI offers prognostic insights, access is limited globally, whereas CT-imaging is readily available in acute stroke. We explored the prognostic utility of acute CT-imaging for predicting dementia.

Patients and methods: We included stroke or transient ischaemic attack (TIA) survivors from participating stroke centres in Scotland. Acute CT-scans were rated using ordinal scales for neurodegenerative and cerebrovascular changes (old infarcts, white matter lesions (WMLs), medial temporal lobe atrophy (MTA), and global atrophy (GA)) and combined together to a 'brain-frailty' score. Dementia status was established at 18-months following stroke or TIA.

Results: Among 195 participants, 33% had dementia after 3 years of follow-up. High brain-frailty score (⩾2/4) correlated with higher risk of dementia (HR (95% CI) 6.02 (1.89-19.21)). As individual predictor, severe MTA was most strongly associated with dementia (adjusted HR (95% CI) 2.09 (1.07-4.08)). Other predictors associated with dementia included older age, higher prestroke morbidity (mRS), WMLs, and GA. Integrated in a prediction model with clinical parameters, prestroke mRS, cardiovascular disease, GA, MTA and Abbreviated-Mental-Test were the strongest predictors of dementia (c-statistic: 0.77).

Discussion and conclusion: Increased brain-frailty, and its individual components (WMLs, MTA, and GA) are associated with a higher risk of dementia in participants with stroke. Combining clinical and brain-frailty parameters created a moderate dementia prediction model but added little value over clinical parameters in combination with cognitive testing. CT-based brain-frailty may provide better prognostic insights when cognitive testing isn't feasible and for identifying highest-risk individuals for dementia prevention trials to increase trial efficiency.

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.

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.

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: Distal arterial occlusions can cause measurable changes in the flow wave profile in proximal segments of the feeding artery. Our objective was to study the diagnostic accuracy of point-of-care ultrasound (POCUS) of the common carotid arteries (CCA) for detection of anterior circulation large vessel occlusion (ac-LVO) in patients with suspected stroke.

Patients and methods: We conducted a prospective, single-center, observational study of adult patients with suspected stroke admitted in the emergency department. Flow wave profiles of both CCAs were generated by non-specialists using POCUS as soon as possible after admission. ac-LVO was defined as an internal carotid artery or M1 occlusion in CT- or MR-angiography. The diagnostic performances for detection of ac-LVO using flow wave parameters were calculated.

Results: Among 283 patients recruited during a 10-month period, 257 patients (91%) had CCA ultrasound images of sufficient quality and were included for analysis. The mean age was 75 years (IQR 62-83), 131 were female (51.0%), median baseline NIHSS was 2 (IQR 0-5). The most frequent final diagnosis was ischemic stroke (49.4%), ac-LVO was present in 30 patients (11.9%). The median duration of POCUS was 3 min (IQR 2-5). Among all flow wave parameters, the highest diagnostic accuracy for ac-LVO detection was found for end-diastolic velocity difference between sides (AUC = 0.90, 95%CI = 0.85-0.93), with a specificity of 83% (95%CI = 78-88%) at a predefined sensitivity threshold of 80%.

Discussion and conclusion: POCUS of the CCA in patients with suspected stroke can predict the presence of ac-LVO. These results need to be replicated in a prehospital setting.

Background: The optimal acute management of patients with acute ischemic stroke and a tandem lesion, defined as intracranial large vessel occlusion (LVO) with concomitant carotid artery stenosis or occlusion, remains unclear. Our aim is to assess the efficacy and safety of immediate carotid artery stenting (CAS) compared to delayed management in patients undergoing endovascular treatment (EVT) for acute ischemic stroke due to tandem lesions.

Study design: CASES is a phase 3 multicenter prospective randomized open-label blinded endpoint (PROBE) non-inferiority clinical trial. Patients with a computed tomography angiography proven intracranial LVO in the anterior circulation and ipsilateral proximal carotid artery stenosis (⩾50%) or occlusion of presumed atherosclerotic origin will be randomized to either immediate CAS during EVT or to EVT followed by a deferred strategy, which may include carotid endarterectomy (CEA), CAS, or medical management. CASES will be conducted in 27 EVT centers in Belgium and the Netherlands. A total of 600 patients will be included.

Study outcomes: The primary outcome is the score on the modified Rankin Scale (mRS) at 90 days. Secondary outcomes include excellent (mRS 0-1) and good (mRS 0-2) functional outcome at 90 days, stroke severity measured with the National Institutes of Health Stroke Scale (NIHSS) at 24 h and 5-7 days, recanalization, infarct volume at 24 h, ischemic stroke recurrence, carotid artery re-occlusion, symptomatic intracranial hemorrhage, and mortality.

Summary: This study will provide high-quality randomized data on the efficacy and safety of immediate CAS in patients undergoing EVT for acute ischemic stroke due to a tandem lesion.

Trial registration: ClinicalTrials.gov NCT06511089; ISRCTN 14956654.

Introduction: The efficacy of different antiplatelet treatment in minor strokes (MSs) or transient ischemic attacks (TIAs) and that of antiplatelet and intravenous thrombolysis (IVT) in MSs remain controversial.

Methods: We searched PubMed, Embase, Web of Science and the Cochrane Library to identify all eligible articles until April 12, 2024. Efficacy outcomes were all-cause mortality, excellent outcome, functional independence and recurrent stroke. Safety outcomes were any types of bleeding and intracerebral hemorrhage (ICH). The associations were calculated for the overall data by using odds ratios (ORs).

Results: Twenty three high-quality studies with 10 RCTs and 13 non-RCTs were included, involving 47,135 patients with MSs or TIAs. In MSs or TIAs, dual antiplatelet therapies (DAPTs) significantly improved the modified Rankin Scale (mRS) scores for patients with recurrent stroke, major vascular events and ischemic stroke although it was associated with an increased risk of ICH and bleeding when compared to aspirin. In MSs, compared to IVT, DAPT had a significant advantage in improving the mRMS scores and SAPT and DAPT significantly reduced the risk of any bleeding or sICH. IVT significantly reduced all-cause mortality, although it also increased the risk of sICH and ICH compared to no IVT.

Conclusions: In MSs or TIAs, compared to aspirin, DAPTs can effectively prevent the recurrence of post-stroke neurological dysfunction and ischemic events, but it may increase the risk of ICH together with moderate or severe bleeding. Dipyridamole + aspirin resulted in the lowest risk of bleeding. In MSs, compared to IVT, DAPT may be associated with better improvements in neurological function, and it may not increase the risk of bleeding.

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.