Cerebrovascular Diseases最新文献

Background The International Classification of Diseases, 10th Revision (ICD-10), is widely used for clinical care, quality assurance, and stroke research. Its ubiquity across healthcare systems makes it an attractive foundation for digital health tools that can support stroke surveillance and population health monitoring. However, a major limitation is that stroke detection algorithms derived from ICD codes have been developed primarily in socially homogenous populations, raising concerns about generalizability and fairness across racially diverse populations. Methods We developed and validated an acute ischemic stroke (AIS) detection algorithm using Classification and Regression Tree (CART) supervised machine learning, using a diverse derivation cohort. Input variables consisted of diagnostic and procedural ICD-10 codes, stratified by position and presence on admission. The model was trained on 75% and tested on 25% of the derivation cohort and externally validated in a second tertiary institution serving patients living in predominantly underrepresented and socially vulnerable communities. Performance of the algorithm was measured by sensitivity, specificity, positive predictive value (PPV), and Cohen's κ. Subgroup analyses were conducted by sex and race/ethnicity. Results In the derivation cohort, the CART model achieved sensitivity of 96%, specificity of 90%, PPV of 99%, and κ=0.78. Applied to the independent validation cohort, the algorithm identified 1,050 AIS cases and 1,664 non-AIS cases, with sensitivity 89%, specificity 95%, PPV of 92%, and κ=0.84. Performance was comparable between women and men (κ=0.80 for both), and strong across Black (κ=0.81), Hispanic (κ=0.76), and White (κ=0.80) subgroups. Lower accuracy was observed in the Asian subgroup (κ=0.73, PPV=62%). Discussion Our findings demonstrate that CART-based algorithms can provide accurate and interpretable AIS detection using ICD-10 data while explicitly addressing social fairness. The algorithm's reproducibility across independent and diverse populations highlights its potential as a low-friction, scalable, and cost-efficient tool for clinical care, surveillance, and quality improvement. Importantly, subgroup analyses underscore the necessity of ongoing fairness evaluation, as performance varied by race/ethnicity, particularly in the Asian subgroup. Limitations include potential missed cases in the gold standard, lack of confidence intervals due to retrospective data, and dependence on local coding practices. Conclusions This study shows that ICD-10-based machine learning algorithms, specifically CART, can serve as a model for developing an accurate and equitable digital health platform for AIS surveillance.

IIntroduction: Worse stroke outcome in women than men is partly explained by differences in age, aetiology and pre-morbid disability, but lower haemoglobin (Hb) could also contribute, particularly at younger ages. We therefore aimed to explore whether lower Hb levels might correlate with stroke outcome in younger women.

Methods: In a population-based cohort (Oxford Vascular study) we studied all patients aged ≤55 years with a stroke between 1st April 2002 and 31st March 2023 and face-to-face follow up at one-month. We used ordinal multi-regression models to assess one-month post-stroke modified Rankin Scale score (mRS), and the change from pre-morbid status (ΔmRS), in relation to Hb levels (continuous and by WHO definition of anaemia) and sex, with adjustment for age, vascular comorbidities, pre-morbid mRS and medications.

Results: Among 348 patients (mean/SD age = 45.4/8.01; 149 female, 42.8%) anaemia was associated with a higher post-stroke mRS (adjusted OR=3.18, 95%CI =1.66-6.06, p<0.001) and greater ΔmRS (adjusted OR=2.72, 1.39-5.30, p=0.003). These trends were consistent in both women and men analysed separately and in those with ischaemic stroke only. Women had higher one-month mRS compared with men (adjusted OR=1.58,1.05-2.38, p=0.03), but further adjustment for the sex difference in Hb (mean/SD Hb: 13.12/1.64 g/dl in women vs 15.13/1.36 in men, p<0.001) removed the effect of sex (fully adjusted OR=1.07, 0.65-1.74, p=0.80). The higher ΔmRS in women (adjusted OR=1.57, 1.04-2.38, p=0.03) also diminished after adjustment for Hb (fully adjusted OR=1.04; 0.64-1.70, p=0.87).

Conclusion: Low Hb levels are associated with a poor outcome after stroke and could be a clinically important determinant of the sex-difference in stroke outcome at younger ages. If confirmed, these findings further justify correction of iron-deficient anaemia at the population level and in situations where stroke risk is increased.

Introduction: To evaluate the association between Risk of Paradoxical Embolism (RoPE) score, patent foramen ovale (PFO) morphological characteristics, and right-to-left shunt severity in ischemic stroke patients with high RoPE scores.

Methods: In this prospective observational study, 162 ischemic stroke patients with confirmed PFO and RoPE scores ≥7 were enrolled. All patients underwent contrast-enhanced transcranial Doppler, transthoracic echocardiography, and transesophageal echocardiography. PFO morphology (size, tunnel length, atrial septal aneurysm, Eustachian valve, Chiari network) and shunt severity were assessed. Associations between RoPE score, its components, and PFO characteristics were analyzed.

Results: Patients with higher RoPE scores (9-10) showed a greater prevalence of complex PFO than those with scores of 7-8 (71.2% vs. 45.4%, p<0.001). RoPE score independently predicted complex PFO morphology (adjusted OR 2.48, 95% CI 1.68-3.67). Younger age and absence of hypertension were the strongest contributing factors. RoPE score correlated positively with shunt severity (ρ=0.58, p<0.001), with severe shunting more frequent in patients with higher scores.

Conclusion: Higher RoPE scores are strongly associated with complex PFO anatomy and severe right-to-left shunting. Integrating detailed PFO assessment with clinical risk stratification may improve individualized management of PFO-associated stroke.

Background: Increasing physical activity is recommended for secondary stroke prevention. Remote telehealth delivery of complex stroke interventions (e.g. exercise) offers potential to meet the challenges of accessible stroke care for all survivors. However, the feasibility of remotely evaluating recommended outcomes, such as device-measured physical activity via wearable technology, is unknown. Furthermore, the effectiveness of physical activity interventions aimed at improving long-term physical activity for people with stroke is unclear.

Aims: To evaluate the feasibility of remote measurement of physical activity via a research grade wearable device in the ENAbLE Pilot trial and report the effect of the physical activity intervention on device- and self-report measure physical activity.

Methods: Analyses of secondary outcomes from a randomised trial (ENAbLE Pilot ACTRN12620000189921) involving adults more than 3 months to 10 years post stroke or TIA who were able to walk independently (with or without aid). Physical activity was measured using the International Physical Activity Questionnaire (IPAQ; self-report measure) and activPAL physical activity device. Feasibility outcomes included proportion of the IPAQ collected, and proportion of activPAL devices returned and days of valid data. To assess the effect of the intervention on physical activity outcomes, we used descriptive statistics and linear mixed models.

Results: Nearly all self-report (99%) and over three quarters (80%) of device-based measurements were available for analyses. No statistically significant differences in device measured physical activity were identified between participants who received the physical activity intervention and those who did not at the 3- or 6-month timepoints. Participants who undertook the physical activity intervention were more active at 12-months than non-physical activity intervention participants (activPAL measured time spent in moderate to vigorous physical activity (MVPA) 0.31 95% CI [0.07 to 0.55] hours/day, light physical activity (LPA) 0.22 [0.05 to 0.39] hours/day and daily step count 2321 [578 to 4064] steps). No statistically significant differences between groups were identified in the type of physical activity undertaken (IPAQ data), except at 12-months, when walking activity was greater in physical activity intervention participants.

Conclusions: Remote measurement of physical activity using a wearable device after stroke and via self-report is feasible. The piloted physical activity intervention shows potential to improve physical activity.

Background: Currently, evidence regarding risk factors for 10-year cardiovascular mortality after ischemic stroke remains limited. This study aimed to develop and validate a robust predictive model for 10-year cardiovascular mortality in ischemic stroke patients.

Methods: The predictive model was derived from the Acute Ischemic Stroke Intervention and Secondary Prevention Registry (AISISPR), in which eligible patients were randomly divided into derivation (60%) and validation (40%) cohorts. We identified 10-year cardiovascular mortality risk factors by analyzing comprehensive clinical data, including (1) medical histories, (2) demographic characteristics, (3) laboratory parameters, and (4) imaging findings. The area under the receiver operating characteristic curve (AUROC) and the calibration curve were used to assess model discrimination and calibration.

Results: A total of 4574 participants were included, with a mean age of 64.3 years. The model showed excellent discrimination for 10-year cardiovascular mortality across derivation (AUROC = 0.839; 95% CI: 0.822-0.856), validation (AUROC = 0.841; 95% CI: 0.820-0.862) cohort. Patients with carotid artery stenosis had a 19% higher cardiovascular mortality risk than those without stenosis(HR 1.19, 95%CI 1.01-1.40). Previous stroke was associated with a 44% increased risk of mortality(HR 1.44, 95%CI 1.24-1.68). In addition, among the subtypes of ischemic stroke, the large-artery atherosclerotic subtype and the modified Rankin Scale (mRS) score at discharge significantly increased the risk of cardiovascular mortality, while the use of standardized secondary prevention medications reduced the risk of cardiovascular mortality.

Conclusion: The current prediction model demonstrates accurate prognostic performance for 10-year cardiovascular mortality following ischemic stroke. However, further validation in diverse populations and larger cohorts is warranted.

Background: Hemorrhagic stroke (HS), including intracerebral and subarachnoid hemorrhages, is a devastating neurological condition with high rates of mortality and long-term disability. Socioeconomic status (SES) has been identified as a critical determinant of outcomes, influencing not only the incidence of HS, but also survival, recovery trajectories, and quality of life. Lower SES is consistently linked to delays in presentation, limited access to specialized stroke units, reduced utilization of rehabilitation services, and greater barriers to long-term care, all of which compounded the risk of poor outcomes. Although global trends show improvements in stroke survival, the burden of HS and its consequences remain disproportionately concentrated in low- and middle-income countries (LMICs).

Summary: This review evaluates current evidence regarding the influence of SES on HS recovery from both national and international perspectives. Within high-income countries (HICs), inequities persist despite advanced health systems, as uninsured or socioeconomically disadvantaged patients remain less likely to receive inpatient rehabilitation or benefit from new interventions. In LMICs, where over 80% of HS cases and nearly two-thirds of HS-related deaths occur, disparities are magnified by systemic limitations, including shortage of neurologists and neurosurgeons, lack of neurocritical care infrastructure, and prohibitive out-of-pocket costs. Rehabilitation is particularly underdeveloped in these regions, leaving many survivors with preventable disability. Innovative strategies such as telestroke networks, mobile stroke units, and digital or AI-driven rehabilitation platforms have begun to demonstrate the feasibility of bridging these gaps, particularly in Brazil, India, and certain parts of sub-Saharan Africa. Lessons from countries with universal healthcare systems have highlighted the importance of structured stroke services and coordinated rehabilitation. However, these models require targeted efforts to address the persistent impact of social determinants.

Key messages: SES has a profound impact on HS outcomes worldwide. Equitable recovery will require not only advances in acute interventions and rehabilitation, but also policies and community-based approaches that reduce barriers to care, enhance patient and caregiver education, and prioritize access to services across socioeconomic strata and global health systems.

Introduction Cerebral Small Vessel Disease (CSVD) is a leading cause of vascular cognitive impairment, and CSVD-related cognitive impairment (CSVD-VCI) heavily burdens individuals, families, and society amid population aging. Current CSVD-VCI treatments only control vascular risk factors and manage symptoms. Acupuncture (Traditional Chinese Medicine, TCM) shows potential for improving cognitive function, but its efficacy and safety for CSVD-VCI need systematic verification. This study evaluated acupuncture's efficacy and safety in treating CSVD-VCI via meta-analysis of randomized controlled trials (RCTs), providing clinical evidence. Methods Seven databases (CNKI, Wanfang, VIP, SinoMed, PubMed, EMbase, Cochrane Library) were searched from inception to September 1, 2024, for RCTs comparing acupuncture (alone/combined with conventional therapy) vs. non-acupuncture for CSVD-VCI. Two reviewers screened literature, extracted data, and assessed bias using Cochrane Risk of Bias Tool. Meta-analyses were done with RevMan 5.4. Outcomes included MMSE, MoCA, ADL scores, ERP-P300 (latency/amplitude), total effective rate, and adverse events. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) were employed to assess evidence reliability and certainty. Results 13 RCTs (916 participants) were included. Acupuncture significantly improved MoCA (MD=2.68, 95%CI 1.41-3.95, P<0.001), MMSE (MD=2.71, 95%CI 1.74-3.67, P<0.001), ADL (MD=0.98, 95%CI 0.34-1.61, P=0.003), shortened ERP-P300 latency (MD=-14.67, 95%CI -19.54 to -9.80, P<0.001), and increased total effective rate (RR=1.28, 95%CI 1.16-1.41, P<0.001). No differences were found in ERP-P300 amplitude (MD=0.78, 95%CI -0.34-1.89, P=0.17) or adverse events (RR=1.50, 95%CI 0.26-8.66, P=0.65). Short/medium-term (4/8 weeks) acupuncture had consistent efficacy; long-term (≥12 weeks) efficacy was non-significant (few studies, poor compliance). No publication bias (MMSE funnel plot); results were robust (sensitivity analysis). GRADE assessment indicated moderate to very low evidence certainty across outcomes. Conclusions Acupuncture effectively improves cognitive function and daily living abilities in CSVD-VCI patients with good safety. However, due to inconsistent acupuncture protocols, unclear methodology reporting, and lack of long-term follow-up, more high-quality, large-sample RCTs with standardized protocols and long-term follow-up are needed.

Introduction: Nasogastric tube (NET) dislodgement is common in dysphagic stroke patients, impacting nutritional adequacy and health resourcing. Nasal bridles can reduce dislodgement risk, but their routine use following acute stroke has not been rigorously evaluated. We assessed whether routine nasal bridle use reduces NET dislodgements and its impact.

Methods: A single-centre pre-post observational study in stroke patients receiving a NET involved: 6-month baseline period (pre); and routine nasal bridle insertion (post). NET dislodgements (primary outcome) and enteral nutrition (EN) adequacy in the pre- and post-groups were compared using negative binomial and ordered beta regression models, respectively, adjusted for patient and stroke characteristics. Data are mean ± standard deviation and adjusted rate ratios (aRRs) with 95% confidence interval (CI).

Results: A total of 119 patients (70 pre, 49 post) were enrolled (median [interquartile range] 78 [70-84] vs. 79 [73-86] years; male 46% vs. 61%; National Institute of Health Stroke Scale scores 13 [8-21] vs. 14 [10-21]. NET dislodgements were significantly lower in the post-group [mean ± SD 1.8 ± 1.7 pre vs. 1.6 ± 2.1 post; aRR 0.624 (95% CI: 0.41-0.92; p = 0.019]) and with bridle (1.7 ± 1.6 no bridle vs. 1.1 ± 1.7 bridle; aRR 0.52 [95% CI: 0.35-0.79; p = 0.002]). EN adequacy was higher in the post-group (77.0% pre vs. 91.5% post) and those with a bridle (84.2% no bridle vs. 96.9% bridle).

Conclusion: Routine nasal bridle insertions following stroke may reduce NET dislodgement frequency and improve nutritional adequacy, yet this requires confirmation in a prospective randomised trial.

Introduction: Orolingual angioedema is a recognized adverse effect of thrombolytic treatment for acute ischemic stroke (AIS). Although it is generally mild with a relatively low incidence (1-5%), orolingual angioedema may trigger life-threatening airway occlusion necessitating rapid intubation. This population-based, retrospective study is the first to examine differences in complications, management, and outcomes of AIS in patients with and without thrombolysis-induced angioedema.

Methods: The National Inpatient Sample (NIS) was queried by International Classification of Disease Ninth and Tenth Revision diagnostic and procedural codes (ICD-9-CM/ICD-10-CM) to identify AIS patients treated with thrombolysis who experienced subsequent angioedema. Baseline characteristics, treatment, complications, and functional outcomes were analyzed through multivariate regression and compared through a propensity-score matching (PSM) analysis.

Results: We examined 99,935 patients diagnosed with AIS and administered thrombolytics between 2010 and 2019. AIS patients with thrombolytic-induced angioedema were younger (67.44 years vs. 69.32 years, p < 0.01), less likely to be white (53.83% vs. 66.48%, p < 0.01), and presented with higher acute stroke severity scores (0.69 vs. 0.63, p < 0.01) than non-angioedema AIS patients. Following PSM analysis, patients with angioedema had higher rates of tracheostomy (5.7% vs. 0.49%, p < 0.01) and lower rates of endovascular mechanical thrombectomy (4.72% vs. 9.63%, p < 0.01). Though patients who developed angioedema were observed to have longer length of stay (LOS) (7.34 days vs. 5.41 days, p < 0.01), they demonstrated similar rates of adverse complications, poor functional outcome (p = 0.25), and in-hospital mortality (p = 0.32) compared to their non-angioedema AIS counterparts.

Conclusion: Although angioedema increased the likelihood of tracheostomy and prolonged hospitalization, outcomes were comparable to those of patients without this complication. These findings are hypothesis-generating and may help guide discussions with families when angioedema occurs, demonstrating that while the need for airway intervention is more likely, the overall prognosis remains reassuring. Future studies should further clarify acute management strategies and long-term outcomes in this patient population.