European Stroke Journal最新文献

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.

Introduction: Blood-brain barrier disruption in acute ischemic stroke is a well described phenomenon associated with hemorrhagic complications. The hyperintense acute reperfusion marker (HARM) represents gadolinium leakage in the cerebrospinal fluid. Gadolinium leakage into ocular structures (GLOS) might represent a dysfunction of the blood-ocular barrier. We aimed to investigate the presence of GLOS in the WAKE-UP trial and its association with HARM, hemorrhagic transformation (HT) and functional outcome.

Patients and methods: Randomized patients from the WAKE-UP trial who underwent dynamic susceptibility contrast perfusion weighted imaging at baseline and fluid attenuated inversion recovery (FLAIR) imaging at both baseline and follow-up, were included. We studied the association between GLOS with baseline and outcome variables.

Results: We were able to analyze the data of 192/503 (38%) randomized WAKE-UP patients. GLOS was detected in 56 (29%) cases, four times more frequently than HARM (7%). GLOS positive patients were older (73 vs 65 years; p < 0.01), had a lower glomerular infiltration rate (GFR 79.5 vs 87.2 mL/min; p = 0.01), higher white matter hyperintensity volume (15.0 vs 9.9 mL; p < 0.01), less often presented with a large vessel occlusion (27% vs 44%; p = 0.02) and HARM was more often observed (9/56 vs 4/136; p = 0.01). In multivariable analysis the presence of GLOS was not associated with HT nor poor functional outcome (modified Rankin scale 3-6).

Discussion and conclusion: GLOS is a relatively common finding in acute ischemic stroke patients and is associated with older age, worse renal function, increased white matter hyperintensity burden and HARM but not with HT or functional outcome.

Introduction: The impact of streamlining algorithms for stroke patients on process times in pre-hospital emergency medicine (PHEM) is not well investigated. We analyzed the changes in pre- and in-hospital process times after implementation of a streamlining algorithm in a physician staffed PHEM system.

Patients: We conducted a prospective observational study and analyzed process times of adult stroke patients attended by emergency physicians (EP) of the city of Göttingen PHEM service after implementation of a streamlining algorithm including stroke triage using the FAST-ED score. Stroke patients with standard emergency treatment attended before the implementation served as a control group. All patients were transported directly to the University Medical Center Göttingen (UMG) and received endovascular therapy (EVT) and/or systemic thrombolytic therapy.

Results: Of 75 suitable patients eligible in the study group, 37 (49.3%) received EVT and were compared to 44 patients in the control group. Pre-hospital process times did not differ significantly. Median door-to-CT time (12 vs 18 min, p = 0.017) and door-to-lysis time (20 vs 24 min, p = 0.005) were significantly shorter in the study group. Door-to-groin time was also shortened in the study group (42 vs 49 min) but not significantly (p = 0.088).

Discussion and conclusions: Our findings indicate that a PHEM streamlining algorithm (namely the FAST-ED score) can significantly shorten in-hospital process times without delaying pre-hospital care. This improved coordination between PHEM and in-hospital emergency medicine (IHEM) may enhance neurological outcomes for stroke patients. Further research is needed to confirm these results and assess their applicability in other healthcare settings.

Introduction: Atrial fibrillation (AF) burden progresses with time. Among ischemic stroke (IS) patients, AF can be detected at different burden progression stages based on the timing and screening method. We hypothesized that AF detected after IS on 12-lead ECGs (ECG-AF) and via 14-day-Holter prolonged cardiac monitoring (AFDAS) are linked to lower IS recurrence risk than AF known before stroke occurrence (KAF) because of being at an earlier progression stage than KAF. Additionally, we posited that IS recurrence risk differences between AF types vary over time due to their differential progression stages.

Patients and methods: Retrospective observational cohort study including IS/TIA patients with KAF, ECG-AF, and AFDAS [2018-2021]. Adjusted hazard ratios (aHR) were estimated using multivariable cause-specific Cox proportional-hazard models to compare IS recurrence between ECG-AF versus KAF and AFDAS versus KAF. Proportional hazards assumptions were tested to assess whether IS recurrence risk differences were time-varying.

Results: Of 758 AF patients (385 KAF, 236 ECG-AF, 137 AFDAS), 603 received anticoagulation and 59 experienced a recurrent IS after 1441 patient-years of follow-up. No IS recurrence risk differences were observed at the end of follow-up between ECG-AF and KAF (aHR 0.67, 95% CI 0.36-1.26), although ECG-AF showed lower risk only within the first year (aHR 0.15; 95% CI 0.04-0.56). AFDAS exhibited a lower IS recurrence risk than KAF (aHR 0.22, 95% CI 0.08-0.63), without time-varying differences.

Discussion: Differences in IS recurrence risk between ECG-AF and KAF varied over time. However, AFDAS showed a consistently lower IS risk than KAF throughout the entire study period.

Introduction: To investigate the clinical characteristics in patients without traditional risk factors (TRFs) after transient ischemic attack or minor ischemic stroke, who were recruited in the TIAregistry.org.

Patients and methods: A total of 3847 patients were analyzed. TRFs included hypertension, diabetes, hypercholesterolemia, current smoking, and atrial fibrillation. Background characteristics and outcomes at 1 and 5 years in patients without TRFs were compared to those in patients with TRFs. The primary outcome was major cardiovascular event (MACE), which was non-fatal stroke, non-fatal acute coronary syndrome, or vascular death. To evaluate the causes, we applied the ASCOD (atherosclerosis, small vessel disease, cardiac pathology, other causes or dissection) grading system.

Results: One-year risk of MACE (5.3% vs 6.3%, hazard ratio (HR) 0.84, 95% confidence interval (CI) 0.53-1.31) was comparable between patients without TRFs (n = 402) and those with TRFs (n = 3445). Five-year risk of MACE was significantly lower in patients without TRFs than in those with TRFs (7.9% vs 13.9%, HR 0.57, 95% CI 0.39-0.82). In patients without TRFs, causal atherosclerosis was a potent risk factor (HR 5.67, 95% CI 2.68-12.02) and ipsilateral extra- or intra-cranial arterial stenosis was only significant predictor of MACE (interaction p = 0.0046) at 5 years.

Conclusion and discussion: The 5-year risk of MACE was lower in patients without TRFs than those with TRFs, although a certain level of risk persisted in the absence of TRFs. The most significant predictor of MACE in patients without TRFs was arterial stenosis.

Introduction: Data on safety and efficacy of endovascular thrombectomy (EVT) for acute ischemic stroke in older patients are limited and controversial, and people aged 80 or older were under-represented in randomized trials. Our aim was to assess EVT effect for ischemic stroke patients aged ⩾80 at a nationwide level.

Patients and methods: The cohort included stroke patients undergoing EVT from the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS). Patients were a priori divided into younger and older groups (<80 vs ⩾80). Primary outcome was good functional outcome (modified Rankin scale, mRS, 0-2 at 90 days). Secondary outcomes were symptomatic intracranial hemorrhage (sICH), successful reperfusion, EVT abortion. Propensity score matching (PSM) was performed between age groups for baseline features, functional status, stroke severity and neuroradiological features. Logistic regression was implemented to test the weight of age group on the predefined outcomes.

Results: Overall, 5872 individuals (1:1 matching, n = 2936 aged ⩾80 vs n = 2936 < 80) were matched from 13,922 records. In ⩾80 group 34.1% had good functional outcome, vs 51.2% in <80 group (absolute difference = -17.1%, p < 0.001), with a 4.4% excess in EVT abortion. Age ⩾80 was a negative independent predictor of good functional outcome (aOR = 0.4, 95% CI = 0.3-0.5), but had no impact on sICH.

Discussion and conclusion: Age ⩾80 years represents a consistent predictor of worse functional outcome, independently from successful reperfusion and sICH. Cost-effectiveness studies are needed for tailored and implement sustainable care, and research should focus on strategies to improve functional outcome in older age patient groups.

Introduction: There is an unmet need for improved detection of intracranial aneurysms (IAs) and distinction between stable and unstable (high rupture risk) IAs. Within the IA wall, synthesis and degradation of type I collagen as the main molecular constituent balance each other to maintain IA stability. We hypothesized that collagen breakdown products could serve as molecular markers for IA presence and instability.

Patients and methods: This prospective, cross-sectional, single-center study included patients with unstable (growing/symptomatic/ruptured) and stable IAs and controls. We determined C-telopeptide (CTx) and c-terminal telopeptide (ICTP) as breakdown products of type I collagen in arterial and venous blood.

Results: We included 107 participants with IAs (52 stable/44 unstable) and 41 controls. The correlation between intra-aneurysmal and venous levels was r = 0.63 (p < 0.001) for ICTP, r = 0.55 (p = 0.001) for CTx. The odds of harboring an IA were five times higher for participants with high compared to low venous levels of collagen breakdown products (ICTP: odds ratio (OR) 4.9 (95% CI 1.1-22.7); CTx: OR 5.3 (95% CI 1.4-20.0)). The OR for having an unstable IA was 9.3 (95% CI 2.1-41.5) for patients with high compared to low venous ICTP levels. The area under the curve for ICTP levels as a marker for IA instability was 0.75.

Discussion and conclusion: Increased levels of venous collagen breakdown products, especially ICTP levels, could serve as a biomarker for IA presence and instability and complement current data for management of unruptured IAs on an individual patient level. Future studies with longitudinal data are needed to validate ICTP as a biomarker for high risk IAs.

Introduction: The risk of dementia in patients with stroke-heart syndrome (SHS) remains unexplored.

Patients and methods: Retrospective analysis using the TriNetX network, including patients with ischaemic stroke from 2010 to 2020. These patients were categorised into two groups: those with SHS (heart failure, myocardial infarction, ventricular fibrillation, or Takotsubo cardiomyopathy within 30 days post-stroke) and those without SHS. The primary outcome was the 1-year risk of dementia (vascular dementia, dementia in other disease, unspecified dementia, or Alzheimer's disease). The secondary outcome was the 1-year risk of all-cause death. Cox regression analysis after 1:1 propensity score matching (PSM) was performed to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) for the outcomes.

Results: We included 52,971 patients with SHS (66.6 ± 14.6 years, 42.2% females) and 854,232 patients without SHS (64.7 ± 15.4 years, 48.2% females). Following PSM, 52,970 well-balanced patients were considered in each group. Patients with SHS had a higher risk of incident dementia compared to those without SHS (HR 1.28, 95%CI 1.20-1.36). The risk was the highest during the first 31 days of follow-up (HR 1.51, 95%CI 1.31-1.74) and was mainly driven by vascular and mixed forms. The increased risk of dementia in patients with SHS, was independent of oral anticoagulant use, sex and age but it was the highest in those aged <75 years compared to ⩾75 years.

Discussion and conclusion: SHS is associated with increased risk of dementia. Future studies are needed to develop innovative strategies for preventing complications associated with stroke-heart syndrome and improving the long-term prognosis of these patients.

Introduction: There is a lack of evidence for the optimal type of anesthesia technique in patients ⩾ 90 years with acute ischemic stroke undergoing mechanical thrombectomy (MT) as this subgroup of patients was often excluded or under-represented in previous trials. We aimed to compare outcomes between general anesthesia (GA) and non-GA techniques in patients ⩾ 90 years with large vessel occlusion (LVO) undergoing MT.

Patients and methods: Our study included patients ⩾ 90 years with anterior circulation LVO, NIHSS ⩾ 6, ASPECTS ⩾ 5 consecutively treated with MT within 6 h after stroke onset in three thrombectomy capable centers between January 1st, 2016 and March 30th, 2023. Inverse probability weighting (IPW) was used to reduce bias by indication of the anesthesia type on study outcomes. We used a weighted ordinal robust logistic regression analysis to explore the primary outcome of modified Rankin Scale (mRS) shift at 90 days in GA versus non-GA treated patients. Secondary outcomes included 90-day mortality, symptomatic intracranial hemorrhage (sICH) and TICI score of 2b, 2c, or 3.

Results: We included 139 patients ⩾ 90 years treated with MT, 62 were in GA group and 77 in non-GA group. There was a significant shift for worse mRS scores at 90-day in non-GA treated patients (cOR 3.65, 95% CI 1.77-7.77, p = 0.001). The weighted logistic regression showed that non-GA technique was an independent predictor of 90-day mortality (OR 7.49, 95% CI 2.00-28.09; p = 0.003).

Conclusion: Our study indicated that nonagenarians with acute ischemic stroke treated with MT without GA have a worse prognosis than their counterparts undergoing MT with GA. Further studies in larger cohorts are warranted to evaluate the optimal type of anesthesia in this patient population.