European Stroke Journal最新文献

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: 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.

Introduction: Endovascular thrombectomy (EVT) is the treatment of choice for LVO stroke, yet nearly half of successfully recanalised patients fail to achieve functional independence, a phenomenon termed futile recanalisation (FR). Predictors of FR remain poorly defined in large, heterogeneous populations. Therefore, we aimed to develop a predictive score for FR.

Patients and methods: Endovascular thrombectomy-treated LVO patients from the prospective, multicentre EVATRISP collaboration were included. All patients had known pre-stroke functional status, modified thrombolysis in cerebral infarction (mTICI) score and 90-day mRS. Futile recanalisation was defined as mRS > 2 at 90 days despite mTICI ≥ 2b. Patients with FR were compared to those with successful recanalisation and mRS ≤ 2. The cohort was randomly split into derivation (70%) and validation (30%) sets. Multivariable logistic regression identified independent predictors that were used to construct the futile recanalisation following endovascular thrombectomy (FRET) score.

Results: Of 9909 patients, 7272 (73%) achieved successful recanalisation and 3420 (47%) of them experienced FR. In the derivation set, FR was independently associated with older age, diabetes, ischaemic heart disease, higher NIHSS, anterior cerebral artery occlusion, seizures at presentation, non-use of intravenous thrombolysis and lower Alberta Stroke Program Early CT Score (ASPECTS) or posterior circulation ASPECTS. Futile recanalisation patients had longer hospital stays and higher mortality rates. The FRET score demonstrated good discrimination (area under the curve [AUC] 0.721; 95% CI, 0.702-0.740), with FRET ≥ 3 indicating high risk. The validation cohort yielded similar performance (AUC 0.708; 95% CI, 0.680-0.737).

Conclusion: The FRET score enables early identification of EVT patients at high risk for FR.

Introduction: Asymptomatic moyamoya angiopathy (MMA) is increasingly detected through noninvasive imaging; however, its optimal management remains controversial. This multicenter retrospective cohort study compared outcomes in asymptomatic versus symptomatic MMA patients undergoing surgical revascularization.

Patients and methods: A total of 475 patients treated with bypass surgery across multiple academic centers were included, with 56 (11.8%) classified as asymptomatic and 419 (88.2%) as symptomatic. Baseline demographics, surgical characteristics, and outcomes-including perioperative stroke, intraoperative complications, and follow-up stroke events-were collected. Asymptomatic MMA was defined as the absence of any prior ischemic or hemorrhagic stroke, seizures, or other neurological symptoms at the time of diagnosis. Both unadjusted analyses and propensity score weighting using inverse probability of treatment weighting (IPTW) were performed to adjust for potential confounders.

Results: In the unadjusted analysis, asymptomatic patients had significantly lower rates of all perioperative strokes (1.7% vs 11.4%; p = 0.05) and intraoperative complications (1.7% vs 11.2%; p = 0.05) compared to symptomatic patients. Additionally, follow-up stroke rates were lower in the asymptomatic group (1.7% vs 11.2%; p = 0.05). After IPTW adjustment, the reduction in intraoperative complications (OR: 0.08, 95% CI: 0.01-0.64; p = 0.01) and follow-up stroke rates (OR: 0.12, 95% CI: 0.01-0.91; p = 0.04) persisted, while differences in overall perioperative stroke were not statistically significant.

Conclusion: Bypass surgery in selected asymptomatic MMA patients is associated with reduced intraoperative complications, and fewer follow-up stroke rates. These findings support the careful consideration of surgical intervention in asymptomatic patients, emphasizing the importance of patient selection for optimal outcomes.

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: Remote ischaemic conditioning (RIC) initiated pre-hospital did not improve 90-day functional outcomes after acute stroke in the RESIST trial. The duration of treatment pre-reperfusion modifies treatment effect for other neuroprotective therapies. We examined whether the effects of RIC might be modified by the duration of pre-hospital treatment.

Patients and methods: This post-hoc analysis of the RESIST randomised-controlled trial (ClinicalTrials.gov: NCT03481777) included patients who presented with pre-hospital stroke symptoms < 4 hours, randomised to RIC or sham, diagnosed with acute ischaemic stroke (AIS) or ICH (modified intention-to-treat [mITT] cohort). Patients were stratified by time from randomisation to hospital admission (ie, pre-hospital treatment duration). The primary outcome was shift in 90-day mRS; secondary outcomes were 90-day mRS 0-2 and 24-hour neurological improvement (NIHSS).

Results: Among 902 mITT patients (AIS, n = 737; ICH, n = 165), median randomisation-to-admission time was 29.4 minutes (IQR: 19.6-39.4) and median onset-to-admission time was 88 minutes (IQR: 62.4-131.3). Across pre-hospital treatment duration strata, RIC conferred no significant benefit on 90-day mRS, mRS 0-2 or early NIHSS improvement in the combined, AIS or ICH populations. In patients with AIS receiving reperfusion therapy, stratification by transport time likewise revealed no efficacy differences. No significant interaction was observed between RIC and pre-hospital treatment duration for any outcome.

Conclusion: Longer pre-hospital treatment duration was not associated with efficacy of RIC in the RESIST trial including in patients with AIS who received reperfusion therapies. Findings may not apply to settings where RIC could be routinely administered for longer periods. We found no treatment duration-dependent benefit of pre-hospital RIC, at least when durations are under an hour.

Introduction: The efficacy of endovascular treatment (EVT) in ischemic stroke patients with distal-medium vessel occlusion (DMVO) remains unclear. We evaluated whether CT-perfusion target mismatch criteria (TMC) could predict functional independence in patients with M2 non- or codominant middle cerebral artery DMVO.

Materials and methods: This retrospective study analyzed consecutive patients with M2 DMVO receiving EVT and imaged with multimodal CT study protocol within 24 h from onset. A receiver operating characteristic curve analysis was used to identify the infarct core volume cutoff to predict functional independence (modified Rankin Scale 0-2 at 3-months). This parameter was subsequently considered as part of TMC together with penumbra volume ⩾ 10 mL and mismatch ratio ⩾1.2. The association between TMC and functional independence was tested with logistic regression.

Results: A total of 115 patients with M2 were included. Infarct core volume had good discriminative ability for functional independence (AUC 0.75; 95%CI 0.64-0.84) and the best cut-off value was ⩽30 mL (77% sensitivity, 61% specificity, 69% positive predictive value, 70% negative predictive value). TMC were independently associated with functional independence (OR [odds ratio] = 6.50, 95%CI = 2.37-17.77, p < 0.001), excellent outcome (modified Rankin scale 0-1 at 3-months, OR = 3.28, 95%CI = 1.30-8.31, p = 0.012) and final infarct volume (B = -35.52, p = 0.004). After including interaction terms, a significant treatment effect on functional independence was observed between successful recanalization and TMC (OR = 3.82, 95%CI = 1.64-8.89, p = 0.002).

Discussion and conclusion: In patients with M2 non- or codominant DMVO receiving EVT, TMC identified as core volume ⩽30 mL, penumbra volume ⩾ 10 mL, and mismatch ratio ⩾ 1.2, were associated with better functional outcome. Our findings suggest that functional independence after EVT was not directly related to successful recanalization, which is indeed effective only in patients with a favorable baseline imaging profile, including a small infarct core size, and in the presence of small penumbra volumes.

Background: The benefits of endovascular thrombectomy (EVT) over medical treatment for medium vessel occlusion (MeVO) remain uncertain. Understanding how vascular reperfusion leads to favorable outcomes is crucial. This study examines whether penumbra salvage and infarct volume reduction quantify EVT benefits in MeVO patients and assesses their impact on clinical improvement post-reperfusion.

Methods: We conducted a multicenter, observational study analyzing MeVO patients who underwent thrombectomy and received multimodal CT imaging from January 2020 to June 2024. EVT efficacy was evaluated by measuring follow-up infarct volume (FIV) on CT scans 24-48 h post-procedure and calculating the penumbra salvage index (PSI). PSI is the ratio of salvaged tissue volume (difference between baseline delay time (DT) >3 s volume and FIV) to baseline DT >3 s volume. Mediation analysis assessed PSI and FIV's contributions to successful reperfusion and functional outcomes.

Results: Of 338 patients, 241 (72%) achieved successful reperfusion. Median FIV was 21 mL (IQR 12-32 mL), and median PSI was 0.68 (IQR 0.50-0.82). Successful reperfusion was linked to a 0.10 increase in PSI (95% CI: 0.05-0.15, p < 0.001) and a 4.36 mL reduction in FIV (95% CI: 1.31-7.20, p = 0.005). Successful reperfusion predicted improved outcomes, with an adjusted odds ratio (aOR) of 1.92 (95% CI: 1.08-3.47, p = 0.020) for excellent outcomes (modified Rankin Scale (mRS) score 0-1) and an aOR of 1.70 (95% CI: 1.01-2.89, p = 0.024) for functional independence (mRS score 0-2). PSI and FIV accounted for 44% and 16%, respectively, of the effect of reperfusion on excellent outcomes.

Conclusions: In acute MeVO patients, penumbra salvage significantly mediates the beneficial relationship between reperfusion and excellent clinical outcomes, more so than infarct volume reduction.