Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment

Increased serum total bile acid level is associated with improved prognosis of ischemic stroke

PURPOSE

Bile acids are implicated in the cholesterol synthesis and lipid metabolism. We aimed to prospectively investigate the relationships between serum TBA and adverse clinical outcomes after ischemic stroke.

METHODS

Serum TBA levels at baseline were measured for 6609 ischemic stroke patients admitted at Minhang Hospital from January 2018 to December 2022. The primary outcome was a composite outcome of death and major disability (modified Rankin Scale [mRS] score, 3-6) at 3 months after stroke onset, and secondary outcomes included major disability (mRS score, 3-5), death (mRS score, 6), and ordered 7-level categorical score of the mRS.

RESULTS

During the 3-month follow-up period, a total of 2118 (34.5 %) patients experienced primary outcome. After multivariate adjustment, the odds ratios of primary outcome for the highest versus the lowest quartile of TBA were 0.71 (95 % CI, 0.58-0.88; Ptrend = 0.001). Each SD increase of log-transformed TBA was associated with a 12 % (95 % CI, 5 %-18 %) decreased risk of the primary outcome. Multiple-adjusted spline regression model showed a linear association of serum TBA levels with the primary outcome (P for linearity = 0.005). Subgroup analyses further confirmed the inverse associations between serum TBA levels and the prognosis of ischemic stroke.

CONCLUSIONS

Elevated serum TBA levels were independently associated with a decreased risk of adverse outcomes at 3 months after ischemic stroke, indicating that TBA might be implicated in the development of ischemic stroke and might be a prognostic biomarker for ischemic stroke.

Relationships between dysarthria, lesion location, and oral/swallowing function in patients with first-ever stroke

OBJECTIVE

Dysarthria negatively affects quality of life and social communication. This study focused on dysarthria in patients with acute-phase stroke and analyzed the association between lesion locations and oral/swallowing functions.

METHODS

Patients with first-ever acute stroke were analyzed. Speech assessments included diadochokinesis rates for "pa," "ta," and "ka," along with reading aloud passages. All patients underwent head magnetic resonance imaging, videofluoroscopic (VF) examinations, and tongue pressure measurements to identify stroke lesions.

RESULTS

We analyzed 82 patients with acute stroke excluding those with bilateral or multi-regional lesions (mean age 67.6 ± 11.5 years, 32 women, NIHSS median 1.5). Dysarthria was diagnosed in 16 patients (19.5 %). The National Institutes of Health Stroke Scale (NIHSS) score (odds ratio [OR] 1.289, 95 % confidence interval [CI] 1.050-1.616) and lesions in the corona radiata (OR 9.981, 95 % CI 1.871 - 60.092) were significant risk factors for dysarthria. Tongue pressure was significantly lower in patients with dysarthria, with a cutoff value of 28.4 kPa for predicting dysarthria (area under of the receiver operating characteristic curve 0.688, p = 0.006). Swallowing assessments via VF examinations showed no significant differences between patients with and without dysarthria.

CONCLUSION

Lesions in the corona radiata are associated with dysarthria in patients with stroke. Reduced tongue pressure is also linked to dysarthria. These findings underscore the importance of evaluating dysarthria independently of dysphagia.

Determinants of post-stroke cognitive impairment in patients with periodontal disease

INTRODUCTION

Periodontal disease (PD) is a risk factor for stroke and cardiovascular disease. The effect of PD on post-stroke cognitive impairment (PSCI) remains underexplored.

METHODS

A cross-sectional analysis of the Periodontal tReatment to Eliminate Minority InEquality and Rural disparities in Stroke (PREMIERS) study participants was conducted. Baseline cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) within 90 days of the index event. MoCA score ≤21 indicated severe PSCI. White matter hyperintensity, indicating cerebral small vessel disease (cSVD), was evaluated using the Fazekas scale on MRI. Due to non-normal MoCA distribution, two analytical approaches were employed: 1) logistic regression using dichotomized MoCA scores based on clinically relevant cutoffs and 2) generalized linear mixed modeling after bootstrap normalization that examined MoCA scores continuously.

RESULTS

Among 280 participants with PD, 48% exhibited severe PSCI. Both analytical approaches demonstrated that severe PD, African American (AA) race, and greater stroke severity significantly and independently predicted severe PSCI, while advanced education was protective. Fazekas' scale showed no significant associations with PSCI.

CONCLUSIONS

This study identifies PD severity as a novel and independent contributor to early PSCI. Traditional predictors like AA race, educational attainment, and stroke severity remained significant.

CLINICAL TRIAL REGISTRATION INFORMATION

https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02541032.

Atrial fibrillation-related ischemic stroke and cognitive impairment: Research progress on the characteristics and pathogenesis

Post-stroke cognitive impairment (PSCI) is a significant neurological complication, affecting up to one-third of stroke survivors. Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia, significantly increasing the risk of ischemic stroke. Increasing evidence suggests that AF plays a pivotal role in exacerbating cognitive decline in stroke patients. This review integrates current clinical, imaging, and mechanistic findings to elucidate how AF-related strokes exacerbate cognitive decline through multiple overlapping pathways, including thromboembolism, neuroinflammation, atherosclerosis, cerebral hypoperfusion, cerebral small vessel disease, and silent infarctions. These processes collectively impair cerebrovascular integrity, induce neuronal damage, and accelerate brain aging. The review further evaluates the role of clinical and neuroimaging biomarkers as predictive tools and their utility in guiding therapeutic strategies. By integrating insights of the latest researches, we aim to provide a comprehensive framework for alleviating cognitive decline in patients with AF-related stroke and highlight future research directions.

The safety and efficacy of left atrial appendage closure devices in patients with non-traumatic intracranial hemorrhage

INTRODUCTION

Anticoagulation in patients with atrial fibrillation and a history of intracranial hemorrhage (ICH) presents with challenges when balancing the risk of recurrent bleeding vs ischemic stroke. Left atrial appendage closure (LAAC) devices have shown promise as a minimally invasive method to prevent stroke without long-term anticoagulation. The goal of our study is to evaluate the efficacy of LAAC devices in patients with non-traumatic ICH and intraspinal hemorrhage which has not been well studied.

METHODS

A retrospective analysis on patients who had a history of atrial fibrillation and ICH/intraspinal hemorrhage was performed. The primary outcome was the development of new hemorrhage or ischemic stroke. Secondary outcomes included procedural complications and mortality.

RESULTS

103 patients were included with a mean follow-up time of 1341 ± 764 days. All patients had successful LAAC placement. 7 patients developed periprocedural complications including groin hematoma, stroke, and pericarditis. 43 had a peri-device leak of any size including 3 device related thrombus. 11 patients suffered a new ischemic stroke with an annualized incidence rate of 2.9 % and 6 suffered a recurrent hemorrhage with an annualized incidence rate of 1.6 %. Those who suffered a new stroke were more likely to have a history of prior stroke (p = 0.04) and had a larger peri-device leak (4.3 vs 2.7 mm, p = 0.04). There was no difference in patient characteristics in those who suffered an ICH.

CONCLUSION

LAAC devices appear to be a safe and effective alternative to anticoagulation in patients with a history of nontraumatic ICH or intraspinal hemorrhage.

Location, size, and risk factors of incident covert brain infarcts in patients with acute non-cardioembolic ischemic stroke: PACIFIC-STROKE trial

INTRODUCTION

Covert brain infarcts (CBIs) identified by imaging are more frequent than symptomatic ischemic strokes and are usually small and/or involve non-eloquent brain areas. The spectrum of incident CBIs in patients following acute ischemic stroke has not been well characterized.

PATIENTS AND METHODS

Exploratory observational cohort study of the size, location, multiplicity and risk factors of incident CBIs identified using serial MRIs in patients with acute non-cardioembolic ischemic stroke participating in the PACIFIC-STROKE trial.

RESULTS

Incident CBIs were identified in 16% (220/1358) of participants during the mean 5.6-month interval between MRIs. Single incident CBIs occurred in 150 (68%) of incident CBI patients and multiple CBIs in 70 (32%); 42% (93/220) of incident CBI patients had a single, small, subcortical CBI. There was no clear relationship between the location of incident CBI and the location of index stroke. Significant independent features associated with incident CBI included diabetes (adjusted OR 1.52, 95%CI 1.09-2.12), current tobacco use (adjusted OR 1.50, 95%CI 1.07-2.09), prior stroke/TIA (adjusted OR 1.59, 95%CI 1.08-2.36), carotid artery atherosclerosis (adjusted OR 1.47, 95%CI 1.07-2.02), and diastolic blood pressure (adjusted OR 1.02 per 1 mmHg increase, 95%CI 1.01-1.04).

DISCUSSION AND CONCLUSION

Incident CBIs in patients following acute non-cardioembolic stroke were frequent, usually small and subcortical, and associated with traditional stroke risk factors. Observations from PACIFIC-STROKE, particularly the absence of correlation between the location of incident CBI and the index infarct and the high frequency of incident small, subcortical CBIs, suggest that incident CBI pathogenesis is complex and heterogeneous in this population.

TRIAL REGISTRATION

https://clinicaltrials.gov (NCT04304508).

Continuing evaluation of atrial fibrillation detection after cryptogenic stroke: 2-year findings from a multicentre study with Confirm Rx ICM

BACKGROUND

The detection of atrial fibrillation (AF) after a cryptogenic stroke (CS) carries important therapeutic implications. In this study, we aimed to accurately assess the incidence of AF among CS subjects by using an insertable cardiac monitor (ICM).

METHODS

A prospective, single-arm, multicentre registry was conducted to identify AF in 155 CS subjects using the Confirm Rx ICM (Abbott, California, USA) across 20 global sites. Inclusion criteria comprised participants aged 40 years or older who had experienced CS within a 90-day window. At each follow-up visit, expert electrophysiologists reviewed and adjudicated ICM detected AF episodes. The primary endpoint was the cumulative incidence of true device-detected AF (lasting more than 30 s) at 6 months, evaluated with Kaplan-Meier methods.

RESULTS

AF incidence was 21.3% (95% CI 15.3% to 29.1%) at 6 months, increasing to 48.8% (95% CI 34.7% to 64.9%) at 24 months. Subjects with AF detection experienced an average of 50.9 true AF episodes per subject per year. The median time from implantation to AF detection (>30 s) was 72 days (IQR 7-261). Among subjects with 30 s AF detection, anticoagulation therapy was initiated in 65.2% (30/46) of subjects. Oral anticoagulation medication was prescribed in 8.3% (9/109) of subjects without AF. Recurrent ischaemic stroke or transient ischaemic attack occurred in 5 subjects (3.2%, 5/155).

CONCLUSION

These results show that ICM-driven long-term continuous AF monitoring is associated with high diagnostic yield in CS subjects.

TRIAL REGISTRATION NUMBER

NCT03505801.

Construction and validation of a multi-mRNA panel and genetic scores for Krüppel-like factors for acute ischemic stroke

Cellular and animal experiments suggest that Krϋppel-like factors (KLFs) may be involved in the pathological mechanisms of acute ischemic stroke (AIS), but epidemiological research on KLFs in AIS is still limited. Therefore, we conducted two AIS case-control studies, and three prospective cohort studies to elucidate the contribution of 14 KLFs' distinct leukocytes mRNA expression (360 AIS cases vs. 363 controls) and 21 genetic tagSNPs (3651 AIS cases vs. 3900 controls) to the etiology and prognosis of AIS. We found KLFs mRNA score constructed by differentially expressed mRNAs significantly enhances the discriminative value for AIS compared to the traditional risk factors [the area under the curve (AUC) increased from 0.724 to 0.871]. Additionally, the KLFs polygenetic risk score could effectively stratify the susceptibility to AIS incidence (Ptrend < 0.001) and the highest PRS group has an increased 42.4 % risk of AIS onset in the cohort study. Furthermore, KLF12 mRNA negatively related to modified Rankin Scale (mRS) both at admission and discharge and KLF12 variants contributed to an elevated risk of IS death after AIS. In conclusion, this study provides new insights into the novel contribution of KLFs mRNA and genetic variants to the incidence risk and prognosis of AIS.

Serum albumin and total bilirubin are associated with poor outcomes in patients with acute ischemic stroke

BACKGROUND

Few studies have investigated the correlation between serum liver function indices and clinical outcomes in acute ischemic stroke (AIS) patients.

METHODS

Patients with AIS from January 2020 to March 2023 were retrospectively analyzed. The clinical outcomes included stroke severity at admission and poor prognosis at discharge and 3 months. Multivariate logistic regression was used to evaluate the associations of liver function indicators with risk and adverse outcomes. Subgroup analysis was conducted to explore the relationships between liver function indices and clinical outcomes. The predictive value of these indices for adverse outcomes was assessed via receiver operating characteristic (ROC) curves.

RESULTS

A total of 2,022 AIS patients were included in this study. After adjustment for confounding factors, lower albumin levels were associated with higher NIHSS scores at admission (OR = 0.924, 95 % CI: 0.901-0.947) and poor functional outcomes at discharge (OR = 0.950, 95 % CI: 0.920-0.981) and at 3 months (OR = 0.913, 95 % CI: 0.878-0.950). Similarly, higher total bilirubin levels were also correlated with higher baseline NIHSS scores (OR = 1.038, 95 % CI: 1.022-1.055) and poor functional outcomes at discharge (OR = 1.021, 95 % CI: 1.001-1.042) and at 3 months (OR = 1.029, 95 % CI: 1.004-1.054). The risk of a poor 3-month prognosis in AIS patients increased with decreasing albumin levels at admission, independent of age, sex, and history of stroke (p < 0.05).

CONCLUSIONS

Decreased ALB and increased total bilirubin levels were associated with increased NIHSS scores at admission and poor prognosis at discharge and 3 months in AIS patients.

Patterns and predictors of delayed functional independence and dependence after thrombectomy in large vessel occlusion stroke: A multicenter analysis

INTRODUCTION

Predicting functional outcomes following endovascular treatment (EVT) for large-vessel occlusion stroke (LVOS) is challenging. Some patients achieve functional independence (modified Rankin Scale (mRS) 0 -2) at 90 days despite being dependent at discharge, termed delayed functional independence (DFI), while others lose independence after discharge, termed delayed functional dependence (DFD). This study explores patterns and predictors of DFI and DFD in LVOS patients undergoing EVT.

PATIENTS AND METHODS

We analyzed anterior circulation LVOS patients from the prospective multicenter German Stroke Registry. Multivariable logistic regression models identified independent predictors of DFI and DFD.

RESULTS

Of 5909 patients, 2346 were independent at discharge, with 16.1% experiencing DFD at 90 days. DFD was associated with older age (median 78 vs 69 years, p < 0.001), female sex (61.4% vs 46.1%, p < 0.001), and greater stroke severity. Variables associated with DFD in multivariable analysis included older age, female sex, higher premorbid and discharge mRS, higher NIHSS at discharge, and absence of IV thrombolysis. Of 3563 patients dependent at discharge, 20.6% achieved DFI. DFI patients were younger (median 71 vs 77 years, p < 0.001), less likely female (38.7% vs 52.6%, p < 0.001) and had lower admission NIHSS, better pre-stroke functional status, higher ASPECTS and more frequent successful recanalization. Variables associated with DFI in multivariable analysis included younger age, male sex, better pre-stroke functional status, lower stroke severity and successful recanalization.

DISCUSSION AND CONCLUSION

Both DFD and DFI are frequent in clinical practice, with higher DFD and lower DFI rates in women, which warrants further investigation. Understanding these predictors can enhance individualized patient counseling and management strategies.

Role of beta-blocker therapy on the sympathetic effects in stroke heart syndrome

BACKGROUND

Sympathetic activation, inflammation, and neuro-endocrine response after an ischemic stroke contribute to the development of the stroke heart syndrome (SHS). One marker of SHS is a troponin "rise and fall pattern" > 30%. Among the beta-blocker drugs, the β1 antagonist class has a selective effect on the heart against sympathetic neurotransmitters. The aim of this study is to evaluate the possible role of pre-stroke chronic cardioselective β1 blocker treatment (B1B) in preventing SHS.

METHODS

We retrospectively analyzed data of 891 acute stroke patients admitted to the stroke unit at the University Hospital of Trieste (Italy) between 2018 and 2020. In total, 490 patients met the inclusion criteria. Clinical data, imaging characteristics and markers of cardiac injury (troponin I [TnI], N-terminal fragment of B type natriuretic peptide (NT-proBNP), and "rise and fall pattern" > 30%) and the chronic pre-stroke use of B1B were collected. We compared SHS against lack of SHS (no-SHS), subsequently examining the data through a multivariable analysis to determine possible SHS predictive factors.

RESULTS

No association between chronic B1B pre-stroke use and SHS (odds ratio [OR] 1.031; 95% confidence interval [CI] 0.636-1.672; p = 0.900) has been observed. The same result has been found in a sub-analysis on patients with chronic heart failure characterized by high NT-proBNP levels (> 900 pg/mL; n = 212), in which no association between chronic pre-stroke use of B1B and SHS (OR 0.807; 95% CI 0.449-1.451; p = 0.474) was identified.

CONCLUSIONS

In our single-center retrospective cohort, a pre-stroke chronic B1B treatment seems not to prevent the development of SHS, including in patients with NT-proBNP > 900 pg/mL with chronic heart failure. These results should be confirmed by future randomized controlled trials to better understand the lack of effect of beta blockers on SHS.

Diagnostic yield of standardized screening for deep venous thrombosis in patients with acute cerebral ischemia and cardiac right-to-left shunt

BACKGROUND

Paradoxical embolism is a potential pathophysiology in patients with acute ischemic stroke or transient ischemic attack (TIA) and patent foramen ovale (PFO) or atrial septal defect (ASD). We sought to determine the frequency of deep vein thrombosis (DVT) detection by standardized lower extremity venous compression ultrasound (LE-CUS) in patients with acute cerebral ischemia and cardiac right-to left shunt due to PFO or ASD on transoesophageal echocardiogram (TEE).

METHODS

We analysed consecutive patients (01/2015-12/2020) with acute cerebral ischemia and PFO or ASD on TEE, who received DVT screening by LE-CUS per institutional standard. We determined clinical baseline variables including shunt-size categorized as small, medium or large, and analysed the frequency of DVT. We performed multivariable analysis to identify predictors for presence of DVT on LE-CUS.

RESULTS

Among 1564 patients with acute ischemic stroke (n = 1326) or TIA (n = 238) who received TEE, 390 patients had PFO and 10 patients ASD, of whom 274 were screened for DVT by LE-CUS (153 [55.8%] female, age 64 years [51-76], NIHSS score 4 [1-9.5]). Of these, 55 patients (20.1%) had DVT on LE-CUS. Among patients with DVT, 23 of 76 patients (30.3%) who received LE-CUS within 72 h from admission compared to 32 of 198 patients (16.2%) who received LE-CUS at later time points had presence of DVT (p = 0.012). The percentage of patients with DVT tended to be higher among patients with cryptogenic ischemic stroke compared to patients with other stroke etiologies (21.8% [49 of 225] vs. 12.2% [6 of 49]; p = 0.168). Presence of DVT was associated with female sex (OR 2.24, 95%CI 1.09-4.62), NIHSS score (OR 1.06, 95%CI 1.03-1.10), Wells score (OR 1.54, 95%CI 1.11-2.13) and shunt size (OR 3.32, 95%CI 1.86-5.91).

CONCLUSIONS

Our data suggest a high diagnostic yield (> 20%) of standardized screening for DVT with LE-CUS in patients with acute cerebral ischemia and PFO or ASD. This particularly applies to females, patients with more severe baseline deficits and large right-to-left shunt. These findings may not be generalizable to all patients with PFO or ASD and need prospective validation.

Comparative clinical profiles and outcomes of prior vs. concurrently diagnosed atrial fibrillation in acute ischaemic stroke: the implication of diagnosis timing

AIMS

Based on the diagnostic sequence in relation to stroke, a recent classification of atrial fibrillation (AF) categorizes AF into known AF (KAF) and AF detected after stroke or transient ischaemic attack (AFDAS). However, relatively little is known about AF 'concurrently diagnosed with stroke'-perhaps the 'grey zone' of AF between KAF and AFDAS, which has been less characterized in terms of its resemblance to clinical characteristics and outcomes compared with AFDAS or KAF.

METHODS AND RESULTS

Patients with AF who were admitted for acute ischaemic stroke (IS) in 2010-20 were retrospectively reviewed. Clinical characteristics and net clinical outcome (NCO)-the composite of recurrent stroke, major bleeding, hospitalization or emergency department visits for cardiovascular events, and death-were compared between AF diagnosed before stroke (prior AF) and incident AF diagnosed concurrently with IS (AFDCS). A total of 720 patients with AF and acute IS (mean age, 72.5 ± 10.1 years; 60.3% male) were included: prior AF, 62.6% (n = 451), and AFDCS, 37.4% (n = 269). Prior AF presented with more prevalent diabetes, heart failure, vascular disease, and valvular heart disease than AFDCS (all P < 0.05). The AFDCS had a significantly higher left ventricular ejection fraction and smaller left atrial diameter than prior AF. During a median follow-up of 2.0 (interquartile range 0.6-4.6) years, AFDCS was associated with a lower risk of NCO than prior AF without significant differences in the risk of recurrent stroke: adjusted hazard ratio (95% confidence interval), 0.776 (0.611-0.986), P = 0.038 for NCO and 0.784 (0.450-1.365), P = 0.389 for recurrent stroke.

CONCLUSION

Prior AF and AFDCS have distinctive clinical profiles supporting AF is a disease of continuum according to its diagnostic vicinity to the IS. In terms of recurrent IS, AFDCS has a comparable risk with prior AF, indicating the importance of early detection and integrated management of AF for patients with IS.

Tongue Pressure and Grip Strength as Indicators of Persistent Dysphagia After Acute Stroke

This study aimed to identify the independent predictors of postacute stroke dysphagia at discharge using sarcopenia-related parameters. This single-center prospective observational study assessed consecutive inpatients diagnosed with cerebral infarction or cerebral hemorrhage upon admission to the stroke unit. Tongue pressure, grip strength, and body composition were evaluated within 48 h. Dysphagia was defined by a functional oral intake scale of ≤ 5. Patient characteristics were compared between non-dysphagia and dysphagia groups using Mann-Whitney or chi-squared tests. Logistic regression analysis was performed using age, sex, tongue pressure, grip strength, skeletal muscle mass index (SMI), and National Institutes of Health Stroke Scale (NIHSS) scores as explanatory variables, with dysphagia at discharge as the objective variable. A total of 302 patients (mean age: 69.4 ± 13.8 years, 67.5% male) were analyzed, with 64 having dysphagia at discharge (21.2%). The dysphagia group was significantly older (p<0.001), had higher NIHSS scores on admission (p<0.001), lower SMI (p = 0.002), lower grip strength (p<0.001), and lower tongue pressure (p<0.001) than the non-dysphagia group. Logistic regression revealed that age (OR: 1.042, p = 0.018), tongue pressure (OR: 0.954, p = 0.010), and grip strength (OR: 0.943, p = 0.048) on admission were independent predictors of dysphagia at discharge, while NIHSS scores (OR: 1.403, p = 0.106), sex, and SMI (OR: 1.403, p = 0.150) were not. Older age, reduced tongue pressure, and reduced grip strength are strong predictors of persistent poststroke dysphagia at discharge. Thus, muscle strength is a more valuable parameter than muscle mass in predicting persistent poststroke dysphagia.

Long-term outcomes after first-ever posterior circulation stroke and the prognostic significance of the New England Medical Center Posterior Circulation Registry stroke classification: A prospective study from the Athens Stroke Registry

BACKGROUND

There is paucity of data on the long-term outcomes after acute ischemic posterior circulation stroke (PCS). Additionally, the long-term prognostic value of the New England Medical Center-Posterior Circulation Registry (NEMC-PCR) classification of PCS has not been studied.

PATIENTS AND METHODS

All consecutive patients with PCS registered in the Athens Stroke Registry between 01/1993 and 12/2012 were prospectively followed for up to 10 years and included in the analysis. The NEMC-PCR criteria were applied to classify them in relation to topography. The main studied outcomes were all cause mortality, stroke recurrence and major adverse cardiovascular events (MACEs).

RESULTS

A total of 653 patients with PCS (455 men, mean age 68.06 years) were followed up for 52.8 ± 44.0 months. Seventy-four (11.3%), 219 (33.5%), 335 (51.3%), and 25 (3.8%) patients had proximal, middle, distal, and multiple territories PCS, respectively. During the 10-year follow-up period, 217 patients died (7.6 per 100 patient years), 127 developed recurrent stroke (4.2 per 100 patient years), and 209 had a MACE (7.3 per 100 patient years). The cumulative 10-year mortality was higher in distal and multiple territories PCS compared to middle and proximal PCS (55.6%, 58.8%, 40.0%, 35.5%, respectively, p < 0.001 by log-rank test). Patients with distal location PCS had almost twofold increased 10-year risk of mortality compared to proximal location patients after adjusting for all confounding variables (HR 1.99, 95% CI 1.05-3.77). Per TOAST classification, large artery atherosclerosis was associated with almost two-fold increase in risk of mortality, stroke recurrence and MACEs.

DISCUSSION AND CONCLUSION

A large proportion of PCS patients experienced 10-year death, stroke and MACE occurrence after PCS. NEMC-PCR topographic classification was found to have significant prognostic value, with distal and middle PCS having worse long-term outcomes than proximal PCS.

The Mediating Effect of Intracranial Hemorrhage Status on the Relationship between the INR and Mortality in Patients with Ischemic Stroke

INTRODUCTION

The international normalized ratio (INR) is a biomarker of coagulopathy. The objective of this study was to assess the relationship between the INR and clinical outcomes in patients with large vessel occlusion (LVO) stroke who received endovascular therapy.

METHODS

The RESCUE BT trial was a multicenter, randomized, double-blind, placebo-controlled clinical trial involving 948 stroke patients from 55 centers across China. We extracted INR data and related data from the BT database, with outcome measures comprising intracranial hemorrhage (ICH) and 90-day mortality. Logistic regression analysis was conducted to examine the associations between the INR and clinical outcomes in the entire patient cohort and across different stratified subgroups.

RESULTS

A total of 885 patients met the study criteria, with 672 exhibiting a normal INR and 213 showing an elevated INR. Multivariable analysis indicated that an elevated INR was linked to an increased risk of ICH (OR 1.65, 95% confidence interval CI 1.17-2.33, P =0.005) and 90-day mortality (OR 1.78, 95% CI 1.17-2.70, P =0.007). Mediation analysis indicated that the association between the INR and 90-day mortality risk was partially mediated by ICH status, with the mediation effect contributing 11.4% to the overall relationship. Subgroup analyses revealed no significant differences between the different subgroups (P for interaction > 0.05). In patients receiving tirofiban, an elevated INR was more strongly associated with an increased 90-day mortality rate (OR 7.75, 95% CI 1.42-42.33, P =0.018).

CONCLUSION

Our findings underscore the critical importance of INR monitoring in patients with LVO stroke undergoing endovascular treatment (EVT). The association between the INR and 90-day mortality was mediated through ICH status. The use of tirofiban strengthened the associated between an elevated INR and a higher 90-day mortality rate. These insights offer valuable guidance for optimizing patient outcomes.

TRIAL REGISTRATION

URL: http://www.chictr.org.cn ; ChiCTR-INR-17014167.

Thrombo-CARE-cardioembolic stroke etiology in cryptogenic stroke suggested by fibrin-/platelet-rich clot histology : Thrombo-CARE (configuration analysis to refine etiology)

BACKGROUND

Despite extensive diagnostic efforts, the etiology of stroke remains unclear in up to 30% of patients. Mechanical thrombectomy (MT) potentially enhances etiological determination by (immuno)histological analysis of retrieved thrombotic material.

METHODS

In this monocentric exploratory study, clots from 200 patients undergoing MT were investigated by hematoxylin and eosin, CD3, and CD45 staining. Semiquantitative and computer-based image analysis defined the histological composition and relative fractions of immunohistochemically stained areas. First, we correlated these results with strokes of known etiology. Subsequently, clots of unknown source were characterized with regard to their (immuno)histological profile to attempt etiological classification.

RESULTS

Samples from 198 patients were accessible for analysis. Fibrin-/platelet-rich histology appeared in 45 (23%), erythrocyte-rich in 18 (9%), and mixed histology in 123 (62%) patients. Etiology was classified as cardioembolic in 87 (44%), arterioembolic in 37 (19%), and as cryptogenic stroke (CS) in 26 (13%) cases. 20 (23%) patients with cardioembolic stroke and 5 (14%) patients with arterioembolic stroke had fibrin-/platelet-rich clots. 8 (22%) patients with arterioembolic stroke and 1 (1%) patient with cardioembolic stroke had erythrocyte-rich clots. In CS, cardioembolic clot features appeared more than twice as often as arterioembolic clot features. Whereas the association between histology and etiology was significant (p = 0.0057), CD3/CD45 staining did not correlate.

CONCLUSION

A significant association between histology and etiology was observed, with the proportion of erythrocyte-rich thrombi being largest among arterioembolic strokes and the proportion of fibrin-/platelet-rich thrombi highest among cardioembolic strokes. A high number of clots from CS presented histological features of cardioembolic clots. Thus, patients with CS and fibrin-/platelet-rich clots particularly require long-term cardiac rhythm monitoring and may benefit from oral anticoagulation.

Non-Stenotic Carotid Plaques and Rate of DWI-positive MRI in Patients with Lower-Risk Transient or Persistent Minor Neurologic Events: DOUBT Sub Study

BACKGROUND & PURPOSE

Non-stenotic (< 50%) carotid plaques are increasingly recognized as a potential mechanism for ischemic stroke. We assessed the prevalence of such plaques in patients with low-risk neurologic events and evidence of DWI (Diffusion Weighted Imaging)-positive ischemia.

METHODS

This is a post-hoc exploratory analysis from the DOUBT study, a prospective, observational, multicenter study of patients with low-risk transient or persistent minor focal neurological symptoms. Patients who had baseline CT angiography (CTA) and an MRI within 8 days of their event were included in the study. We aimed to assess the prevalence of non-stenotic carotid disease in patients with versus without DWI-positive events, and in patients with ipsilateral DWI-positive events. A carotid-level analysis with univariable logistic regression analysis was performed to assess whether any of the assessed plaque features were associated with ipsilateral stroke.

RESULTS

Of the 334 patients (mean age 62.7 years, 50.4% females) with available vascular neuroimaging, 153 (45.9%) had non-stenotic carotid plaques (≤50% stenosis), 174 (52.1%) had no stenosis and 7 (2.1%) patients had >50% stenosis. Of those with non-stenotic carotid plaques, 31/153 (20.3%) had evidence of DWI-positive ischemia, approximately half (15/31; 48.4%) of which was in the territory of the carotid plaque. Amongst patients with DWI-positive ischemia, non-stenotic plaques were significantly more common on the side of DWI-positive lesions [31/49 (63.3%) versus 18/49(36.7%)]. Presence of non-stenotic plaque was a risk marker for DWI-positive events (RR 1.4, 95% CI 1.1-1.8, p 0.012). On matched analysis, non-stenotic plaques were more likely on the side of DWI+ ischemia (odds ratio 1.14, 95% CI 0.36-3.70, McNemar's p value 0.80). Plaque features, including hypodensity, irregularity and greater plaque thickness were significantly associated with a higher likelihood of ipsilateral DWI+ ischemia.

CONCLUSION

In patients with low-risk transient or persistent neurologic events, non-stenotic carotid plaques are more common in patients with DWI-positive ischemia. Plaque features like hypodense and irregular plaque were more common with DWI-positive changes in the territory of the affected carotid.

Application of Human Genetics to Prioritize Coagulation Cascade Protein Targets for Ischemic Stroke Prevention

BACKGROUND

While interindividual variations in concentration and function of coagulation cascade proteins are established risk factors for venous thromboembolism (VTE), their associations with arterial ischemic stroke are less well defined.

METHODS

We identified and validated genetic proxies for lifelong, randomized perturbations of coagulation cascade proteins in genome-wide association studies of circulating protein levels (deCODE, n=35 559; UK Biobank, n=46 218) and of VTE risk (81 190 cases and 1 419 671 controls). Study participants were all of European ancestry. We performed 2-sample Mendelian randomization and colocalization analyses to test associations of these genetic proxies with risk of ischemic stroke (62 100 cases and 1 234 808 controls from the GIGASTROKE consortium) and ischemic stroke subtypes, and further contextualized associations with VTE and secondary efficacy and safety outcomes.

RESULTS

We identified genetic proxies for 30 coagulation factors, with cross-trait associations recapitulating canonical coagulation biology. Mendelian randomization and colocalization analyses supported causal associations of genetically proxied levels of 5 proteins with risk of ischemic stroke, with all proteins associating with the cardioembolic stroke subtype: factor XI (odds ratio [OR] of cardioembolic stroke per 1-SD increase, 1.31 [95% CI, 1.19-1.44]; P=3.30×10-8), high-molecular-weight kininogen (OR, 1.19 [95% CI, 1.09-1.30]; P=7.79×10-5), prothrombin (OR, 1.83 [95% CI, 1.31-2.57]; P=4.20×10-4), soluble PROCR (protein C receptor; OR, 0.88 [95% CI, 0.82-0.95]; P=6.19×10-4), and γ' fibrinogen (OR per doubling in VTE risk due to lower γ' fibrinogen levels, 1.44 [95% CI, 1.25-1.66]; P=3.96×10-7). γ' Fibrinogen and prothrombin also associated with large artery atherosclerotic stroke, and no proteins were associated with small vessel stroke risk. By contrast, genetic proxies for several coagulation factors (including proteins C and S and factors V and VII) showed selective associations with VTE.

CONCLUSIONS

These data highlight specific coagulation cascade components implicated in ischemic stroke pathogenesis, while identifying proteins with distinct roles in VTE. These findings may inform development of novel anticoagulants and optimize their use in targeted populations with stroke.

U-Shaped Relationship of Serum Albumin and Neurological Functional Outcomes After Acute Ischemic Stroke: A Prospective Cohort Study

INTRODUCTION

Several studies indicate that individuals with acute ischemic stroke (AIS) who have low levels of serum albumin (SA) have a dismal prognosis. However, intravenously administering albumin 25% at a dose of 2 g/kg did not lead to improved outcomes for patients with AIS after 90 days. Our objective was to examine the possible correlation between SA levels and stroke outcomes in a prospective cohort investigation.

METHODS

The research included a total of 5111 participants diagnosed with AIS. The correlation between SA level and modified Rankin Scale (mRS) scores 90 days after onset was examined via univariate and multivariate logistic analyses. The relationships were examined employing restricted cubic splines. An investigation was conducted to ascertain the connection between SA levels and neurological functional results by employing mediation analysis, with the mediation impact of low-density lipoprotein (LDL) taken into account. In addition, the subgroup analyses were performed using the logistic regression.

RESULTS

The connection between levels of SA and neurological functional outcomes following AIS exhibited a U-shaped pattern. The likelihood of a negative result dropped significantly with an elevation in SA (per g/L: OR (odds ratio) 0.88; 95% CI (confidence interval) 0.847-0.913) among individuals with SA levels below 42.2 g/L. Conversely, the likelihood of a negative outcome rose with an increase in SA (per g/L: OR 1.033, 95% CI 1.009-1.058) among people with SA levels of 42.2 g/L or above. Comparable findings were seen for mortality outcomes. A mediation study revealed that LDL had a mediating function in the statistical connection between SA levels and neurological functional outcomes, accounting for 12.3% of the connection. No significant interactions were seen in any of the groupings.

CONCLUSION

Among patients with AIS, there was a U-shaped relationship between SA levels at admission and the likelihood of poor outcomes, which was partially mediated by LDL. There is a Graphical Abstract available for this article.

Risk of long-term post-stroke dementia using a linked dataset of patients with ischemic stroke without a history of dementia

BACKGROUND

Post-stroke dementia (PSD) is a common and disabling sequela of stroke. However, the long-term incidence of PSD after an ischemic stroke and factors which predict its occurrence are incompletely understood. Linkage of large health datasets is being increasing used to study long-term outcomes after disease. We used large-scale linked data from Korea to determine the long-term incidence of PSD after ischemic stroke, and identify which factors predicted its occurrence.

METHODS

From January 2008 to December 2014, patients with ischemic stroke (n = 37,553) without a history of dementia were included in a linked dataset comprising the claims database of the Health Insurance Review and Assessment Service and the Clinical Research Center for Stroke registry data. The outcome measure was PSD after ischemic stroke. Clinical factors evaluated included vascular risk factors, acute stroke management including reperfusion therapy, antithrombotics, and statins, stroke severity, and educational levels, were evaluated.

RESULTS

Among 37,553 patients with ischemic stroke without a history of dementia (mean age: 64.9 years; 61.9% males), 6052 (16.1%) experienced PSD during a median follow-up period of 5 (interquartile range, 3.4-7.0) years. The 10-year estimated cumulative incidence of dementia was 23.5%. Age (hazard ratio (HR) 1.82 per 10 years, 95% confidence interval (CI) 1.75-1.88) and a lower educational level (illiteracy or no education HR 1.65 (CI = 1.44-1.88), 0-3 years 1.53 (CI = 1.31-1.79), 4-6 years 1.60 (CI = 1.43-1.80), 7-9 years 1.32 (CI = 1.16-1.49), 10-12 years 1.17 (CI = 1.04-1.32)) were independently associated with an elevated risk of PSD. Male sex was associated with a significantly lower risk of PSD (HR 0.86, CI = 0.79-0.92). Diabetes mellitus (HR 1.21, CI = 1.14-1.29), a history of stroke before index stroke (HR 1.31, CI = 1.21-1.41), and initial National Institutes of Health Stroke Scale (HR 1.03, CI = 1.03-1.04) were independent risk factors for PSD. Regarding medications, the use of anticoagulation and antipsychotic medications after stroke appeared to be associated with increased PSD risk, whereas statin therapy was associated with a reduced risk.

CONCLUSIONS

PSD is common with a 5- and 10-year incidence in patients with ischemic stroke without a history of dementia of 16.1% and 23.5%, respectively. Factors associated with PSD include age, female sex, lower educational level, diabetes mellitus, initial stroke severity, antipsychotics, and anticoagulants. Further studies are required to determine whether reducing those risk factors which are treatable reduces the incidence of PSD.

Anxiety and depression one year after the first stroke among Lebanese survivors: proportions, changes, and predictors

BACKGROUND

About 1 in 2 stroke survivors suffer from anxiety and depression in the first year after stroke. This study aimed to calculate the proportions of 1-year post-stroke anxiety and depression (PSA and PSD), evaluate their changes over time, and identify the contributing factors among first-ever stroke survivors in Lebanon, where relevant research has been scarce.

METHODS

A hospital-based multicenter study was conducted among 150 subjects aged ≥ 18 years involving scheduled home visits at 3, 6, and 12 months after stroke index. Several scales were employed, including Hospital Anxiety and Depression Scale (HADS), Mini-Mental State Examination (MMSE), modified Rankin Scale (mRS), Short Form Health Survey (SF12), National Institutes of Health Stroke Scale (NIHSS), Visual Analogue Scale (VAS), Douleur Neuropathique 4 (DN4), Modified Ashworth Scale (MAS), and Fatigue Severity Scale (FSS), to assess levels of anxiety and depression, cognitive function, disability degree, quality of life, stroke severity, general pain, central pain, spasticity, and fatigue after stroke, respectively. Descriptive analyses were performed to describe baseline and stroke characteristics and to calculate proportions of PSA and PSD, followed by univariate and multivariable analyses to identify the contributing factors.

RESULTS

High HADS scores were reported in our cohort, with the most prevalent symptoms occurring within the first 3 months after stroke index (77.3% for PSD and 51.2% for PSA with HADS ≥ 8). Despite a slight decrease over the subsequent 6 and 12 months, proportions remained elevated, affecting at least 40% to 60% of survivors. PSA was a consistent independent predictor of PSD (Adjusted Odds Ratio ≅ 2). Other contributing factors to PSA and PSD were highlighted, including a history of atrial fibrillation, longer sedentary hours, high scores of NIHSS and mRS, lower scores of SF12 and MMSE, and the presence of immobility-related problems, of which high DN4 scores were independent predictors. Better 1-year psychological outcomes were noticed in those with higher educational levels and employment after stroke.

CONCLUSION

Routine psychological screening and support for stroke survivors are urgently needed. By identifying factors and emphasizing early detection, our research offers valuable insights that can inform clinical practice and improve the well-being of stroke survivors.

Association between post-stroke cognitive impairment and gut microbiota in patients with ischemic stroke

More than half of stroke survivors have post-stroke cognitive impairment (PSCI). The role of gut microbiota, which can communicate with the brain through the gut-brain axis and affect inflammation, has been receiving increased attention. This cross-sectional study aimed to investigate the association of PSCI, gut microbiota, and inflammatory markers. Patients with first ischemic stroke and complete 3-month and 1-year follow-up data were included and divided into PSCI and non-PSCI groups according to the Montreal Cognitive Assessment (MoCA) score at the above time points. PSCI was defined as having a MoCA less than 23 at either 3 months or 1 year, or a decrease of more than 2 points at both time points. Gut microbiota was assessed by 16 S rRNA gene sequencing and Next Generation Sequencing analysis. The inflammatory markers included interleukins (ILs), eotaxin, G-CSF, TNF-α, IFNγ, sCD40L, and MCP-1. There were 95 ischemic stroke patients (mean age, 60.5 ± 12.1 years; male, 68.4%), including 30 with PSCI and 65 with non-PSCI. In gut microbiota analysis, the PSCI group had a higher abundance of Bacteroidaceae and Clostridiaceae, and the non-PSCI group had a higher abundance of Prevotellaceae, Ruminococcaceae, Oscillibacter, and Faecalibacterium. Ruminococcaceae family under the Oscillospirales order remains significantly different in the two groups in logistic regression model adjusting confounding variables (p = 0.044). In an analysis of inflammatory markers, the plasma levels of eotaxin (p = 0.041) and IL-12p40 (p = 0.031) were significantly higher in the PSCI group than those in the non-PSCI group, and the plasma level of eotaxin was significantly positively correlated with the amount of Clostridiaceae (rho = 0.389, p = 0.045). The study found that PSCI was associated with certain gut microbiota, and these gut microbiotas correlated with the pro-inflammatory marker eotaxin. This suggests that gut microbiota might play a role in the development of cognitive impairment after ischemic stroke.

Left atrial appendage function by strain and structure is associated with thromboembolic risk in patients with cryptogenic stroke and TIA

BACKGROUND

We investigated the impact of left atrial appendage (LAA) function by LAA strain, LAA morphology and subclinical atrial fibrillation (AF) on LAA thrombus presence and thromboembolic risk conditions (TRC) in patients with cryptogenic stroke and transient ischaemic attack (TIA).

METHODS

185 patients (mean age 68±13 years, 33% female) were included in this prospective cohort study and underwent clinical evaluation, comprehensive transthoracic and transoesophageal echocardiography shortly after index event. LAA function and morphology were evaluated by monoplane/multiplane/speckle tracking strain and three-dimensional echocardiography. Combination of LAA thrombus and/or spontaneous echo contrast (SEC) was defined as TRC. An insertable cardiac monitor was implanted in all patients to detect subclinical AF.

RESULTS

LAA function by novel LAA strain and LAA chicken wing were independent predictors of LAA thrombus (OR 0.9 (95% CI 0.8 to 0.95), p<0.01 and OR 2.5 (95% CI 1.1 to 5.8), p=0.04, respectively). LAA chicken wing and multilobate LAA were independent predictors of TRC (OR 2.3 (95% CI 1.2 to 4.5), p=0.01 and OR 2.2 (95% CI 1.2 to 4.2), p=0.02, respectively).LAA morphology was characterised as chicken wing in 79 (43%), windsock in 64 (34%), cactus in 35 (19%), cauliflower in 7 (4%) and multilobate LAA in 115 (62%) patients. LAA thrombus was found in 29 (16%), TRC in 123 (67%) and subclinical AF in 60 (32%) patients. Duration of subclinical AF >6 hours was associated with SEC and recurrent stroke and TIA.

CONCLUSION

LAA function by novel LAA strain and LAA structure are independently associated with LAA thrombus and TRC in patients with cryptogenic stroke and TIA.

TRIAL REGISTRATION NUMBER

NCT02725944.

Dietary zinc intake associated with stroke in American adults

Evidence on the relationship between dietary zinc intake and stroke in American populations is limited. This study aimed to investigate the association between dietary zinc consumption and stroke prevalence among US adults. This cross-sectional study analyzed data from adults (≥ 18 years) who participated in the National Health and Nutrition Examination Survey (NHANES) between 2013 and 2020. Dietary zinc intake, stroke history, and other relevant factors were examined. Logistic regression models were used to assess the association between dietary zinc consumption and stroke risk, while restricted cubic splines (RCS) were applied to explore potential non-linear relationships. A total of 2642 adults from four NHANES cycles (2013-2020) were included in the analysis. In multivariate logistic regression, individuals in the second quartile of dietary zinc intake (Q2: 6.09-8.83 mg/day) had a significantly lower odds ratio (OR) for stroke (OR = 0.64, 95% confidence interval (CI) 0.41-0.99, p = 0.044) compared with those in the lowest quartile (Q1: ≤6.08 mg/day). RCS analysis indicated an L-shaped relationship between dietary zinc intake and stroke odds (p = 0.041). Threshold analysis revealed that for individuals consuming less than 8.82 mg of zinc daily, the OR for stroke was 0.858 (95% CI 0.74-0.99, p = 0.037). Our findings suggest an L-shaped association between dietary zinc intake and stroke prevalence in American adults, with higher zinc intake associated with lower odds of stroke within a specific intake range.

Skeletal muscle quantity predicts short-term outcomes after endovascular thrombectomy for acute stroke due to large-vessel occlusion of the anterior circulation

OBJECTIVE

Endovascular thrombectomy (EVT) is an essential treatment for large vessel occlusion (LVO) stroke, with expanding indications, including elderly patients and those with extensive ischemic regions. Skeletal muscle mass, a component of frailty, is gaining attention as a potential predictor of EVT outcomes. This study explored the relationship between skeletal muscle mass, assessed by bioelectrical impedance analysis (BIA), and short-term functional prognosis in EVT-treated LVO of anterior-circulation stroke.

METHODS

This cohort study included 151 patients who underwent EVT for anterior-circulation LVO between July 2020 and January 2025. Skeletal muscle mass index (SMI) was measured using BIA within 72 h of admission. Functional outcomes were evaluated using the Functional Independence Measure (FIM) at discharge. Multiple regression analysis was performed to identify predictors of FIM, adjusting for age, NIHSS, ASPECTS, mTICI, pre-mRS, and other clinical variables.

RESULTS

In multiple regression models, low SMI was independently associated with lower FIM scores at discharge (β =  - 10.255, P = 0.013), alongside age (β =  - 0.925, P < 0.001), NIHSS on admission (β =  -1.506, P < 0.001), mTICI (β = 7.168, P = 0.027), symptomatic intracranial hemorrhage (β =  - 2.982, P = 0.010), and pre-mRS (β =  - 5.424, P = 0.030). Logistic regression revealed that older age (odds ratio [OR], 1.088; 95 % confidence interval [95 % CI], 1.040-1.139), higher NIHSS (OR, 1.065; 95 % CI, 1.002-1.132), and lower GNRI (OR, 0.925; 95 % CI, 0.886-0.965) were significantly associated with low skeletal muscle mass during admission.

CONCLUSION

This study highlights the role of skeletal muscle mass as an independent predictor of short-term prognosis after EVT. BIA-based assessments offer a novel approach to evaluating treatment responsiveness. Enhancing skeletal muscle mass may represent a modifiable factor to improve EVT outcomes, emphasizing the need for further research to validate these findings and explore long-term effects.

Diagnostic value of the perfusion mismatch ratio in identifying intracranial atherosclerotic disease related occlusion

BACKGROUND

The ability to differentiate intracranial atherosclerotic disease (ICAD) related large vessel occlusion (LVO) from embolism is critical for stroke management. We hypothesized that the mismatch ratio derived from the automated computed tomography perfusion (CTP) could predict underlying ICAD.

METHODS

Patients with acute ischemic stroke (AIS) and LVO from prospective registry databases who underwent CTP were included in the derivation cohort (n=1100). The mismatch ratio, calculated as the ratio of the hypo-perfused volume to the infarct core volume by software, was defined. Receiver Operating Characteristic (ROC) analysis was performed to assess the predictive performance of the mismatch ratio for ICAD, and logistic regression analysis was used to identify independent predictors of LVO associated with underlying ICAD. External validation was conducted using cohorts from two other stroke centers (n=385).

RESULTS

In the derivation cohort, 390 patients were classified as ICAD and 720 as embolism. The ICAD group had a higher mismatch ratio (9.8 vs 3.6, P<0.001). The mismatch ratio outperformed age and National Institutes of Health Stroke Scale (NIHSS) score in predicting ICAD (area under the curve (AUC), 0.77 vs 0.36 vs 0.28, P<0.001). The ROC curve had a best cut-off of 7.1 for predicting ICAD, which was an independent predictor of ICAD-related occlusion (adjusted odds ratio (aOR) 5.43, 95% CI 3.68 to 8.03), with 68% sensitivity and 76% specificity. These results were validated in an external cohort (AUC=0.78; 95% CI, 0.73 to 0.83).

CONCLUSION

The perfusion mismatch ratio may be an optimal and simple predictor of anterior circulation ICAD- related LVO before endovascular treatment (EVT). When this ratio was ≥7.1, ICAD was five times more likely than embolism.

Newly identified cerebral microbleeds in patients on anticoagulation for secondary stroke prevention

Patients with cardioembolic ischemic stroke are commonly prescribed direct oral anticoagulants (DOACs), such as dabigatran (a direct thrombin inhibitor) and factor Xa inhibitors (e.g., apixaban and rivaroxaban), or warfarin to reduce the risk of recurrent stroke. A major concern in anticoagulant therapy is the risk of intracerebral hemorrhage, which is associated with a high mortality rate. Cerebral microbleeds (MBs), small asymptomatic brain hemorrhages detectable by susceptibility-weighted imaging (SWI) on magnetic resonance imaging (MRI), are associated with increased hemorrhagic stroke risk. This study evaluated the incidence of new MBs during 1 year of anticoagulation therapy in patients after cardioembolic stroke. Patients indicated for anticoagulant therapy after cardioembolic stroke and monitored in the cerebrovascular outpatient clinic of our department underwent brain MRI at baseline and after 1 year of therapy. The occurrence of new MBs was assessed using SWI sequences. MBs were categorized based on location into 3 groups: deep (dMBs), lobar (lMBs), and infratentorial (iMBs). A total of 79 patients were included, 53 of whom were male (67.1%), with a median age of 71 years (IQR: 64-76). The majority of patients (n = 50, 63.3%) were treated with apixaban, 16 patients (20.3%) with dabigatran, and 13 patients (16.5%) with warfarin. Baseline MRI revealed MBs in 17 patients (21.5%), including dMBs in 2, lMBs in 16, and iMBs in 2 patients. Follow-up MRI showed new MBs in 8 patients (10.1%), with new dMBs in 1, lMBs in 5, and iMBs in 4 patients. No statistically significant differences were observed in MBs the incidence of new MBs between anticoagulant groups (P = .912). Over 1 year of anticoagulant therapy, new MBs were detected in 10.1% of patients, predominantly in lobar and infratentorial regions. No differences in the incidence of new MBs were identified between the different anticoagulant groups.

Major Cardiovascular Events and All-Cause Mortality after Ischemic Stroke in Central Norway - A Three-Year Prospective Multicenter Study

BACKGROUND

A substantial decline in the incidence of stroke and ischemic heart disease during the last decade is probably due to improved preventive treatment and a reduction in cardiovascular risk factors. Updated estimates on long-term outcomes following first-ever ischemic stroke are therefore limited.

PURPOSE

To assess the incidence of major cardiovascular events and all-cause mortality three years post-stroke, and to evaluate the impact of modifiable cardiovascular and other prognostic factors.

METHODS

MIDNOR STROKE is a multicenter prospective study including patients with first-ever ischemic stroke admitted to stroke units in Central Norway during 2015-2017. Data were collected during the hospital stay. Information on major cardiovascular events and survival three years post-stroke was retrieved from national medical registries. Competing risk models were used to analyze cardiovascular events. All-cause mortality was analyzed by using Kaplan-Meier and Cox regression.

RESULTS

Among 787 included participants, the cumulative incidence of major cardiovascular events was 15.0% (95% CI: 12.0-17.0%), with recurrent stroke as the most common event. The all-cause mortality rate was 18.0% (95% CI: 15.0-20.0%). Coronary artery disease was associated with a higher risk of major vascular events HR: 1.59, 95% CI: 1.06, 2.38) and all-cause death (HR: 1.66, 95% CI: 1,11, 2.50). NIHSS at day 1 predicted all-cause mortality (HR: 1.08, 95% CI: 1.05, 1.10).

CONCLUSION

Three-year survival rates post-stroke were higher compared to previous reports; however, the risk of major cardiovascular events remains substantial, affecting 15% of stroke survivors within three years. Reducing cardiac disease risk and interventions aimed at minimizing stroke severity may improve long-term stroke outcomes.

Association of MTMR3 rs12537 at miR-181a Binding Site with Ischemic Stroke in Southern Chinese Han Population

Background

Single nucleotide polymorphisms (SNPs) at microRNA (miRNA)--binding sites influence the development of ischemic stroke (IS) by affecting the expression of specific target genes. Myotubularin-related protein 3 (MTMR3), which is involved in autophagy, is directly targeted by miR-181a. This research examined the potential association between the SNP rs12537 in the miRNA-181a binding location within the 3' untranslated region (3'-UTR) of MTMR3 and the incidence and prognosis of IS.

Methods

An improved multitemperature ligase detection reaction assay was used to perform genotyping analysis in two independent case-control datasets consisting of 1128 subjects with IS and 1140 healthy controls with matched ages.

Results

The distribution frequencies of the T allele (p = 5.2×10-4) of SNP rs12537 in MTMR3 were elevated significantly in IS patients as compared to healthy controls. Further categorization based on IS subtypes revealed that individuals carrying the variation T allele were linked with a higher risk of suffering large-artery (p = 1.2×10-3) and small-artery (p = 7.0×10-4) atherosclerotic stroke subtypes. The T allele of rs12537 was shown to be linked to both moderate and severe stroke (NIHSS ≥ 6) (p = 0.011), as well as a poor short-term outcome (p = 0.016) of IS. A significant correlation was also found between the rs12537 T allele mutation and a decrease in MTMR3 (p = 0.019), as well as an elevated miR-181a (p = 0.021) and LC3B (p = 0.026) in individuals with IS.

Conclusion

This study identified a novel role for the rs12537 variant in influencing IS susceptibility and prognosis, potentially by modulating MTMR3 expression and leading to increased autophagy.

High-Normal Serum Potassium, Calcium, and Magnesium Levels Are Associated With Decreased Risks of Adverse Outcomes After Ischemic Stroke

BACKGROUND

High serum potassium, calcium, and magnesium levels have been reported to be associated with decreased risks of ischemic stroke, whereas their prognostic values in ischemic stroke remain unclear. We aimed to prospectively explore the associations of serum potassium, calcium, and magnesium levels with the prognosis of ischemic stroke.

METHODS

We measured serum potassium, calcium, and magnesium levels at baseline among 5469 patients with ischemic stroke from the Minhang Stroke Cohort study. The primary outcome was the composite outcome of death and major disability (modified Rankin Scale score ≥3) at 3 months after ischemic stroke. Secondary outcomes included major disability, death, and the ordered 7-level categorical score of the modified Rankin Scale.

RESULTS

During 3-month follow-up, 1834 patients developed the primary outcome. After multivariate adjustment, the adjusted odds ratios of primary outcome for the highest versus the lowest quartile were 0.79 (95% CI, 0.68-0.93; Ptrend=0.007) for potassium, 0.69 (95% CI, 0.58-0.82; Ptrend<0.001) for calcium, and 0.83 (95% CI, 0.70-0.99; Ptrend=0.015) for magnesium. Multivariable-adjusted restricted cubic spline analyses showed linear dose-response relationships of serum potassium, calcium, and magnesium with the risk of primary outcome (all P for linearity<0.05).

CONCLUSIONS

High-normal serum potassium, calcium, and magnesium levels were associated with decreased risks of adverse outcomes at 3 months after ischemic stroke, suggesting that serum potassium, calcium, and magnesium might be valuable prognostic biomarkers for ischemic stroke.

Endovascular treatment in ischemic stroke with active cancer: retrospective analysis of university stroke center data

INTRODUCTION

Active cancer (AC) associates strongly with ischemic stroke (IS). Intravenous thrombolysis (IVT) is often contraindicated in AC, and endovascular treatment (EVT) is considered the gold treatment standard, although data on its safety and efficacy is scarce.

METHODS

Digital records of patients receiving EVT in a tertiary university hospital with comprehensive stroke center from 2016 to 2022 were assessed. Demographic, clinical, and laboratory parameters were extracted and compared between patients with and without AC. In-hospital mortality was set as the primary outcome.

RESULTS

39 AC and 297 non-AC patients were included. No significant differences were reported in demographic and baseline stroke parameters (NIHSS, mRS, stroke etiology). In-hospital mortality did not differ between groups (11/39 vs. 57/297, p > 0.99). Successful recanalization, change in mRS and NIHSS from admission to discharge, periinterventional complications, and stroke-related mortality were also comparable. Significantly fewer AC patients received IVT. In the binary logistic regression analysis (adjusting for confounder variables), older age, large artery atherosclerosis, unsuccessful recanalization, and higher admission NIHSS were independent predictors of all-cause in-hospital mortality (aOR): 1.04, 95% confidence interval (CI): 1.01-1.08; OR: 3.21, 95% CI: 1.03-9.92, OR: 7.28, 95% CI: 3.61-15.1, OR: 1.07, 95% CI: 1.01-1.14, p-value < 0.05, respectively).

CONCLUSIONS

EVT was shown as safe and effective in AC patients as in non-AC patients. Long-term functional outcomes are often poorer in AC, due to the cancer itself, but given how oncological treatment depends on functional status, AC patients should be considered for EVT.

Lipoprotein(a) as a Risk Factor for Recurrent Ischemic Stroke in Type 2 Diabetes

Objective

This study aimed to investigate the effect of LP(a) on recurrent ischemic stroke among persons with and without diabetes, providing a basis for the precise management of patients with recurrent ischemic stroke with diabetes in clinical practice.

Methods

This study was conducted on consecutive patients with cerebral infarction diagnosed between January 2019 and March 2023 in the Second Hospital of Hebei Medical University. Stratified analyses were performed according to LP(a) level (≤/>90th percentile) and logistic regression modeling was performed to investigate the relationship between LP(a) and recurrent ischemic stroke with or without T2DM.

Results

In the final enrollment of 2029 patients, the number of recurrent ischemic stroke according to LP(a) >90th percentile combined with T2DM was 59.15%, which was significantly higher than in LP(a) ≤90th percentile combined with T2DM (46.17%, P=0.039). After multivariate adjustment, LP(a) >90th percentile emerged as an independent risk factor for patients with T2DM (OR=2.062, 95% CI 1.218-3.489, P=0.007). In patients with large artery atherosclerotic ischemic stroke, LP(a) was an independent risk factor for recurrent ischemic stroke in diabetic patients (OR=2.553, 95%CI 1.385-4.707, P = 0.003), while this was not in non-diabetic patients (P = 0.228).

Conclusion

LP(a) is an independent risk factor for recurrent ischemic stroke in the diabetic population but not in nondiabetic individuals. Simple categorization based on the presence or absence of comorbid T2DM significantly influences the association between LP(a) and recurrent ischemic stroke. Therefore, in clinical practice, for ischemic stroke patients with comorbid diabetes, the LP(a) level should be more strictly controlled.

Using proteomic biomarkers to estimate acute ischaemic stroke onset time

BACKGROUND

Current guidelines recommend intravenous thrombolysis (IVT) for acute ischaemic stroke (AIS) patients within 4.5 hour (h) of symptom onset. Our study aims to use proteomic biomarkers to identify AIS patients with an onset time within 4.5 h when the history is not clear.

METHODS

We conducted a retrospective case-control study between June 2022 and July 2023 in Ningbo No. 2 Hospital, recruiting 30 AIS patients and 12 controls. Patients with AIS were grouped into early-onset (ES, symptom onset time ≤ 4.5 h, n = 16) and late-onset (LS, symptom onset 4.5-24 h, n = 14). Plasma proteome were identified using mass spectrometry. A stepwise analysis was conducted to screen for candidate proteins. Multiple logistic regression was used to construct various combinations.

RESULTS

Here we show six proteins discriminate ES from LS, with the area under curve (AUC) ranging from 0.897 to 0.951. Protein 4.2 (EPB42) achieves the highest AUC of 0.951 (95% confidence interval 0.882-1), a specificity of 0.929 (0.714-1) and a sensitivity of 0.875 (0.750-1). Ten combinations are derived from these six proteins, of which EPB42 and Phosphatidylethanolamine-binding protein 1 achieve an AUC of 0.991 (0.970-1), a specificity of 0.929 (0.857-1), and a sensitivity of 1 (0.875-1) in differentiating ES from LS.

CONCLUSIONS

The six proteins and their combinations show promise as molecular clocks for determining the onset time of AIS in patients whose symptom onset time are unknown, potentially increasing their chances of receiving effective IVT to improve stroke outcomes.

P2Y12 Reaction Units With Prasugrel in Acute Large Artery Atherosclerosis and Transient Ischemic Attack: An Open-Label Randomized Controlled Study, ACUTE-PRAS

BACKGROUND

The antiplatelet effect of prasugrel for acute ischemic stroke or transient ischemic attack (TIA) remains unclear. This study compared platelet reactivity between prasugrel and clopidogrel, considering cytochrome P450 family 2 subfamily C member 19 (CYP2C19) gene polymorphisms (extensive metabolizers [EM], intermediate metabolizers [IM], and poor metabolizers [PM]), in patients with acute large artery atherosclerosis (LAA) or high-risk TIA.

METHODS AND RESULTS

In this multicenter open-label randomized controlled study, patients with acute LAA or high-risk TIA received prasugrel or clopidogrel with aspirin. The primary endpoint was platelet reaction units (PRU) 5 days after the start of drug administration, stratified according to CYP2C19 polymorphism. In all, 176 patients participated (88 in each group). Compared with the clopidogrel group, PRU on Day 5 in the prasugrel group were significantly lower in the overall population (adjusted mean 136.0 vs. 169.9; estimated difference -33.9; 95% confidence interval [CI] -49.0, -18.8), EM group (118.5 vs. 144.8; estimated difference -26.2; 95% CI -48.0, -4.4), and IM group (140.3 vs. 173.1; estimated difference -32.8; 95% CI -56.6, -9.0), and tended to be lower in the PM group (164.7 vs. 196.2; estimated difference -31.6; 95% CI -68.3, 5.1). The prevalence of new infarct lesions was comparable between the prasugrel and clopidogrel groups, as was the incidence of adverse events (30.7% vs. 26.1%, respectively) and bleeding events up to Day 5 of administration.

CONCLUSIONS

In patients with acute LAA or high-risk TIA, prasugrel resulted in stable inhibition of platelet aggregation 5 days after starting drug administration compared with clopidogrel, regardless of CYP2C19 polymorphisms.

Predictive role of a combined model for futile recanalization in acute ischemic stroke: a retrospective cohort study

Objective

There is a lack of data regarding patients with acute ischemic stroke caused by large vessel occlusions (LVOs) undergoing mechanical thrombectomy (MT) and their predictors of futile recanalization (FR). We sought to investigate the predictors of FR in patients with AIS-LVO undergoing mechanical thrombectomy.

Method

A retrospective analysis was conducted on 229 acute AIS patients who received MT, after eliminating the 31 patients not meet the requirements. The patients were categorized into the FR group and the useful recanalization (UR) group. Multivariate logistic regression analysis was used to explore the factors that influence FR after mechanical thrombectomy. ROC curve was used to plot the ability to predict FR after MT, and then the combined model was constructed and evaluate the predictive ability of this model to FR.

Results

198 patients who achieved successful recanalization were included in the analysis, of whom 124 experienced UR and 74 experienced FR. Patients with FR had higher Baseline NIHSS; they were more frequently on hypertension history and had longer door-to-puncture time (DPT) and door-to-recanalization time (DRT). Multivariable regression analysis showed that the hypertension history, Admission NIHSS, Admission DBP, Admission blood glucose, ischemic core, and DPT were associated with an increased probability of FR. The combined model was better than the models alone in predicting the risk of FR.

Conclusion

Admission blood pressure, admission NIHSS scores, admission DBP, ischemic core and DPT are independent risk factors for FR after MT in patients with AIS, and the combined model established by them has high predictive efficacy for FR risk after MT.

Electromechanical-assisted training for walking after stroke

RATIONALE

Walking difficulties are common after a stroke. During rehabilitation, electromechanical and robotic gait-training devices can help improve walking. As the evidence and certainty of the evidence may have changed since our last update in 2020, we aimed to update the scientific evidence on the benefits and acceptability of these technologies to ensure they remain a viable option for stroke rehabilitation.

OBJECTIVES

Primary • To determine whether electromechanical- and robot-assisted gait training versus physiotherapy (or usual care) improves walking in adults after stroke. Secondary • To determine whether electromechanical- and robot-assisted gait training versus physiotherapy (or usual care) after stroke improves walking velocity, walking capacity, acceptability, and death from all causes until the end of the intervention phase.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and seven other databases. We handsearched relevant conference proceedings, searched trials and research registers, checked reference lists, and contacted trial authors to identify further published, unpublished, and ongoing trials. The date of the latest search was December 2023.

ELIGIBILITY CRITERIA

We included all randomised controlled trials and randomised controlled cross-over trials in people over the age of 18 years diagnosed with stroke of any severity, at any stage, in any setting, evaluating electromechanical- and robot-assisted gait training versus physiotherapy (or usual care).

OUTCOMES

Our critical outcome was the ability to walk independently, measured with the Functional Ambulation Category (FAC). An FAC score of 4 or 5 indicated independent walking over a 15-metre surface, irrespective of aids used, such as a cane. An FAC score less than 4 indicates dependency in walking (supervision or assistance, or both, must be given in performing walking). Important outcomes included walking velocity and capacity, as well as dropouts.

RISK OF BIAS

We used Cochrane's RoB 1 tool.

SYNTHESIS METHODS

Two review authors independently selected trials for inclusion, assessed methodological quality and risk of bias, and extracted data. We used random-effects models for the meta-analysis. We assessed the certainty of evidence using the GRADE approach.

INCLUDED STUDIES

We included 101 studies (39 new studies plus 62 studies from previous versions) with a total of 4224 participants after stroke in our review update.

SYNTHESIS OF RESULTS

Electromechanical-assisted gait training in combination with physiotherapy probably increases the odds of participants becoming independent in walking (odds ratio (OR) 1.65, 95% confidence interval (CI) 1.21 to 2.25; P = 0.001; I² = 31%; 51 studies, 2148 participants; moderate-certainty evidence); probably does not increase mean walking velocity (mean difference (MD) 0.05 m/s, 95% CI 0.02 to 0.08; P < 0.001; I² = 58%; 73 studies, 3043 participants; moderate-certainty evidence); and does not increase mean walking capacity (MD 11 metres walked in 6 minutes, 95% CI 1.8 to 20.3; P = 0.02; I² = 43%; 42 studies, 1966 participants; high-certainty evidence). Electromechanical-assisted gait training does not increase or decrease the risk of loss to the study during the intervention or the risk of death from all causes (high-certainty evidence). At follow-up after study end, electromechanical-assisted gait training in combination with physiotherapy may not increase the odds of participants becoming independent in walking (OR 1.64, 95% CI 0.77 to 3.48; P = 0.20; I² = 69%; 8 studies, 569 participants; low-certainty evidence), and probably does not increase mean walking velocity (MD 0.05 m/s, 95% CI -0.03 to 0.13; P = 0.22; I² = 66%; 17 studies, 857 participants; moderate-certainty evidence) or mean walking capacity (MD 9.6 metres walked in 6 minutes, 95% CI -14.6 to 33.7; P = 0.44; I² = 53%; 15 studies, 736 participants; moderate-certainty evidence). Our results must be interpreted with caution because (1) some trials investigated people who were independent in walking at the start of the study; and (2) there was variation between trials with respect to the devices used and duration and frequency of treatment.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that people who receive electromechanical-assisted gait training in combination with physiotherapy after stroke are probably more likely to achieve independent walking than people who receive gait training without these devices.We concluded that nine patients need to be treated to prevent one dependency in walking. Further research should consist of large, definitive pragmatic phase 3 trials undertaken to address specific questions about the most effective frequency and duration of electromechanical-assisted gait training, as well as how long any benefit may last. Future trials should consider time poststroke in their trial design.

FUNDING

This Cochrane review had no dedicated funding.

REGISTRATION

Protocol (2006): doi:10.1002/14651858.CD006185 Original review (2007): doi:10.1002/14651858.CD006185.pub2 Review update (2013): doi:10.1002/14651858.CD006185.pub3 Review update (2017): doi:10.1002/14651858.CD006185.pub4 Review update (2020): doi:10.1002/14651858.CD006185.pub5.

Influence of Asymptomatic Hemorrhagic Transformation After Endovascular Treatment on Stroke Outcome: A Population-Based Study

BACKGROUND AND OBJECTIVES

In patients with acute ischemic stroke (AIS), the impact of hemorrhagic transformation (HT) after endovascular treatment (EVT) on poorer stroke outcome is well established when associated with clinical deterioration. However, the influence of asymptomatic HT remains unclear. We aimed to examine the impact of asymptomatic HT after EVT on functional outcome and mortality.

METHODS

Drawing on Catalan (Spain) population-based prospective stroke registry data, we included patients from 10 comprehensive stroke centers with anterior circulation AIS (2017-2023) who underwent EVT, excluding patients without data on the presence of HT or functional outcome at 3 months of follow-up. HT was categorized as parenchymal hemorrhage (PH), hemorrhagic infarct (HI) types 1 and 2, and remote PH (rPH). Asymptomatic HT was defined as any HT not causing death or the NIH Stroke Scale (NIHSS) score to increase by ≥ 4 points. Functional outcome was centrally assessed using the modified Rankin Scale (mRS). The primary end point was a shift in the 3-month mRS score. After excluding symptomatic intracerebral hemorrhage (sICH), multivariable ordinal regression analyses (adjusted by age, mRS, baseline NIHSS score, baseline Alberta Stroke Program Early CT Score, and modified Thrombolysis In Cerebral Infarction score ≥2b) were performed to test for asymptomatic HT association with the primary end point.

RESULTS

We included 3,067 patients (72.0 ± 13.6 years, 50.7% women), 179 (5.8%) with sICH and 612 (20.0%) with asymptomatic HT. HT category frequencies were 8.9% HI1, 7.2% HI2, 4.4% PH1, 3.8% PH2, and 1.5% rPH. The percentage of asymptomatic patients showed a hierarchical distribution, ranging from 93.4% in HI1 to 25.0% in PH2. In the multivariable analysis, asymptomatic HT was associated with poorer outcomes (common odds ratio [cOR] 2.24, 95% CI 1.89-2.66) and higher mortality (adjusted odds ratio 1.50, 95% CI 1.17-1.91). In the sensitivity analyses, the association with functional outcome remained significant for each HT category, with asymptomatic PH2 showing the highest odds of poorer outcomes (cOR 3.15, 95% CI 1.46-6.83).

DISCUSSION

In patients with AIS undergoing EVT, asymptomatic HT was associated with poorer functional outcomes and higher mortality, suggesting that any HT, regardless of its clinical impact or radiologic category, should be considered as an additional EVT safety measure.

Left Ventricular Injury Detected by Cardiac MRI and Incident Ischemic Stroke and Dementia Risk: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND AND OBJECTIVES

Left ventricular injury (LVI) can be detected by cardiac magnetic resonance (CMR) imaging with high sensitivity; however, the implication of these findings on brain health longitudinally is uncertain. We aimed to evaluate the association between LVI biomarkers detected by CMR and the risk of developing ischemic stroke and dementia.

METHODS

We analyzed the prospective, observational cohort of participants in the Multi-Ethnic Study of Atherosclerosis (MESA) study (median follow-up of 8.7 years). MESA is a population-based cohort recruited from 6 communities. The complete case analysis (CCA) sample included stroke-free participants who underwent CMR at Exam 5 (2010-2012). The multiple imputation (MI) sample consisted of stroke-free participants at Exam 5, irrespective of CMR collection. Missing CMR variables were imputed because of the nonrandom missingness of CMR data. The primary exposure was LVI defined by LV ejection fraction < 50% or circumferential strain ≥ -10 in any LV apical wall. Secondary exposures were left ventricular ejection fraction (LVEF) and strain as continuous measures. Primary outcomes were (1) incident ischemic stroke and (2) newly diagnosed all-cause dementia. Cox proportional hazard models were adjusted for demographic and clinical covariates.

RESULTS

There were 2,584 (11.7% with LVI [mean age 71, 65% male], 88.3% without LVI [mean age 69, 44% male]) and 4,594 participants in the CCA and MI cohorts, respectively. Incident ischemic stroke occurred in 18 (6%) participants with and 65 (3%) without LVI in the CCA sample (302 or 12% with and 18 or 6% without LVI in the MI sample). Both groups had similar rates of cardiovascular disease (6% vs 4%, p = 0.143). LVI was significantly associated with incident ischemic stroke in the MI cohort (adjusted hazard ratio [HR] 1.82, 95% CI 1.08-3.09), but not in the CCA cohort. LV apical peak strain was significantly associated with newly diagnosed dementia only in the MI cohort (adjusted HR 1.06, 95% CI 1.01-1.12). LVEF per 10% was significantly associated with newly diagnosed dementia in both cohorts (adjusted HR in MI cohort 0.73, 95% 0.59-0.90).

DISCUSSION

CMR-detected LVI is associated with incident ischemic stroke and newly diagnosed dementia. Further studies are needed to validate CMR biomarkers of brain injury risk.

Comparative analysis of prognostic scores for functional outcome after ischemic stroke

BACKGROUND

Comparative data on the predictive performance of stroke prognostic scores in a real-world setting are sparse.

OBJECTIVE

We aimed to compare the performance of existing scores for acute stroke outcomes in an observational cohort.

METHODS

Using data from 12,486 patients with acute ischemic stroke (mean [SD] age, 72.5 [12.6] years; male, 59.4 %) prospectively registered in Fukuoka, Japan, between 2007 and 2017, we evaluated the predictive performance of six stroke prognostic scores, namely ASTRAL, iScore, PLAN, HIAT, SPAN-100, and THRIVE. The discriminative power of the scores was evaluated by the area under the receiver operating characteristic curve (AUROC). Calibration was evaluated using calibration plots. Overall performance, incorporating both discrimination and calibration, was assessed using Brier score.

RESULTS

In comparative analyses using un identical study population, AUROCs for predicting 3-month poor functional outcome were 0.87 for ASTRAL, 0.88 for iScore, and 0.89 for PLAN among the scores for all patients, and 0.74 for HIAT, 0.81 for SPAN-100, and 0.78 for THRIVE among the scores for patients receiving reperfusion therapy. The calibration plots showed fair agreement between the outcome predictions and the observed outcomes in all scores, and no substantial difference was found among the scores. The analysis of overall performance indicated that PLAN was better than ASTRAL, whereas no significant difference was found among HIAT, SPAN-100, and THRIVE.

CONCLUSIONS

The predictive performance of all six scores was good, even in our observational cohort, reflecting the real-world setting. The prognostic scores could provide useful information for the management of acute stroke patients.

High serum glial fibrillary acidic protein levels are associated with increased risk of post-stroke cognitive impairment

Background and purpose

The correlation between glial fibrillary acidic protein (GFAP) and cognitive impairment in acute ischemic stroke patients remains uncertain. We aimed to evaluate GFAP in serum as predictor of post-stroke cognitive impairment (PSCI) at 90 days.

Methods

From March 2022 to February 2023, patients with first-ever ischemic stroke were prospectively enrolled. Serum GFAP concentrations were measured within 24 h after admission using an enzyme-linked immunosorbent assay. Cognitive function measurement was performed at the 90 days follow-up using the Mini-mental state examination (MMSE). A MMSE score <27 was defined as PSCI. Multiple logistic regression and restricted cubic spline were performed to examine the association between GFAP and cognitive impairment.

Results

A total of 336 patients (mean age: 66.3 ± 9.0 years; 58.3% male) with acute ischemic stroke were included. The median GFAP levels were 0.73 ng/mL (interquartile range, 0.38-1.09 ng/mL). During the 3-month follow-up, 164 participants (48.8%) experienced PSCI. Higher GFAP levels were independently associated with PSCI after adjusting for potential confounders (per 1-unit increase, odds ratio: 3.91; 95% confidence interval: 2.24-6.82; p = 0.001). Additionally, restricted cubic spline confirmed a linear relationship between serum GFAP concentrations and PSCI risk (P for linearity = 0.001).

Conclusion

This study demonstrated that higher levels of GFAP were associated with PSCI, suggesting that GFAP could be a promising and straightforward screening indicator of cognitive impairment after stroke.

Anticoagulants or antiplatelets for secondary prevention of cryptogenic stroke: an updated systematic review and meta-analysis

BACKGROUND

Patients with cryptogenic stroke or embolic stroke of undetermined source (ESUS) face a high risk of recurrent ischaemic stroke, but the optimal antithrombotic strategy remains unclear. This systematic review and meta-analysis compared the effectiveness and safety of oral anticoagulants (OACs) versus antiplatelets in these populations, with a focus on subgroup effects by key clinical characteristics.

METHODS

Six databases were searched through March 2024 to identify randomised controlled trials (RCTs) comparing OACs and antiplatelets in patients with cryptogenic stroke or ESUS. The primary outcome was recurrent ischaemic stroke. Subgroup analyses evaluated treatment effects based on supracardiac atherosclerosis risk, presence of patent foramen ovale (PFO) and signs or risk factors for atrial cardiopathy. Meta-regression with interaction p values was employed to assess differences in treatment effects between subgroups.

RESULTS

Nine RCTs comprising 15 451 participants were included. In the overall population, there was no significant difference in recurrent ischaemic stroke risk between OACs and antiplatelets (relative risk (RR) 0.90, 95% CI 0.79 to 1.02; I2=0%). Subgroup analyses showed that OACs reduced ischaemic stroke risk in patients with low-risk supracardiac atherosclerosis (RR 0.53, 95% CI 0.35 to 0.80; I2=0%) compared with those with high-risk supracardiac atherosclerosis (RR 0.91, 95% CI 0.78 to 1.06; I2=0%) and evidence of supracardiac atherosclerosis (RR 1.13, 95% CI 0.84 to 1.53; I2=0%) (p interaction=0.0002). Similarly, OACs were more effective in patients with signs or risk factors for atrial cardiopathy (RR 0.84, 95% CI 0.70 to 0.99; I2=0%) than in those without atrial cardiopathy (RR 1.05, 95% CI 0.85 to 1.30; I2=0%) (p interaction=0.02). There was no significant interaction by PFO status (p interaction=0.28). While the risk of major bleeding risk was comparable between groups (RR 1.34, 95% CI 0.73 to 2.44; I2=65%), a significantly higher risk of major bleeding other than intracerebral haemorrhage was observed in patients taking OACs compared with antiplatelets (RR 1.69, 95% CI 1.18 to 2.43; I2=0%).

CONCLUSIONS

OACs are more effective than antiplatelets for preventing ischaemic stroke in patients who had a cryptogenic stroke or ESUS with low-risk supracardiac atherosclerosis or atrial cardiopathy. The findings highlight the need for personalised treatment strategies and further trials in these subgroups.

PROSPERO REGISTRATION NUMBER

CRD42024518903.

Endovascular Treatment of Acute Large Vessel Occlusion in the Anterior and Posterior Circulation

Endovascular treatment (EVT) has been strongly recommended as a first-line treatment for acute ischemic strokes (AIS) caused by large vessel occlusion (LVO). To evaluate the efficacy, safety, and predictors of favorable outcomes of EVT for LVO-caused AIS in both the anterior and posterior circulations, consecutive patients who had undergone EVT for AISs caused by LVO were retrospectively enrolled, and the clinical data, symptomatic intracranial hemorrhage (sICH), modified Rankin Scale (mRS) score, and mortality at 90 days were analyzed. In total, 231 patients were enrolled with a mean age of 63.25 ± 11.48 years, including 167 (72.29%) patients with anterior circulation occlusion (ACO) and 64 (27.71%) patients with posterior circulation occlusion (PCO) treated with EVT. The median baseline National Institutes of Health Stroke Scale (NIHSS) Score on admission was 17 (12-20). The median time from symptom onset to recanalization (OTR) was 380 (307.5-461) minutes. Successful recanalization was achieved in 90.04% of patients. At 3-month follow-up, 118 (51.08%) patients had favorable clinical outcomes (mRS 0-2), with a mortality rate of 18.61% (43/231). Younger age (p = 0.001), a lower baseline NIHSS score (p < 0.001), a higher recanalization rate (p = 0.018), and shorter OTR time (p = 0.026) were significant independent risk factors for favorable outcomes. Compared to patients with ACO, PCO patients had a lower favorable outcome rate (p = 0.049) and a higher mortality rate (p < 0.001). In conclusion, EVT is safe and effective for patients with LVO-caused AIS, and younger age, lower baseline NIHSS scores, a higher recanalization rate, and shorter OTR time are independent risk factors for favorable outcomes. PCO patients may have worse clinical outcomes and a higher mortality rate than ACO patients.

Monocyte Chemoattractant Protein-1 as a Biomarker in Acute Ischemic Stroke: A Prospective Pilot Study

Background: Monocyte chemotactic protein-1 (MCP-1) was implicated in the progression of atherosclerosis and is associated with elevated stroke risk. However, there is limited evidence regarding the MCP-1 role as an early biomarker for predicting the severity and outcomes of acute ischemic stroke (AIS). This prospective pilot case-control study aims to offer preliminary evidence into whether MCP-1 levels are elevated in AIS, whether they vary across different stroke subtypes, and their potential utility as a biomarker for assessing stroke severity and predicting outcomes. Methods: MCP-1 levels were quantified using ELISA in patients with AIS or transients ischemic attack (TIA) and healthy participants. Stroke severity was assessed with the NIHSS score and functional outcome with the mRS scale. Results: A total of 32 patients with AIS or TIA were compared to 13 healthy controls. MCP-1 levels were found to be 77% higher in stroke patients compared to healthy controls (p < 0.001). No significant differences in MCP-1 levels were observed between patients with AIS and those with TIA, nor among different stroke subtypes. A positive correlation was observed between MCP-1 levels and NIHSS changes from admission to discharge (b = 0.376, p < 0.05) and mRS scale at 6-month follow-up (b = 0.507, p < 0.05). Conclusions: This prospective pilot study provides preliminary evidence that MCP-1 levels are significantly elevated in AIS and are associated with NIHSS change during hospitalization and unfavorable outcome at 6-month follow-up. These findings indicate the potential of MCP-1 as an early biomarker for assessing disease severity and predicting outcomes in AIS.

Long-term dual-trajectories of TyG and LAP and their association with cardiometabolic multimorbidity in midlife: the CARDIA study

BACKGROUND

Insulin resistance and central obesity are major risk factors for cardiometabolic diseases. The triglyceride-glucose index (TyG) and lipid accumulation product (LAP) are markers that independently predict cardiometabolic risk. However, their combined long-term trajectories and impact on cardiometabolic multimorbidity (CMM) development remain unclear.

METHODS

This cohort study utilized data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, which tracked 3467 participants at baseline. Dual-trajectory of TyG and LAP were identified using a group-based dual-trajectory model. Cox proportional hazards models were employed to assess the relationships between dual-trajectory groups and primary cardiometabolic outcomes, including first cardiometabolic disease (FCMD), CMM (two or more conditions such as type 2 diabetes, coronary heart disease, or stroke), and all-cause mortality. Multi-state models were performed to assess the associations of dual-trajectory with CMM development.

RESULTS

The study included 3467 participants with a mean age of 25.08 years (SD = 3.59). Of these, 43.4% (n = 1505) were male, and 53.2% (n = 1561) were White. Three distinct dual-trajectory groups were identified: low-increasing (61.5%), high-amplitude fluctuation (7.6%), and high-increasing (30.9%). After multivariate adjustment, compared with the low-increasing group, the high-amplitude fluctuation group exhibited significantly higher risks for FCMD (hazard ratio [HR] 1.38, 95% confidence interval [CI]: 1.08-1.77), CMM (HR 2.63, 95% CI 1.21-5.71), and all-cause mortality (HR 2.16, 95% CI 1.30-3.56), as well as elevated risks for transitions from baseline to FCMD (HR 1.41, 95% CI 1.17-1.63), FCMD to CMM (HR 2.07, 95% CI 1.53-3.96), CMM to death (HR 2.87, 95% CI 1.19-7.62). The high-increasing group showed similar results.

CONCLUSIONS

Elevated and fluctuating trajectories of TyG and LAP from early adulthood are associated with increased risks of CMM development in midlife.

Hemostatic Activation Markers and Early Neurological Deterioration in Branch Atheromatous Disease-Related Stroke

AIMS

Branch atheromatous disease (BAD)-related stroke, caused by atherosclerotic occlusion at the origin of a deep penetrating artery, are prone to early neurological deterioration (END). This study aimed to assess the association between hemostatic activation markers and occurrence of END in patients with BAD-related stroke.

METHODS

This prospective observational study included 88 patients with BAD-related stroke within 7 days of onset. On admission, plasma beta-thromboglobulin (beta-TG), platelet factor 4 (PF4), and D-dimer levels were measured. END was defined as an increase of ≥ 2 points in the total National Institutes of Health Stroke Scale (NIHSS) score or ≥ 1 point in the motor items of the NIHSS within 7 days of admission.

RESULTS

Of the 88 patients, 34 (38.6%) experienced END. Mean beta-TG (158 ng/mL vs. 102 ng/mL; P = 0.021), PF4 (61 ng/mL vs. 35 ng/mL; P = 0.024), and D-dimer (2.0 µg/mL vs. 1.2 µg/mL; P = 0.037) levels were significantly higher in patients with END than in those without END. Multivariate analysis revealed that beta-TG and PF4 levels were independently associated with the occurrence of END, with an adjusted odds ratio per 10 ng/mL increase (95% confidence interval) of 1.09 (1.01-1.20) and 1.21 (1.02-1.49), respectively. In contrast, D-dimer levels were not independent predictors. The optimal cutoff values for predicting END were 130 and 55 ng/mL for beta-TG and PF4, respectively.

CONCLUSIONS

Elevated beta-TG and PF4 levels were independent predictors of END in patients with BAD-related stroke. Hence, the measurement of these platelet activation markers helps improve the risk assessment of BAD-related stroke and may provide management implications.

Construction and validation of a nomogram for predicting 3-month outcome in elderly patients with nonvalvular atrial fibrillation-induced acute ischemic stroke

Aim

Cardiogenic embolism caused by atrial fibrillation (AF) leads to higher disability, mortality, and recurrence rates compared to stroke independent of AF, resulting in a poorer prognosis for patients. Effective risk assessment and timely clinical intervention are essential. This study aimed to develop and validate a personalized nomogram to predict the 3-month outcomes for elderly patients with nonvalvular atrial fibrillation (NVAF) induced acute ischemic stroke (AIS).

Methods

A retrospective cohort study was implemented at Hefei First People's Hospital. Participants were patients diagnosed with NVAF-induced acute ischemic stroke (NVAF-AIS) who fulfilled the study's inclusion criteria. Data collection encompassed baseline demographic, clinical, and laboratory information. The primary endpoint was the 3-month outcome, evaluated using the modified Rankin Scale (mRS). To identify potential predictors, univariate logistic regression and the least absolute shrinkage and selection operator (LASSO) regression algorithm were employed. Subsequently, a binary regression model was established, and internal validation was conducted using bootstrap resampling with 1,000 iterations. The assessment tools included receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA). Ultimately, a nomogram was constructed to forecast the 3-month outcomes for this demographic.

Results

A total of 178 patients were included, of whom 95 (53.3%) had a poor outcome (mRS > 2). Independent risk factors for poor outcomes in NVAF-AIS patients included stroke history (OR = 9.140; 95% CI: 3.481-26.923), NIHSS score (OR = 1.167; 95% CI: 1.071-1.284), glycated hemoglobin (HbA1c) (OR = 2.211; 95% CI:1.573-3.220), D-dimer (OR = 1.157; 95% CI: 1.022-1.361), neutrophil-to-lymphocyte ratio (NLR) (OR = 1.531; 95%CI:1.242-1.972), and left atrial diameter (LAD) (OR = 1.163; 95%CI: 1.072-1.280). A nomogram was created based on these factors. The area under the ROC curve (AUC) for the nomogram was 0.933 (95%CI:0.897-0.969) before and 0.933(95%CI:0.895-0.964) after internal validation, demonstrating good discriminative ability. The nomogram also showed excellent calibration and clinical applicability, as confirmed by calibration curve analysis and DCA.

Conclusion

Stroke history, NIHSS score, HbA1c, D-dimer, NLR, and LAD are independent risk factors for poor outcomes in elderly patients with NVAF-AIS. The nomogram, integrating these factors, provides intuitive, individualized predictions for the risk of poor outcomes, aiding in the selection of treatment options for these patients.

Values of lymphocyte-related ratios in predicting the clinical outcome of acute ischemic stroke patients receiving intravenous thrombolysis based on different etiologies

Background

While neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and platelet-to-lymphocyte ratio (PLR) have been associated with acute ischemic stroke (AIS) outcomes, their differential predictive value across etiological subtypes (TOAST classification) in thrombolysis-treated patients remains underexplored.

Methods

In this retrospective cohort study, we analyzed 381 AIS patients receiving intravenous thrombolysis. Hematological indices were calculated from pre-thrombolysis. Using multivariable logistic regression adjusted for age, NIHSS, and comorbidities, we assessed associations between baseline ratios and 90-day unfavorable outcomes (mRS 3-6). Receiver operating characteristic (ROC) analysis was used to determine optimal cutoffs stratified by TOAST subtypes.

Results

A total of 381 patients were included in the study. NLR showed superior predictive performance: large-artery atherosclerosis: AUC = 0.702 (aOR = 1.35, 95%CI = 1.14-1.61, p = 0.001), small-artery occlusion: AUC = 0.750 (aOR = 1.51, 95%CI = 1.08-2.10, p = 0.015), cardioembolic stroke: AUC = 0.679 (aOR = 1.82, 95%CI = 1.07-3.10, p = 0.028). LMR showed predictive value only in large-artery atherosclerosis (AUC = 0.632, p = 0.004). Optimal NLR cutoffs: 3.19 (large-artery), 3.94 (small-artery), 3.17 (cardioembolic stroke).

Conclusion

NLR emerged as a robust, subtype-specific predictor of post-thrombolysis outcomes, particularly in atherosclerotic stroke variants. These findings supported NLR's clinical utility for risk stratification in thrombolysis-eligible AIS patients.

Feasibility of emergent single-step intracranial self-expanding stent deployment using over-the-wire coronary balloons in intracranial atherosclerosis-related large vessel occlusion thrombectomy

BACKGROUND

The currently US Food and Drug Administration approved intracranial stent delivery system involves a multistep deployment process that requires the use of an exchange length microwire (ELW). In this study, we describe a single-step approach to deploy the Neuroform Atlas stent without the need for ELW or lesion re-access, using the MINI TREK II over-the-wire (OTW) semi-compliant coronary balloon.

METHODS

We performed a retrospective review of prospectively maintained mechanical thrombectomy databases from two comprehensive stroke centers. The study included consecutive large vessel occlusion (LVO) stroke patients who underwent single-step angioplasty with the MINI TREK II OTW balloon followed by deployment of the Neuroform Atlas intracranial stent, without the use of an ELW.

RESULTS

A total of 12 patients met the inclusion criteria. Among them, the median age was 67 years (IQR: 58-73) and 50% were female. Most patients had middle cerebral artery (MCA) M1 occlusion (75%). One-third of the patients received intravenous thrombolysis. All patients achieved successful reperfusion (modified Treatment in Cerebral Ischemia (mTICI) 2b/3) with a median of two passes. The median National Institutes of Health Stroke Scale (NIHSS) score decreased from 14 (IQR: 10-19) at baseline to 4 (IQR: 1-9) at discharge, and the median modified Rankin Scale (mRS) score was 1 (IQR: 1-4) at discharge and 3 (IQR: 2-4) at 90 days. None of the patients in this series experienced symptomatic intracranial hemorrhage, though two patients (16.7%) were dead at 90 days but there was no procedural-related mortality.

CONCLUSIONS

This preliminary experience demonstrates the technical feasibility and success of single-step deployment of the Neuroform Atlas stent following angioplasty with the MINI TREK II OTW balloon, without the need for an ELW or lesion re-access. Larger prospective studies with extended clinical follow-up are needed to validate these findings.