European Stroke Journal最新文献

Introduction: Data on safety of endovascular therapy (EVT) in the very elderly are scarce. Using data from a large prospective EVT registry, we aimed at providing better evidence for EVT decision-making in patients aged 90 years and older.

Patients and methods: In this multicentre observational study from the EVA-TRISP collaboration outcomes were compared between patients aged ⩾90 years with those aged <90 years using multivariate logistic regression analysis and reporting odds ratios and 95% confidence intervals. Outcomes were occurrence of poor functional outcome in survivors (modified Rankin Scale (mRS) 3-5 if pre-stroke mRS 0-2 and mRS higher than pre-stroke mRS if pre-stroke mRS 3-5), mortality at 3 months after stroke, unsuccessful recanalization (mTICI 0-2a) and symptomatic intracranial hemorrhage (sICH, defined by ECASS-II-/III-criteria).

Results: Of 13,306 eligible patients, 892 were ⩾90 years old (6.7%). The very elderly had a higher median National Institutes of Health Stroke Scale (NIHSS) on admission (16 vs 14) and were more likely to have a pre-stroke mRS of 3-5 (38.0% vs 8.7%). The odds of poor functional outcome (ORadjusted 2.35 (95%-CI 1.87-2.97); 61.6% vs 38.7%), death (ORadjusted 3.04 (95%-CI 2.60-3.55); 53.9% vs 21.3%) and unsuccessful recanalization (ORadjusted 1.34 (95%-CI 1.14-1.57); 32.4% vs 27.2%) were higher in patients aged ⩾90 years. The odds of sICH did not differ (ORadjusted 0.92 (95%-CI 0.66-1.28); 5.1% vs 5.0%).

Discussion and conclusion: EVT-treated stroke patients ⩾90 years had higher odds of poor functional outcome, mortality and unsuccessful recanalization than younger patients. However, the probability of sICH after EVT was not increased. The decision in favor of or against EVT in the very elderly should not be based on age alone.

Rationale: Intra-arterial fibrinolytics may be used for distal remaining vessel occlusions after incomplete mechanical thrombectomy (MT). However, their efficacy in improving reperfusion in this specific clinical scenario is unclear. While better reperfusion may lead to improved clinical outcomes, additional fibrinolytics could also increase the risk of hemorrhagic complications.

Aim: To assess the safety and reperfusion efficacy of intra-arterial tenecteplase (TNK) compared to no further interventional treatment in patients with incomplete reperfusion and mechanically non-amendable residual occlusions after MT.

Methods and design: This is an international, multicenter, randomized (1:1) controlled, two-arm, open, assessor-blinded, surrogate endpoint trial. The interventional arm receives 3 mg (not weight-adjusted) intra-arterial TNK, administered as close as possible to the residual occlusion. The control arm receives no further interventional treatment.

Sample size: TECNO will randomize 156 participants 1:1 to 3 mg intra-arterial tenecteplase or no further interventional treatment. This sample size is based on anticipated absolute improvements in early and late reperfusion with intra-arterial TNK of 25% and 30%, respectively.

Outcomes: The two co-primary imaging outcomes are early and late reperfusion. Early reperfusion is defined as an extended Thrombolysis in Cerebral Infarction (eTICI) score ⩾ 2a for residual occlusions on angiography 25 min after randomization. Late reperfusion is defined as the absence of a wedge-shaped perfusion delay on delay-sensitive perfusion maps assessed on 24 h ± 6 h perfusion imaging. Standard secondary clinical outcomes will be assessed at 24 h and 90 ± 15 days.

Discussion: The TECNO trial will provide evidence on the safety and reperfusion efficacy of locally administered intra-arterial TNK in patients with residual occlusions following MT.

Introduction: Neutral results from trials assessing mechanical thrombectomy (MT) for medium/distal vessel occlusions (MDVO) suggest the need for better selection criteria in these patients. Tortuous vascular anatomies may negatively influence MT efficacy and safety.

Patients and methods: Consecutive patients with middle cerebral artery (MCA)-MDVO (M2/M3) who underwent MT at our center between January 2017 and September 2024 were included. Baseline CTAs were semi-automatically analyzed using an in-house vascular analysis framework. The internal carotid artery (ICA) tortuosity index (TI) and anatomical features of the MCA were extracted. Logistic regression adjusted for intravenous thrombolysis administration and onset-to-puncture time evaluated associations of anatomical features with treatment efficacy and safety endpoints. Primary endpoints were complete recanalization (final eTICI 2c/3) and symptomatic intracranial hemorrhage (sICH).

Results: 213 patients (81 years IQR 72-87, 51.2% female) were included. MCA bending length (aOR 0.48 [95%CI 0.27-0.86], p = 0.013), MCA-TI (aOR 0.77 [0.60-0.98], p = 0.032) and ICA-TI (aOR 0.59 [0.36-0.96], p = 0.034) were associated with lower probability of complete recanalization. ICA-TI (aOR 0.51 [0.31-0.84], p = 0.008) and mean MCA diameter (aOR 0.34 [0.13-0.90], p = 0.030) correlated with decreased odds of first-pass recanalization. Large mean MCA diameter was associated with lower likelihood of excellent functional outcome (aOR 0.30 [0.09-0.96], p = 0.042). Regarding safety endpoints, larger diameter at occlusion was associated with sICH (aOR 4.04 [1.03-15.87], p = 0.046), while MCA bending length (aOR 2.47 [1.24-4.92], p = 0.010) was linked to subarachnoid hemorrhage.

Discussion: Automatic evaluation of anatomical vascular features may predict safety and efficacy of MT in stroke patients with MCA-MDVO. The value of these features as inclusion criteria for future MCA-MDVO clinical trials should be explored.

Conclusion: Intracranial vascular tortuosity is associated to poor thrombectomy outcomes in patients with MDVO.

Introduction: Whether sex influence the clinical pathway of stroke, has been debated. In this study, we want to compare and add knowledge to presentation of symptoms and time to treatment of cerebral infarction in men and women.

Patients and methods: Data on 38,489 patients with cerebral infarction from 2018 to 2022 were obtained from the Norwegian Stroke Registry (NHR). The analyses were stratified by sex and age groups.

Results: Overall, there was a substantial sex parity for both focal neurological deficits and time to treatment. However, women were less likely to be awake at admission (RR 0.96, CI 0.95-0.97). A higher proportion of women presented with FAST symptoms (RR 1.06, CI 1.04-1.07), and women presented more often with arm paresis (RR 1.11, CI 1.08-1.14), facial paresis (RR 1.08, CI 1.05-1.11), aphasia (RR 1.17, CI 1.13-1.21), leg paresis (RR 1.18, CI 1.15-1.21) and neglect (RR 1.24, CI 1.18-1.31). Men presented more often with ataxia (RR 0.85, CI 0.81-0.89) and double vision (RR 0.72, CI 0.64-0.81). At admission, women had significantly higher National Institutes of Health Stroke Scale (NIHSS) score compared to men (average 5.60 vs 4.66), and significantly longer time from symptom onset to notification of Emergency Medical Communication Center (EMCC; average 298 vs 282 min).

Discussion and conclusion: Our findings indicate a large degree of sex equality in terms of symptoms and time to treatment for Norwegian patients with cerebral infarction. Further research exploring possible sex disparity in stroke treatment, is warranted.

Introduction: Early recurrence (ER) after an acute stroke event (ASE; ischemic or hemorrhagic) in patients with atrial fibrillation (AF) presents a therapeutic challenge due to the need to balance ischemic prevention with hemorrhagic risk. This study aimed to quantify ER incidence, both ischemic and hemorrhagic, and identify its predictors using real-world data from a prospective registry.

Patients and methods: Retrospective analysis of patients with AF, either known or detected within 6 months, who were admitted for a first-ever ASE to a tertiary stroke center between 2005 and 2024. ER was defined as any recurrent event within 6 months. Baseline characteristics, CHA2DS2-VASc score, CHADS-VA score, stroke severity, anticoagulation type, AF detection timing, and monitoring duration were recorded. Cox and Fine-Gray models identified independent predictors.

Results: Among 1795 patients, 108 (6.0%) experienced ER. The cumulative incidence was 6.3% (95% CI 5.1-7.4), and most events occurred within the first 30 days. Independent predictors included higher CHA2DS2-VASc score (sHR = 1.252, p = 0.023), lower initial stroke severity (sHR = 0.918, p < 0.001), concomitant stroke etiologies (sHR = 2.008, p = 0.001), and AF detected within 30 days after stroke (sHR = 1.644, p = 0.026). DOAC use was protective (sHR = 0.484, p = 0.003), while VKA showed a non-significant trend (sHR = 0.637, p = 0.068). Interaction analysis showed increased recurrence risk only in non-anticoagulated patients with AF detected after stroke. These findings were consistent across sensitivity analyses restricted to ischemic stroke, incorporating time-dependent anticoagulation, or comparing CHADS-VA and CHA2DS2-VASc scores.

Conclusions: ER, predominantly ischemic, occurred mainly within 30 days. Risk factors included AF detection timing, CHA2DS2-VASc score, stroke severity, concomitant causes, and anticoagulation status, supporting early risk stratification and DOAC initiation.

Introduction: In patients with intracerebral haemorrhage (ICH), perihaematomal oedema (PHO) is considered a marker of secondary injury and is associated with worse functional outcomes. Minimally invasive surgery (MIS) has been suggested to reduce PHO when performed within 72 h of symptom onset. However, the effect of early surgery on PHO formation remains unclear. We aimed to determine the effect of MIS within 8 h of ICH onset on PHO formation.

Patients and methods: We included patients with spontaneous, supratentorial ICH ≥10 mL undergoing MIS within 8 h from the DIST-pilot study and compared them to patients receiving standard care from a cohort study. ICH and PHO volumes at baseline and 24(±12) h were manually segmented. The primary outcome was absolute PHO (aPHO) volume at 24 h. Secondary outcomes included aPHO growth between baseline, and 24 h and oedema extension distance (OED).

Results: We included 34 patients (median age 61 years, 68% male) undergoing MIS and 16 patients (median age 65 years, 69% male) receiving standard medical care. At baseline, median ICH, aPHO and OED volume were similar between groups. Median aPHO volume at 24 h was similar between groups (median difference -3.0 mL, 95% CI, -19.4 to 9.8, P =.67), while median aPHO growth was smaller in the MIS-group (median difference -6.8 mL, 95% CI, -18.67 to 0.33, P =.002). Median OED was greater in the MIS-group (median difference 0.18 cm, 95% CI, 0.05-0.40, P =.002).

Conclusion: Absolute PHO growth in the first 24 h after ICH was less pronounced after early MIS than after standard care, suggesting that early MIS may ameliorate secondary injury after ICH.

Introduction: Observed disparities in stroke care between the biological sexes are based on observational data from stroke centres or focus on single aspects of stroke care. Hence, we offer a comprehensive analysis encapsulating the entire stroke treatment path.

Patients and methods: The quality-controlled, population-based Tyrolean Stroke Care pathway, recording all ischemic stroke cases in the entire federal state independent of treating hospital or department, was applied. Data from all patients (2019-2023) were analysed, which encompass information from stroke call activation to the time of recurrent stroke associated re-hospitalisation.

Results: 5733 ischemic stroke cases (men/women 56.0%/44.0%) were recorded with an incidence of first ever stroke of 133/100,000 inhabitants. Men were numerically more likely to suffer a stroke during that time period (149 vs 118/100,000 respectively). After adjusting for age, National Institute of Stroke Scale, and the pre-stroke modified Rankin Scale, no differences in pre-hospital stroke care, post-stroke rehabilitation access as well as most in-hospital metrics were seen. Still, women were less likely to be admitted to stroke units (odds ratio [OR] 0.89 [0.80, 1.00]) and less frequently underwent MRI (OR 0.85 [0.74, 0.96]) or echocardiography (OR 0.85 [0.76, 0.96]) during their hospital stay. However, women less frequently suffered serious post-stroke in-house complications (OR 0.80 [0.66, 0.97]). Upon follow-up, men had higher rates of all cause-mortality (OR 0.81 [0.69, 0.94]) as well as recurrent stroke-related re-admission (OR 0.63 [0.48, 0.83]).

Conclusion: Within a highly structured and quality-controlled stroke care pathway, disparities in stroke care between sexes are low. Differences exist in terms of diagnostic algorithms, post-stroke mortality and recurrent stroke-related re-admissions, which merit further research.

Introduction: ICH is a common complication following endovascular therapy (EVT) for ischaemic stroke. While sICH is known to worsen outcomes, the impact of ICH without early neurological deterioration (END), commonly referred to as "asymptomatic" (aICH), remains controversial. This study aimed to assess imaging patterns of aICH and its effect on clinical outcomes.

Patients and methods: This study used data from the prospective, multicentre German Stroke Registry-Endovascular Treatment. Bleedings were assessed on follow-up imaging at 24 hours applying the Heidelberg Bleeding Classification. European Cooperative Acute Stroke Study III (ECASS)-III criteria were used to stratify patients into (1) no ICH, (2) aICH and (3) sICH. The primary outcome was functional independence (mRS ≤ 2) at 3 months. Secondary outcomes included mRS shift and 3-month mortality.

Results: Among 4834 patients with EVT (median age 76, 51% female, median NIHSS 14), ICH occurred in 13.2% (aICH: 9.7%, sICH: 3.5%). Haemorrhage patterns differed, with sICH being more often parenchymal (48.2% vs 34.6%), multicompartmental (34.1% vs 20.2%) and involving the ventricular system (18.8% vs 7.6%), while aICH were predominantly haemorrhagic transformation (34.6% vs 21.8%). Functional independence at 90 days was reached by 40.0% (no ICH), 25.4% (aICH; adjusted odds ratio [aOR] 0.43 [0.32-0.58]) and 6.5% (sICH; aOR 0.06 [0.03-0.14]), respectively. aICH was associated with worse overall recovery (mRS shift adjusted common OR 0.51 [0.41-0.63]) and higher 90-day mortality (35.5% vs 24.9%; aOR 1.90 [1.44-2.51]), when compared to no ICH.

Conclusion: ICH after EVT was associated with worse functional recovery and higher mortality, even in the absence of END. Given these results, the term "asymptomatic ICH" warrants reconsideration.

Introduction: Focused cardiac ultrasound (FoCUS) has a high diagnostic yield and a rapid theoretical learning curve. FoCUS can be applied in stroke assessments performed by stroke neurologists when a cardioembolic stroke is suspected.

Patients and methods: An international multicenter, prospective validation study was conducted to assess neurologists' ability to perform FoCUS. The FoCUS examination was defined as a simplified 2D transthoracic echocardiography. Neurologists and cardiologists performed the FoCUS independently and blinded. A twenty-question test evaluated neurologists' ability to recognize sources of cardioembolic stroke from recorded FoCUS studies.

Results: A total of 432 paired studies involving 216 patients were conducted across 11 centers. No significant differences were found between neurologists and cardiologists in detecting: Left Ventricle (LV) dysfunction (7.4% vs 7.9%, p = 0.834), LV dilation (2.8% vs 2.3%, p = 0.766), VC collapsibility (7.2% vs 9.1%, p = 0.501), Right Ventricle dysfunction (0.9% vs 0.9%, p = 0.999), and pericardial effusion (0.5% vs 1.9%, p = 0.212). Cohen Kappa showed substantial agreement for LV dysfunction (0.640), moderate for LV dilation (0.589), and fair for VC collapsibility (0.226). Neurologists demonstrated 93.82% sensitivity and 92.92% specificity for detecting embolic sources. Success rate for LV akinesia was 88% (16/18), LV dysfunction 83% (15/18), complex aortic plaque 88% (16/18), and mitral stenosis 55% (10/18).

Discussion and conclusion: Properly trained neurologists can reliably perform FoCUS, particularly for assessing LV function and dilation, with better results in patients with favorable echocardiographic windows. While VC assessment requires further training, neurologists demonstrated high accuracy in identifying cardioembolic sources (over 90% of cases correctly identified). This study supports implementing standardized FoCUS training for neurologists through collaboration with cardiology specialists to enhance stroke diagnostics and management.