2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association

Neurologic Specific Risk: Strokes, Lytics, and Litigation

Misdiagnosis in Emergency Medicine can be associated with patient harm, with neurologic diagnoses among the most common conditions to confound physicians. These are often complex, time-sensitive and nuanced, offering opportunity for mimics and chameleons to make assessment, diagnosis and treatment challenging. This article discusses the legal considerations pertinent to neurologic diagnoses for the emergency physician, including assessment, diagnosis, treatment, transfer and documentation in order to ensure excellent patient care as well as protection from liability.

Altered callosal morphology in post-stroke cognitive impairment

Stroke is the second leading cause of death and cognitive impairment. Post-stroke cognitive impairment (PSCI) is one of the most common sequelae among stroke survivors, yet its underlying neural mechanisms remain largely unclear. The corpus callosum (CC) plays a crucial role in interhemispheric integration and hemispheric segregation, with changes in CC morphology potentially overlapping with the spectrum of PSCI. This study aimed to investigate the morphological changes in the CC and their diagnostic value in PSCI patients. Structural MRI, neurobehavioral, and clinical data were collected from 104 PSCI patients and 54 demographically matched healthy controls. Significant reductions in CC area, circularity, and genu thickness were observed in PSCI patients, with these changes strongly correlating with global cognitive function. Subgroup analysis revealed that CC circularity significantly decreased when lesions were located in the posterior circulation, while both CC area and circularity markedly decreased with anterior circulation lesions. Receiver Operating Characteristic analyses identified the midbody areas of the CC as having high diagnostic value, with area under the curve values of 0.748 and 0.746, respectively. Further validation analyses suggest that the transcallosal fibers in these CC subregions are connected to the premotor, dorsal attention, and frontoparietal system. These findings show that areal CC atrophy in PSCI patients, particularly in regions with transcallosal connections to the premotor cortex and frontoparietal network, parallels global cognitive impairment. This suggests that CC morphology may serve as a potential imaging marker for the diagnosis and prognosis of PSCI.

Early vs Late Anticoagulation After Ischemic Stroke in Patients With Atrial Fibrillation and Covert Brain Infarcts

BACKGROUND AND OBJECTIVES

Covert brain infarcts (CBIs) in patients with first-ever ischemic stroke (IS) and atrial fibrillation (AF) are associated with an increased risk of stroke recurrence. We aimed to assess whether CBIs modify the treatment effect of early vs late initiation of direct oral anticoagulants (DOACs) in patients with IS and AF.

METHODS

We conducted a post hoc analysis of the international, multicenter, randomized-controlled ELAN trial, which compared early (<48 hours after ischemic stroke for minor and moderate stroke, 6-7 days for major stroke) vs late (>48 hours for minor, 3-4 days for moderate, 12-14 days for major stroke) initiation of DOACs in patients with IS and AF. The primary outcome was a composite of recurrent IS, symptomatic intracranial hemorrhage (sICH), major extracranial bleeding, systemic embolism, or vascular death within 30 days after stroke; secondary outcomes were the individual components. We estimated outcomes based on the presence of CBIs (any CBI vs no CBI) on prerandomization imaging (core-lab rating) using adjusted risk differences (aRDs) between treatment arms. Point estimates and 95% CIs are presented without reporting p values.

RESULTS

Of the 1,694 participants with first-ever IS included (median age: 77 years, 45.9% female), 678 (40.0%) had CBI. The imaging core-lab interrater reliability for the presence of CBI was 0.87 (0.81-0.94). The primary outcome occurred in 8 (2.3%; recurrent IS: 3/342) of 342 participants with CBI assigned to the early treatment arm vs 20 (6.0%; recurrent IS: 12/336) of 336 assigned to the late treatment arm (aRD: -3.6%, 95% CI -6.6 to -0.6) (p for interaction: 0.063). With early DOAC treatment, IS recurrence risk was lower in participants with CBI (aRD: -2.7%, 95% CI -5.0 to -0.4), but not in participants without CBI (aRD: -0.4, 95% CI -2.1 to 1.2). No sICH was observed in the early treatment group.

DISCUSSION

The presence of CBI may indicate a subgroup of patients with first-ever IS and AF who particularly benefits from early DOAC initiation to prevent ischemic event recurrence, without increasing harm. Our findings should be considered in clinical decision making regarding timely DOAC treatment in patients with stroke and AF.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that in patients with covert brain infarcts, atrial fibrillation, and first-ever ischemic stroke, early (vs late) initiation of DOACs is associated with lower risk of recurrent stroke with no increase in harm.

TRIAL REGISTRATION INFORMATION

URL: clinicaltrials.gov/study/NCT03148457; Unique identifier: NCT03148457; submitted: April 7, 2017; first patient enrolled: November 6, 2017.

Left ventricular disease as a risk factor for adverse outcomes and stroke recurrence in patients with embolic stroke of undetermined source

BACKGROUND

Severe left ventricular (LV) systolic dysfunction (ejection fraction [EF] < 30%) is a known cardiovascular risk factor and a major cause of cardioembolism. However, less severe forms of LV disease (LVD), such as mild-to-moderate LV dysfunction and LV wall motion abnormalities (LVWMAs), are considered potential minor cardiac sources in Embolic Stroke of Undetermined Source (ESUS), but their role is underexplored. This study aims to evaluate the prevalence of LVD in ESUS and its association with adverse vascular events and mortality.

METHODS

Retrospective, single-center study including consecutive ESUS patients admitted from January 2016 to May 2024. LVD was defined as either global systolic dysfunction (LV ejection fraction 30%-49%) or regional LVWMAs, unrelated to acute or recent (within 4 weeks) myocardial infarction. Univariate and multivariate Cox regression analyses evaluated the association of LVD with a primary composite outcome (including ischemic stroke recurrence, acute coronary events, and all-cause mortality), and its components separately.

RESULTS

Among the 556 ESUS patients (median age 71 years [IQR 60-80], 44.6% female), 95 (17.1%) had LVD, including 51 (53.7%) with reduced LVEF (30%-49%), and 81 (85.3%) presenting LVWMAs. During follow-up (median 30 months), LVD(+) patients had significantly higher rates of the composite outcome (41.0% vs 21.3%, p < 0.001), ischemic stroke recurrence (13.7% vs 5.9%, p = 0.007), acute coronary events (7.4% vs 2.4%, p = 0.012), and all-cause mortality (28.4% vs 15.2%, p = 0.002), compared to LVD(-) patients. Multivariate Cox regression analysis showed that LVD independently increased the risk of ischemic stroke recurrence (adjusted HR 2.13, 95%CI 1.08-4.24, p = 0.032) and the composite outcome (aHR 1.92, 95%CI 1.27-2.90, p = 0.002), but not acute coronary events (aHR 1.65; 95%CI 0.54-5.01, p = 0.374), or all-cause mortality (aHR 1.62; 95%CI 0.98-2.70, p = 0.062).

CONCLUSIONS

LVD is significantly associated with an increased risk of ischemic stroke recurrence and adverse outcomes in ESUS patients. These findings highlight the clinical importance of identifying and optimizing LVD management among ESUS to improve long-term outcomes in this population.

Trends and cost structure of drug-based secondary prevention of ischemic strokes

BACKGROUND

Advances in secondary stroke prevention, including direct oral anticoagulants (DOACs), dual antiplatelet therapies (DAPT), and cardiovascular risk management, have changed costs over the past decade. This study aimed to evaluate annual treatment costs and trends in drug-based secondary prophylaxis after ischemic strokes.

METHODS

Annual treatment costs were evaluated using the net costs per defined daily dosage (DDD) of discharge medications for ischemic stroke patients treated in 2020 at the University Hospital Frankfurt, Germany. Evaluated drugs included acetylsalicylic acid, adenosine diphosphate inhibitors, DOACs, vitamin K antagonists, lipid-lowering drugs (LLD), antihypertensives (AHT), and oral antidiabetics (OD). Kruskal-Wallis test examined intergroup differences in substance groups and stroke etiologies. DDD development between 2004 and 2021 was further evaluated for significant trend changes using an interrupted time series analysis.

RESULTS

The study included 422 patients (70.5 ± 12.9 years, 43.1% female). Etiologies divided into large-artery atherosclerosis (29.9%), cardioembolic (25.6%), cryptogenic (26.8%), and small-vessel disease (17.8%). The total estimated annual drug expenditure was € 241,808; of which 51.6% was due to DOACs (median € 1157 [Q1-Q3:1157-1157], p < 0.006), 20.0% to AHTs (€127.8 [76.7-189.8]), 15.7% to ODs (€525.6 [76.7-641.5]), and 8.7% to LLDs (€43.8 [43.8-43.8]). Cardioembolic strokes had the highest annual costs per patient (€1328.6 [1169.0-1403.4]) with higher expenditure for DOACs (p < 0.001) and AHTs (p < 0.026). DAPT costs were highest for large-vessel strokes (p < 0.001) and accounted for 2.5% of total costs. There was a significant trend change in DDDs for clopidogrel in 2010 (p < 0.001), for prasugrel in 2017 (p < 0.001), for ASA in 2015 (p < 0.001) and for DOACs in 2012 (p = 0.017).

CONCLUSIONS

DOACs for cardioembolic strokes were the primary cost driver in drug-based secondary stroke prevention, whereas permanent ASA and DAPT only accounted for a minor cost proportion. LLDs were associated with lower costs than AHTs and ODs. There were significant changes in DDDs for the respective substances, whereas the costs for DOACs as the most expensive pharmaceuticals remained widely stable across the last decade.

Trajectories of physical activity after ischaemic stroke: Exploring prediction of change

BACKGROUND AND PURPOSE

Physical activity (PA) is associated with lower risk of stroke and better functional outcome. However, low levels of PA after stroke are prevalent. The aim was to identify predictors of PA change after first-time ischaemic stroke and to develop prediction models to predict change in PA.

METHODS

Pre-stroke and 6 months post-stroke PA were quantified with the Physical Activity Scale for the Elderly (PASE). Considered predictors were clinical data and demographics including data on socioeconomic status (SES). PASE change was analysed using mixed models of repeated measures. Elastic net regression models were used to predict decrease from higher PASE quartile to the lowest and increase from lowest to higher.

RESULTS

A total of 523 first-time ischaemic stroke patients were included. Median (interquartile range, IQR) age was 69 years (IQR 59, 77), 181 (35%) were female and median National Institutes of Health Stroke Scale score was 3 (IQR 2, 5). Overall PASE score did not change, but 20% of patients decreased to the lowest PASE quartile whereas 48% from the lowest quartile increased to a higher. Prediction performance measured by area under the receiver operating curve was 0.679 for PA decrease and 0.619 for increase. SES factors were the most consistent predictors.

CONCLUSIONS

Half of the least active patients increased PA level after stroke whereas a fifth decreased with SES being the most consistent predictor. Despite comprehensive data, the prediction models only performed modestly. Efforts to optimize PA should include all stroke survivors to increase PA for least active patients and to prevent PA decrease.

Adherence to Physical Activity Recommendations Among Stroke Survivors in the United States

BACKGROUND

Physical activity is an effective modifiable behavior for preventing recurrent strokes. This study aims to determine the adherence to physical activity recommendations among stroke survivors in the United States. We further compared our findings with the adherence observed among myocardial infarction (MI) survivors and healthy adults, each assessed against distinct physical activity guidelines specific to their respective populations.

METHODS

We utilized data from the 2011 to 2019 Behavioral Risk Factor Surveillance System, a nationally representative survey. To establish benchmarks for stroke survivors, we referenced 3 different physical activity recommendations outlined in 2011, 2014, and 2021 American Heart Association stroke prevention guidelines. Similarly, for MI survivors and healthy adults, we used the 2011 guidelines for secondary prevention of coronary vascular diseases and the 2020 World Health Organization physical activity guidelines, respectively. Adherence to recommendations was determined by the respondents' self-reported intensity, duration, and frequency of physical activity. Multivariate logistic regression compared adherence in stroke survivors, MI survivors, and healthy adults.

RESULTS

Among 48 222 stroke survivors in the United States, the overall adherence rates to 2011, 2014, and 2021 physical activity guidelines were 75.4%, 40.2%, and 69.2%. For independently mobile stroke survivors, the adherence rates increased to 78.1%, 42.1%, and 69.9%. Among MI survivors and healthy adults, the adherence rates were 42.7% and 72%. When 2021 recommendations were used as a benchmark, older (aged ≥65 years) stroke survivors were more likely to adhere to recommendations than younger survivors (71.9% versus 62.3%; P<0.0001). After adjusting for sociodemographic factors and comorbidities, non-Hispanic Black survivors were less likely to adhere to recommendations (adjusted odds ratio, 0.81 [95% CI, 0.7-0.94]), whereas older and higher educated stroke survivors were more likely to adhere to recommendations. Geographically, stroke belt and nonrural residents were less likely to adhere to recommendations ([63.5% versus 67.9%; P<0.0001]; [53.8% versus 58.7%; P<0.0001]). Stroke and MI survivors were less likely to adhere to the latest recommendations than healthy adults (adjusted odds ratio, 0.74 [95% CI, 0.69-0.8]; (adjusted odds ratio, 0.24 [95% CI, 0.22-0.26]).

CONCLUSIONS

A substantial number of stroke survivors do not meet physical activity recommendations. Tailored interventions should be designed for at-risk populations, for example, non-Hispanic Black survivors and lower educated stroke survivors.

A systematic review and meta-analysis on the outcomes of carotid endarterectomy after intravenous thrombolysis for acute ischemic stroke

BACKGROUND

Intravenous thrombolysis (IVT) is the mainstay of treatment for patients presenting with acute ischemic stroke, whereas carotid endarterectomy (CEA) is indicated in patients with symptomatic carotid stenosis. However, the impact of prior IVT on the outcomes of CEA (IVT-CEA) is not clear. The aim of this study was to determine whether IVT may create additional stroke and death risk for CEA, compared with CEA performed in the absence of a history of recent IVT, and to determine the optimal timing for CEA after IVT.

METHODS

We conducted a systematic review and meta-analysis of studies comparing the outcomes of IVT-CEA vs CEA, using the Medline, Embase, and Cochrane databases.

RESULTS

We included 11 retrospective comparative studies, in which 135,644 patients underwent CEA and 2070 underwent IVT-CEA. The pooled rate of perioperative stroke was 4.2% in the IVT-CEA group and 1.3% in the CEA group (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.12-1.58; P = .21), with a high heterogenicity (I2 = 93%). The rate of stroke/death was 5.9% in patients undergoing IVT-CEA 1.9% in those receiving CEA only (OR, 0.42; 95% CI, 0.15-1.14; I2 = 92%; P = .09); after exclusion of studies including TIA as presenting symptom, stroke/death risk was 3.6% in IVT-CEA and 3.0% in CEA (OR, 1.42; 95% CI, 0.80-2.53; I2 = 50%; P = .11). The risk of stoke decreased with a delay in the performance of CEA (P = .268). Using results of the metaregression, the calculated delay of CEA that allows for a <6% risk was 4.6 days. Compared with CEA, patients undergoing IVT-CEA had a significantly higher risk of intracranial hemorrhage (2.5% vs 0.1%; OR, 0.11; 95% CI, 0.06-0.21; I2 = 28%; P < .001) and neck hematoma requiring reintervention (3.6% vs 2.3%; OR, 0.61; 95% CI, 0.43-0.85; I2 = 0%; P = .003).

CONCLUSIONS

In patients presenting with an acute ischemic stroke, CEA can be safely performed after a prior endovenous thrombolysis, maintaining a stroke/death risk of <6%. After IVT, CEA should be deferred for ≥5 days to minimize the risk for intracranial hemorrhage and neck bleeding.

10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Long-Term Mortality and Morbidity after Carotid Endarterectomy for Symptomatic and Asymptomatic Carotid Stenosis

BACKGROUND

To investigate whether the occurrence of ischemic stroke due to carotid stenosis is a marker of the severity of atherosclerotic disease and of an excess risk of cardiovascular morbidity and mortality, and of all-cause mortality, after carotid endarterectomy (CEA).

METHODS

Patients who had undergone a CEA from June 2015 to august 2016 were included. Patients were classified into 2 groups, namely symptomatic and asymptomatic. Neurological event, myocardial infarction, and death during early follow up were monitored. Major adverse cardiovascular events, major limb eventss, and all-cause mortality were compared for patients with a CEA for an asymptomatic carotid stenosis versus those with a symptomatic stenosis.

RESULTS

Among the 190 patients included, 86 (51%) had a CEA for an asymptomatic stenosis and 84 (49%) for a symptomatic stenosis. During the first 30 days, the rate of all-cause death or ischemic stroke was similar in both groups (1%, P = 0.986). After 30 days, there were a total of 35 major adverse cardiovascular events (21.3%) and 15 major limb events (9.1%) during mean follow up of 53 (22.6) months. Overall cardiovascular morbidity and mortality was 30.4% and did not differ between groups (P = 0.565). New ischemic stroke occurred in 11 patients (9.1%) and was significantly more frequent in the asymptomatic group (9 (14.8%) versus 2 (3.6%) in the symptomatic group, (odds ratio: 4.96; confidence interval 95% [1.04-23.77]; P = 0.013)). Overall all-cause mortality was 24% in both groups (P = 0.93) CONCLUSIONS: The occurrence of ischemic stroke of carotid origin before revascularization does not appear to be associated with an excess risk of cardiovascular morbidity or mortality or all-cause mortality after surgery.

Vascular Neurology Considerations for Antiamyloid Immunotherapy: A Science Advisory From the American Heart Association

Antibodies directed at the amyloid-β peptide offer the prospect of disease-modifying therapy for early-stage Alzheimer disease but also carry the risk of brain edema or bleeding events, collectively designated amyloid-related imaging abnormalities. Introduction of the antiamyloid immunotherapies into practice is therefore likely to present a new set of questions for clinicians treating patients with cerebrovascular disease: Which manifestations of cerebrovascular disease should preclude, or permit, antibody treatment? Is it safe to prescribe amyloid immunotherapies to individuals who require antithrombotic treatment, or to administer thrombolysis to antibody-treated individuals with acute stroke? How should severe amyloid-related imaging abnormalities be managed? This science advisory summarizes the data and key considerations to guide these challenging decisions as the medical community collects further data and experience with these groundbreaking agents.

A 50-Year-Old Man with Left-Sided Weakness and Difficulty Speaking Clearly

Morning Report is a time-honored tradition where physicians-in-training present cases to their colleagues and clinical experts to collaboratively examine an interesting patient presentation. The Morning Report section seeks to carry on this tradition by presenting a patient's chief concern and story, inviting the reader to develop a differential diagnosis and discover the diagnosis alongside the authors of the case. This report examines the story of a 50-year-old man who presented for evaluation of weakness on the left side of his body and difficulty speaking clearly. Using questions, physical examination, and testing, an illness script for the presentation emerges; the differential is refined until a diagnosis is made.

Influence of prestroke glycemic status on outcomes by age in patients with acute ischemic stroke and diabetes mellitus

BACKGROUND

This study aimed to explore the association between admission HbA1c and the risk of 1-year vascular outcomes stratified by age group in patients with acute ischemic stroke (AIS) and diabetes mellitus (DM).

METHODS

This study analyzed prospective multicenter data from patients with AIS and DM. Admission HbA1C were categorized as:≤6.0%, 6.1%-7.0%, 7.1%-8.0%, and >8.0%. Age was analyzed in categories:≤55 years, 56-65 years, 66-75 years, 76-85 years, and >85 years. The primary outcome was 1-year composite of stroke, MI, and all-cause mortality. The modifying effect of age on the relationships between HbA1c and 1-year primary outcome was explored by Cox proportional hazards model.

RESULTS

A total of 16,077 patients (age 69.0 ± 12.4 years; 59.4% males) were analyzed in this study. Among patients ≤55 years, the hazard ratio (HR) of the 1-year primary outcomes increased with an HbA1C > 8.0% (adjusted HR 1.39[1.13-1.70]). For patients aged 56-65 and 66-75, the highest HRs were observed for an HbA1c of 7.1-8.0% (aHRs; 1.21 [1.01-1.46] and 1.22 [1.05-1.41], respectively). In the 85+ age group, the highest HR occurred for HbA1c ≤ 6.0% (aHR 1.47 [0.98-2.19]). The HbA1c 8.0% showed evident age-dependent heterogeneity in the post hoc HR plots.

CONCLUSION

Our study revealed that in patients with AIS and diabetes under 55, higher admission hbA1c was associated with an increased risk of the 1-year primary outcome, while in patients aged over 85, lower HbA1c value (≤6.0%) may be associated with an increased risk of vascular events. The results of our study suggest the age-stratified, heterogeneous associations between admission HbA1c and 1-year vascular outcomes in patients with AIS and diabetes.

TICA-CLOP STUDY: Ticagrelor Versus Clopidogrel in Acute Moderate and Moderate-to-Severe Ischemic Stroke, a Randomized Controlled Multi-Center Trial

BACKGROUND

Many studies evaluated the efficacy and safety of ticagrelor versus clopidogrel in patients with ischemic stroke; none of these trials included North African participants, and all of these trials comprised only participants who experienced transient ischemic attack (TIA) or minor stroke.

OBJECTIVES

We compared the efficacy and safety of ticagrelor versus clopidogrel in patients with first-ever noncardioembolic moderate or moderate-to-severe ischemic stroke.

METHODS

Our trial involved 900 first-ever noncardioembolic patients with acute ischemic stroke (AIS) who randomly received either loading and maintenance doses of ticagrelor or clopidogrel within the first 24 h of stroke onset.

RESULTS

We involved 900 patients in the intention-to-treat analysis. A total of 39 (8.7%) patients in ticagrelor arm and 62 (13.8%) in clopidogrel arm experienced a new stroke [hazard ratio (HR) 0.46; 95% confidence interval (CI) 0.34-0.83; P value = 0.006]. A total of 57 (12.7%) patients in ticagrelor group and 80 (17.8%) patients in clopidogrel group experienced composite of new stroke, myocardial infarction (MI), or death due to vascular insults (HR 0.51; 95% CI 0.43-0.82; P value = 0.004). Participants who received ticagrelor experienced less frequent unfavorable outcomes. We found no significant variation between our study's two arms concerning the hemorrhagic and non-hemorrhagic complications.

CONCLUSION

Patients with noncardioembolic moderate or moderate-to-severe ischemic stroke who received ticagrelor within the first 24 h after ischemic stroke had better clinical outcomes based on recurrent stroke rates and unfavorable modified Rankin Scale (mRS) rates compared with those who received clopidogrel. There were no significant variations between ticagrelor and clopidogrel regarding hemorrhagic and non-hemorrhagic complications.

REGISTRATION

ClinicalTrials.gov identifier number NCT05553613.

Predictors of paroxysmal atrial fibrillation in patients with a cryptogenic stroke: Selecting patients for long-term rhythm monitoring

BACKGROUND

After a cryptogenic stroke, patients often will require prolonged cardiac monitoring; however, the subset of patients who would benefit from long-term rhythm monitoring is not clearly defined.

OBJECTIVE

The purpose of this study was to create a risk score by identifying significant predictors of atrial fibrillation (AF) using age, sex, comorbidities, baseline 12-lead electrocardiogram, short-term rhythm monitoring, and echocardiographic data and to compare it to previously published risk scores.

METHODS

Patients admitted to Montefiore Medical Center between May 2017 and June 2022 with a primary diagnosis of cryptogenic stroke or transient ischemic attack who underwent long-term rhythm monitoring with an implantable cardiac monitor were retrospectively analyzed.

RESULTS

Variables positively associated with a diagnosis of clinically significant AF include age (P <.001), race (P = .022), diabetes status (P = .026), chronic obstructive pulmonary disease status (P = .012), presence of atrial runs (P = .003), number of atrial runs per 24 hours (P <.001), total number of atrial run beats per 24 hours (P <.001), number of beats in the longest atrial run (P <.001), left atrial enlargement (P = .007), and at least mild mitral regurgitation (P = .009). We created a risk stratification score for our population, termed the ACL score. The ACL score demonstrated superiority to the CHA2DS2-VASc score and comparability to the C2HEST score for predicting device-detected AF.

CONCLUSION

The ACL score enables clinicians to better predict which patients are more likely to be diagnosed with device-detected AF after a cryptogenic stroke.

Patient Insights on Integrating Sleep Apnea Testing into Routine Stroke and TIA Care

AHA/ASA guidelines recommend patients with ischemic stroke or transient ischemic attack (TIA) be considered for obstructive sleep apnea (OSA) evaluation, given the high prevalence of OSA and improved outcomes for cerebrovascular disease when OSA is treated. However, OSA testing has not been incorporated into routine cerebrovascular management. We interviewed 30 patients hospitalized for acute stroke/TIA at six Veterans Affairs facilities participating in a stepped-wedge implementation trial to improve timely OSA testing after stroke/TIA. Thematic analysis of semi-structured interviews explored the experiences of care received, sleep testing, and education about the association between OSA and cerebrovascular disease. Patients perceived OSA testing as an integrated component of stroke/TIA care and reported few barriers to OSA testing. Patients had limited recall of details concerning sleep testing during hospitalization and education about OSA but expressed preferences about the timing, setting, and importance of caregiver participation. Patients expressed high levels of acceptance of sleep testing as a routine part of cerebrovascular care. Facilities could use these results to implement guideline-concordant screening for OSA, post-stroke/TIA.

Polyphyllin VII ameliorates neuroinflammation and brain injury via modulating Treg/Th17 balance in a mouse model of cerebral ischemia-reperfusion injury

Dysregulation of Th17 and Treg cells contributes to the pathophysiology of cerebral ischemia. Metabolic changes of peripheral CD4+ T cells lead to the imbalance of Treg/Th17 polarization, which represents a promising strategy for post-stroke therapy. Polyphyllin VII (PVII), a steroidal saponin extracted from traditional Chinese herb Rhizoma Paridis, has multiple bioactivities, but the potential function of PVII in cerebral ischemia-reperfusion injury is not elucidated yet. In our study, a mouse transient middle cerebral artery occlusion (MCAO) model was constructed. TTC staining, H&E staining, TUNEL staining, ELISA assay, flow cytometry, western blot, RT-qPCR, Open-field test, Morris water maze test, hanging wire test, rotarod test and foot-fault test were performed to evaluate the potential function of PVII in MCAO mice. We found that PVII showed protective effects on cerebral ischemia-reperfusion injury by reducing infarct volume, ameliorating brain injury and neuroinflammation, and improving long-term functional recovery of MCAO mice. PVII promoted Treg infiltration and suppressed infiltration of Th1/Th17 cells in ischemic brain in vivo. Moreover, PVII impaired peripheral CD4+ T cell activation and modulated Treg/Th17 differentiation in vitro. Mechanistically, PVII suppressed mTORC1 activation to influence glycolytic metabolism and ROS generation of T cells, thus leads to the imbalance of Treg/Th17 polarization towards Treg skewed. Furthermore, reactivation of mTORC1 by MHY1485 abolished the influence of PVII on brain injury and neuroinflammation in MCAO mice. Our data provided a novel role of PVII in cerebral ischemia-reperfusion injury via manipulating Treg/Th17 imbalance.

Incident Stroke After First-Time TIA According to ABCD2 Score: A Nationwide Cohort Study

BACKGROUND AND OBJECTIVES

Transient ischemic attack (TIA) is associated with a higher short-term incidence of stroke. However, long-term data on this association are lacking. Therefore, this study aimed to determine the long-term incidence of ischemic stroke after TIA according to ABCD2 score and to identify factors associated with stroke after TIA.

METHODS

All Danish patients ≥18 years with first-time TIA were included from the Danish Stroke Registry (2014-2020). The study population was stratified into a high-risk (≥4 points) and low-risk (<4 points) group according to the modified ABCD2 score (age ≥60 years, hypertension, clinical features, and diabetes). The 3-year cumulative incidence of stroke and all-cause mortality was assessed using the Aalen-Johansen and Kaplan-Meier estimators, respectively. Factors associated with 3-year stroke rate were identified using multivariable Cox regression models.

RESULTS

In total, 21,433 patients with first-time TIA were included: 1,280 (6.0%) in the high-risk group and 20,153 (94.0%) in the low-risk group. Patients with high-risk ABCD2 scores were older (median 77.5 [P25-P75 70.8-84.1] vs 70.3 [P25-P75 60.1-78.2]), more often female (53.1%), had more comorbidities (e.g., ischemic heart disease, heart failure, and atrial fibrillation), and received more medication (e.g., any antiplatelet therapy or oral anticoagulants and cholesterol-lowering drugs) at baseline. The 3-year cumulative incidence of stroke after TIA was 6.0% (95% CI 4.6-7.5) in the high-risk group and 4.2% (95% CI 3.9-4.5) in the low-risk group (p = 0.004) with an unadjusted hazard ratio (HR) 1.56 (95% CI 1.21-2.00). Factors associated with 3-year stroke rate included age ≥60 years (HR 2.21, 95% CI 1.76-2.78), current smoking (HR 1.37, 95% CI 1.13-1.65), unilateral weakness (HR 1.25, 95% CI 1.04-1.51), peripheral artery disease (HR 1.53, 95% CI 1.09-2.14), and chronic kidney disease (HR 1.39, 95% CI 1.01-1.90). The 3-year cumulative incidence of all-cause mortality was 28.9% (95% CI 26.1-31.7) in the high-risk group and 10.3% (95% CI 9.9-10.8) in the low-risk group.

DISCUSSION

Patients with high-risk ABCD2 score had an almost 60% higher associated long-term rate of ischemic stroke compared with those with low-risk ABCD2 score. Future trials focusing on preventive strategies, including evidence-based antithrombotic strategies, especially for the high-risk group are warranted.

Proton Pump Inhibitors Use in Patients With Ischemic Stroke on Dual Antiplatelet Therapy at Low Risk of Upper Gastrointestinal Bleeding

BACKGROUND

Current guidelines lack recommendations regarding the use of proton pump inhibitors (PPIs) for preventing upper gastrointestinal bleeding (UGIB) among patients at low risk for UGIB treated with dual antiplatelet therapy for ischemic stroke (IS). Our objective was to assess the effectiveness of PPIs in lowering the risk of significant UGIB in this patient group.

METHODS AND RESULTS

A retrospective cohort study was conducted involving patients at low risk for UGIB admitted for IS between 2014 and 2018 and treated with dual antiplatelet therapy. The study used a nationwide claims database in Korea. The primary end point was significant UGIB during 12 months after IS. To evaluate the risk of significant UGIB based on PPI use, we performed a multivariable Cox regression analysis. Subgroup analyses and propensity score matching analysis were conducted for validation. Among 96 722 patients with IS at low risk for UGIB who were on dual antiplatelet therapy (mean age, 67.0 years; men: 63.0%), 16 084 (16.6%) were treated with PPIs. During 12 months of follow-up, 325 patients experienced significant UGIB, and 479 experienced any UGIB. PPI use was associated with a reduced risk of significant UGIB (hazard ratio, 0.63 [95% CI, 0.45-0.89]; P=0.009). This association was consistent in the subgroup and propensity score matching analyses.

CONCLUSIONS

In patients with IS receiving dual antiplatelet therapy, PPI use reduced the risk of significant UGIB by 37% on average, even among low-risk patients. However, the use of PPIs in this patient group was limited, highlighting the need for additional prospective studies.

Protocol for a systematic review and meta-analysis of the combination of ezetimibe and statins for hyperlipidemia

INTRODUCTION

Hyperlipidemia is increasingly recognized as a significant global health issue, often associated with conditions such as hypertension, diabetes, and obesity. While statins are frequently prescribed to manage lipid levels, recent studies indicate that reliance solely on statin therapy may present certain disadvantages, including prolonged treatment durations, the potential for drug resistance, and various adverse effects. Research indicates that the combination of ezetimibe and statins demonstrates a favorable therapeutic effect in the management of hyperlipidemia. However, existing studies have not consistently confirmed these benefits, and there is no current meta-analysis available. As a result, we will perform a meta-analysis to assess the effectiveness and safety of the combination of ezetimibe and statins in managing hyperlipidemia, aiming to offer evidence-based medical guidance for clinical practice.

METHODS AND ANALYSIS

The systematic review and meta-analysis will adhere to the PRISMA guidelines for systematic reviews and meta-analyses. We will search for randomized controlled trials that investigate the efficacy and safety of the combination of ezetimibe and statins in treating hyperlipidemia, based on specific criteria. The following electronic databases will be searched by two researchers for relevant records published up to October 1, 2024: Cochrane Central Register of Controlled Trials (CENTRAL) in Cochrane Library, Embase.com, Web of Science, MEDLINE (via PubMed), Wanfang China Database, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM) and Chinese Scientific Journal Database (VIP). They will also check references and relevant journals manually. Two independent reviewers will handle screening, data extraction, and quality assessment. Subgroup analysis, sensitivity analysis, and publication bias analysis will be performed to assess consistency and reliability. Review Manager 5.4 will be used for data analysis and synthesis, while the GRADE approach will be employed to evaluate the overall study's evidence quality.

EXPECTED RESULTS

The findings of this systematic review will be shared with various stakeholders who are interested in the combination of ezetimibe and statins for hyperlipidemia. This will offer valuable insights for researchers undertaking future investigations and for clinical practitioners specializing in the treatment of hyperlipidemia.

ETHICS AND DISSEMINATION

This study is based on a secondary analysis of the literature, so ethical review approval is not required. The final report will be published in a peer-reviewed journal.

STUDY REGISTRATION

The protocol of the systematic review has been registered on Open Science Framework, with a registration DOI https://doi.org/10.17605/OSF.IO/TEVUY.

Sex-Related Outcomes in Asymptomatic Carotid Artery Stenosis Undergoing Carotid Endarterectomy

INTRODUCTION

This study aims to retrospectively analyze the perioperative and long-term outcomes of carotid endarterectomy (CEA) performed in asymptomatic patients, stratifying the results by sex.

METHODS

Data on CEAs performed from January 2009 to December 2020 at our institution were collected. A neurologic evaluation was conducted 30 d after surgery to assess the occurrence of neurological events. Instrumental evaluations using Doppler ultrasound were performed within the first 3 mo, at 12 mo, and annually thereafter. The primary endpoints were perioperative mortality, major neurological events, and major complications. Secondary endpoints included long-term overall survival, stroke-free survival, absence of neurological symptoms, and absence of significant (>70%) restenosis.

RESULTS

Two thousand one hundred ninety-four CEAs were performed in asymptomatic patients, with 758 females and 1436 males. There were no differences in perioperative outcomes between the two groups. In the multivariate analysis, female sex was found to be a protective factor for the risk of 30-d stroke (hazard ratio: 0.2; 95% confidence interval: 0.04-0.9; P = 0.05). At a median follow-up of 24 mo, the estimated 10-y overall and stroke-free survival rates were 77.6% in males versus 62.7% in females, P = 0.2 and 70% in males versus 61% in females, P = 0.1, respectively. Also the rates of significant restenosis did not differ between males and females (82.2% versus 87.7%, P = 0.5).

CONCLUSIONS

This study suggests that female sex, by itself, does not represent a risk factor for adverse outcomes after carotid surgery and it appears to be protective in the first 30 d following surgery.

The Effect of Xanthine Oxidase Inhibitors in the Prevention and Treatment of Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

Xanthine oxidase inhibitors (XOIs) may help prevent stroke. However, heterogeneity can be found in the conclusions of different studies. The relevant evidence was summarized in this systematic review and meta-analysis to further clarify the role of XOIs in the prevention and treatment of stroke, with a focus on evaluating the effects of XOIs in primary and secondary prevention of stroke, acute stroke treatment, and reduction of post-stroke complications.

METHODS

Randomized controlled trials (RCTs) or cohort studies on the effect of XOIs in the prevention and treatment of stroke were searched in PubMed, EMBASE, and Cochrane Library from inception to 3 March 2024, along with hand searching. The analyses were carried out using Review Manager 5.4.

RESULTS

The analysis included 14 studies (115,579 patients). While XOIs did not significantly reduce the risk of stroke (RR: 0.89; 95% CI: 0.59-1.34), they improved post-stroke functional outcomes, with a reduction in the modified Rankin scale scores (mean difference: -0.6; 95% CI: -0.8 to -0.4), decreased intercellular adhesion molecule-1 levels (mean difference: -15.2 ng/mL; 95% CI: -22.3 to -8.1), improved augmentation index (AIx) by 4.2% (95% CI: 2.5-5.9%), reduced central blood pressure (mean reduction: 4.8 mmHg; 95% CI: 2.6-6.9), and delayed carotid intima-media thickness progression (mean difference: -0.05 mm/year; 95% CI: -0.08 to -0.02).

The pleiotropic effects of statins: a comprehensive exploration of neurovascular unit modulation and blood-brain barrier protection

The blood-brain barrier (BBB) is the most central component of the neurovascular unit (NVU) and is crucial for the maintenance of the internal environment of the central nervous system and the regulation of homeostasis. A multitude of neuroprotective agents have been developed to exert neuroprotective effects and improve the prognosis of patients with ischemic stroke. These agents have been designed to maintain integrity and promote BBB repair. Statins are widely used as pharmacological agents for the treatment and prevention of ischemic stroke, making them a cornerstone in the pharmacological armamentarium for this condition. The primary mechanism of action is the reduction of serum cholesterol through the inhibition of 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase, which results in a decrease in low-density lipoprotein cholesterol (LDL-C) and an increase in cholesterol clearance. Nevertheless, basic and clinical research has indicated that statins may exert additional pleiotropic effects beyond LDL-C reduction. Previous studies on ischemic stroke have demonstrated that statins can enhance neurological function, reduce inflammation, and promote angiogenic and synaptic processes following ischemic stroke. The BBB has been increasingly recognized for its role in the development and progression of ischemic stroke. Statins have also been found to play a potential BBB protective role by affecting members of the NVU. This review aimed to provide a comprehensive theoretical basis for the clinical application of statins by systematically detailing how statins influence the BBB, particularly focusing on the regulation of the function of each member of the NVU.

Benefits of early MR-Imaging in patients with acute spontaneous intracerebral hemorrhage: a retrospective study

BACKGROUND

Neuroimaging plays a vital role in the diagnosis of intracerebral hemorrhage (ICH) and in identifying the underlying etiology for appropriate therapeutic approach. This study aims to determine the significance and potential advantages of using early magnetic resonance imaging (MRI) as a diagnostic tool for ICH.

METHODS

This retrospective study included 359 patients with ICH treated at the Department of Neurology, Mannheim University Hospital between January 2017 and December 2021. Patient characteristics, stroke severity and imaging procedures were descriptively analyzed. Factors associated with the choice of imaging modalities were evaluated. The etiology of hemorrhage was retrospectively analyzed using the existing data. We recorded the reassignment of ICH etiology by comparing the assessment after first sole review of CT scan and then subsequent MRI review. The overall rate of reassignments and the reassignments per CT-based initial etiology were analyzed.

RESULTS

In the sample of 359 patients with ICH (mean age 73.1 years, 55.4% male), patients receiving an additional MRI were significantly younger (p < .001) and were less severely affected by stroke (median NIHSS score 5 vs. 15, p < .001). MRI was performed significantly less frequently in patients who died during hospitalization (11.7% vs. 63.9%, p < .001). MRI led to a reassignment of ICH etiology in 48.2% of cases (80/166), uncovering unknown underlying causes in 69% of cases (49/71). Reassignment occurred most frequently in patients with a CT-based diagnosis of hypertensive ICH (18/50). The most frequent reassigned etiologies after MR imaging were cerebral amyloid angiopathy (CAA; 36 patients) and secondary hemorrhage of an ischemic stroke (30 patients).

CONCLUSIONS

Early MR imaging in patients with ICH improves the determination of underlying etiology and the conception of an appropriate treatment approach, potentially contributing to better patient outcomes.

Lipid-Lowering Therapy Use When Indicated and Subsequent Ischemic Stroke Severity

BACKGROUND

Elevated low-density lipoprotein cholesterol is a risk factor for atherosclerotic cardiovascular disease, including acute ischemic stroke (AIS), due to large- and small-vessel disease. Cholesterol management guidelines recommend lipid-lowering therapy (LLT) to prevent atherosclerotic cardiovascular disease events. This study assessed use of LLT at the time of AIS according to guideline recommendations and determined the association of prestroke LLT use with stroke severity.

METHODS AND RESULTS

We conducted a retrospective study of patients hospitalized with AIS from 2015 to 2020 at a large academic comprehensive stroke center. Patients with AIS secondary to either small-vessel disease or large-artery atherosclerosis recorded in the institutional Get With The Guidelines-Stroke registry and with a prestroke indication for LLT were included. Using propensity score subclassification, adjusted logistic regression models were built to explore the associations between LLT use before AIS when indicated and presenting National Institutes of Health Stroke Scale score >4. There were 384 patients with AIS who met guideline-recommended criteria for prestroke LLT (median age 70 years, 57% men), of whom only 207 patients (54%) were prescribed LLT before AIS. Not being prescribed LLT when indicated was associated with a significantly higher likelihood of a presenting with National Institutes of Health Stroke Scale score >4, even when adjusted for specific stroke cause (odds ratio, 1.13 [95% CI, 1.03-1.20]; P=0.006).

CONCLUSIONS

LLT is underused in patients who present with atherosclerosis-related AIS. Lack of prestroke LLT use was associated with more severe stroke symptoms upon presentation. These findings emphasize the need to prescribe LLT when indicated, because its use may mitigate poststroke disability.

Stroke-bleeding risk score pairings within individuals in the outcomes registry for better informed treatment of atrial fibrillation (ORBIT-AF) registry

BACKGROUND

Decisions about stroke prevention strategies in atrial fibrillation (AF) typically balance thromboembolism reduction against increased bleeding from oral anticoagulation therapy (OAC). When determining eligibility for OAC, guidelines recommend calculation of thromboembolic event rates using a validated score such as CHA2DS2-VASc. In contrast, routine calculation of bleeding scores is not recommended, in part because many patient factors associated with an increased risk of bleeding are associated with an even larger increased risk of ischemic stroke. We set out to characterize patients by paired stroke and bleeding risk scores to understand the level of concordance.

METHODS

Between 2010 and 2016, we identified 20,451 AF patients in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) I and II Registries. We grouped patients by stroke and bleeding risk pairings: low and high stroke risk (CHA2DS2-VASc < and ≥2), low and high bleeding risk (ORBIT < and ≥ 4) and described treatment rates with OAC and antiplatelet (AP) therapy.

RESULTS

Most patients (68.6 %) were at high stroke and low bleeding risk. Patients at high bleeding risk (19.4 %) had high stroke risk (98.5 %). Treatment rates differed with combined OAC + AP therapy highest for patients at high stroke and bleeding risks. Ischemic and bleeding events were also highest in this group.

CONCLUSIONS

Nearly all AF patients in this cohort with high bleeding risk (ORBIT score ≥ 4) had high stroke risk (CHA2DS2-VASc ≥ 2), supporting that bleeding risk should not obviate the need for stroke prevention. In contrast, most at high stroke risk were at low bleeding risk (ORBIT <4), supporting OAC for the majority. Bleeding scores, in combination with factors that specifically indicate a higher risk of bleeding, may identify patients who might be candidates for alternative stroke prevention such as left atrial appendage occlusion devices or bleeding mitigation strategies such as de-escalation of antiplatelet therapy.

Benzydamine attenuates microglia-mediated neuroinflammation and ischemic brain injury by targeting cathepsin s

Microglia, the primary immune cells of the central nervous system, play a crucial role in the neuroinflammatory processes following ischemic stroke. Targeting neuroinflammation is a promising strategy to enhance the outcomes of ischemic stroke. Benzydamine (BA), a well-known non-steroidal anti-inflammatory drug, has demonstrated potential in inhibiting pro-inflammatory cytokines across various disease models. However, the potential role of BA in microglial activation and post-stroke neuroinflammation remains unclear. Our study reveals that BA effectively suppresses the lipopolysaccharide (LPS)-stimulated pro-inflammatory responses of primary microglia, with high-dose BA (10 μM) suppressing LPS-induced inflammatory markers by up to 59.1 % in the mRNA levels of IL-1β. Furthermore, BA mitigated ischemic brain injury in experimental stroke mice. BA treatment also significantly attenuated neuroinflammatory responses and attenuates ischemic brain injury in experimental stroke mice. Further investigation revealed that BA reduces the release of the LPS-stimulated pro-inflammatory factors and activation of primary microglia by directly binding to and inhibiting the activity of cathepsin S (CTSS). In conclusion, our study identifies BA as a promising CTSS inhibitor with potential to suppress neuroinflammation following ischemic stroke. Our findings provide a theoretical basis for developing new neuroprotective strategies.

Sex Differences in Nonadherence to Secondary Stroke Prevention Medications Among Patients With First-Ever Ischemic Stroke

BACKGROUND

More women than men experience recurrent strokes. Medication adherence is critical to prevent recurrence; however, studies investigating sex differences are limited. We examined sex differences in poststroke medication adherence, overall and by drug class, and identified influencing factors.

METHODS AND RESULTS

Patients with first-ever ischemic stroke were identified from a population-based study (2008-2019). At 90 days after a stroke, self-reported medication adherence was defined as never or rarely missing a dose in a typical week for each secondary stroke prevention medication (antihypertensives, cholesterol-lowering drugs, antiplatelets, anticoagulants). We generated prevalence ratios (PRs) using modified Poisson models to assess sex differences with and without adjustment for potential confounding factors, including demographics, social factors, health system-related, lifestyle-related, health condition-related, prestrokehealth-related, and stroke-related factors. Among 1324 participants (48.4% women, 58.0% Mexican American individuals), women were more likely to report nonadherence to cholesterol-lowering drugs (PR, 1.80 [95% CI, 1.14-2.84]) and antiplatelets (PR, 1.53 [95% CI, 1.003-2.34]). Adjusting for obesity attenuated while adjusting for age, marital status, access to care, smoking, and alcohol consumption accentuated sex differences. Race and ethnicity modified the sex difference in nonadherence to cholesterol-lowering drugs (Pinteraction=0.054) such that the sex difference was larger in Mexican American individuals (PR, 3.00 [95% CI, 1.65-5.48]) than in non-Hispanic White individuals (PR, 1.30 [95% CI, 0.52-3.27). No significant sex differences were found for nonadherence to antihypertensives and overall nonadherence.

CONCLUSIONS

Poststroke medication nonadherence was more prevalent among women than men. This was partially due to the confounding effects of lifestyle, marital status, and access to care, suggesting potential subgroups for interventions to improve adherence.

Real-world comparison of dual versus single antiplatelet treatment in patients with non-cardioembolic mild-to-moderate ischemic stroke: A propensity matched analysis

BACKGROUND

Short-term dual antiplatelet treatment (DAPT) is superior to single antiplatelet treatment (SAPT) for secondary prevention in non-cardioembolic minor ischemic stroke and high-risk transient ischemic attack (TIA). As the real-world use of DAPT is broader than in trials, it is important to clarify its benefit/risk profile in a diverse population.

METHODS

Post hoc analysis of prospectively collected data from the READAPT cohort and three prospective stroke registries including patients with mild-to-moderate (National Institute of Health Stroke Scale (NIHSS) score 0-10) ischemic stroke receiving early DAPT or SAPT. The primary effectiveness outcome was 90-day return to pre-stroke neurological functioning using modified Rankin Scale (mRS) score. Secondary effectiveness outcomes were 90-day mRS shift, new ischemic stroke/TIA, vascular and all-cause death, 24 h early neurological improvement or deterioration. The safety outcome was 90-day intracranial hemorrhage.

RESULTS

We matched 1008 patients treated with DAPT and 1008 treated with SAPT. Compared to SAPT, patients treated with DAPT showed higher likelihood of 90-day primary effectiveness outcome (87.5% vs. 84.4%, risk difference 3.1% (95% confidence interval (CI): 0.1%-6.1%); p = 0.047, risk ratio 1.03 (95% CI: 1.01-1.07); p = 0.043) and higher rate of 24-h early neurological improvement (25.3% vs. 15.4%, risk difference 9.9% (95% CI: 6.4%-13.4%); p < 0.001, risk ratio 1.65 (95% CI: 1.37-1.97); p < 0.001). No differences were observed for other study outcomes. Subgroup analysis confirmed benefit of DAPT over SAPT for primary effectiveness outcome in patients with moderate stroke, those treated with intravenous thrombolysis, and those who received antiplatelet loading dose.

CONCLUSION

Our findings suggest that DAPT use might be safe and more effective than SAPT even in the real world and in patients who do not strictly fulfill the criteria of landmark large clinical trials.

Antithrombotic therapy for secondary Stroke prevention in patients with symptomatic large artery atherosclerosis and atrial fibrillation (FIB-CAS study) A single-center experience

INTRODUCTION

Atrial fibrillation (AF) and large artery atherosclerotic diseases are major causes of ischemic stroke and their coexistence increases the risk of stroke and mortality. Research on antithrombotic strategies for AF patients with symptomatic large artery atherosclerosis is limited. This study aims to report a single center's experience regarding the antithrombotic regimens prescribed for this population and the association with stroke recurrence and hemorrhagic events.

METHODOLOGY

This retrospective cohort study included AF patients admitted to the Medical University of South Carolina with stroke due to symptomatic intracranial (sICAS) or extracranial atherosclerosis (sECAS). Patients were grouped based on prescribed antithrombotic regimens and compared according to their outcomes.

RESULTS

Of 1,924 ischemic stroke patients with AF, 114 (6%) met the inclusion criteria. At discharge, the majority of patients were prescribed anticoagulants alone (sAC) or combined with a single antiplatelet (sAC + sAP) 26% and 34% respectively. Stroke recurrence was highest during the first 90-days after index stroke (11%). Patients on combination sAC + sAP had fewer recurrent strokes in the first 90-days compared to sAC (5.5% vs. 22.2%,p = 0.056) without significant increase in symptomatic hemorrhagic events (5.5% vs. 3.7%, p = 0.6). However the hemorrhagic risk significantly increased with prolonged therapy beyond 90-days (18% vs. 0%,p = <0.02). Early deaths were also high with 37% of total deaths occurring within 90-days after index stroke.

CONCLUSION

In this cohort, AF patients with stroke due to sICAS or sECAS had early stroke recurrence and mortality. While combination AC + sAP may reduce short-term stroke recurrence they may increase the hemorrhagic risk in the long-term.

Pharmacological Mechanisms of Cryptotanshinone: Recent Advances in Cardiovascular, Cancer, and Neurological Disease Applications

Cryptotanshinone (CTS) is an important active ingredient of Salvia miltiorrhiza Bge. In recent years, its remarkable pharmacological effects have triggered extensive and in-depth studies. The aim of this study is to retrieve the latest research progress on CTS and provide prospects for future research. The selection of literature for inclusion, data extraction and methodological quality assessment were discussed. Studies included (1) physicochemical and ADME/Tox properties, (2) pharmacological effects and mechanism, (3) conclusion and bioinformatics analysis. A total of 915 titles and abstracts were screened, resulting in 184 papers used in this review; CTS has shown therapeutic effects on a variety of diseases by modulating multiple molecular pathways. For example, CTS primarily targets NF-κB pathway and MAPK pathway to have a therapeutic role in cardiovascular diseases; in cancer, CTS shows superior efficacy through the PI3K/Akt/mTOR pathway and the JAK/STAT pathway; CTS act on the Nrf2/HO-1 pathway to combat neurological diseases. In addition, key targets of CTS were predicted by bioinformatics analysis, referring to disease ontology (DO), Kyoto Encyclopedia of Genes and Genomes (KEGG) and gene ontology (GO) enrichment analysis, with R Studio; AKT1, MAPK1, STAT3, P53 and EGFR are predicted to be the key targets of CTS against diseases. The key proteins were then docked by Autodock software to preliminarily assess their binding activities. This review provided new insights into research of CTS and its potential applications in the future, and especially the targets and directly binding modes for CTS are waiting to be investigated.

Exploring physical activity in people after stroke: a substudy of the Falls After Stroke Trial

PURPOSE

The Falls After Stroke Trial (FAST) intervention involves habit-forming functional exercise and mobility practice which may increase physical activity. This substudy of FAST explores physical activity in community-dwelling people after stroke comparing the FAST intervention to usual care.

METHODS

This study used a subset of 49 participants from a randomised trial. Outcome measures were taken at baseline, 6- and 12-months. The primary outcome was physical activity (step count, upright time and sedentary time, activPAL4™ micro).

RESULTS

Thirty-nine participants (80%) had valid primary outcome data at 6 months and 36 participants (73%) at 12 months. Compared to baseline, the experimental group completed 485 (95% CI -434 to 1405) more steps/day than the control group at 6 months and 724 (95% CI -239 to 1667) more steps/day at 12 months; and spent 36 (95% CI -46 to 118) fewer min/day in sedentary behaviour than the control group at 6 months and 34 (95% CI -51 to 119) fewer min/day at 12 months, although the differences were not significant.

CONCLUSIONS

FAST may improve physical activity more than usual care at 6- and 12-months but results are inconclusive. Further research could be conducted to confirm any benefit in a larger sample.

Lower Ticagrelor Dosing in the Dual Antiplatelet Regimen for Neurointerventional Procedures

BACKGROUND

Ticagrelor, a P2Y12 inhibitor, offers a rapid onset and consistent platelet inhibition, making it a viable alternative for dual antiplatelet therapy (DAPT). The optimal ticagrelor dose for neurointerventional procedures, however, remains unclear. We report our experience with ticagrelor 60 mg twice daily plus aspirin 81 mg daily compared with the standard aspirin and clopidogrel regimen for intracranial stenting.

METHODS

We conducted a retrospective analysis of a prospectively maintained database, identifying consecutive patients who underwent intracranial stenting for aneurysm treatment or intracranial atherosclerosis. Patients received either ticagrelor 60 mg with aspirin or aspirin with clopidogrel 75 mg daily. Primary outcomes included peri-procedural ischemic and/or hemorrhagic events within 30 days. Secondary outcomes were the median P2Y12 reaction unit and in-stent stenosis rates at 6-month follow-up.

RESULTS

Among 119 patients, 59 received ticagrelor and 60 (50.4%) received clopidogrel. Baseline characteristics including age and gender were comparable between the two groups, although the ticagrelor group had a higher proportion of African-American patients. The majority of patients underwent aneurysm treatment (n=105; 88.23%), while the remainder received stenting for intracranial atherosclerosis (n=14; 11.77%). No ischemic events occurred in either group and intracranial hemorrhage rates were comparable (1.7% in both groups). The median P2Y12 reaction unit was significantly lower in the ticagrelor group (69 vs 126, P<0.001). In-stent stenosis rates were lower with ticagrelor (5% vs 21%).

CONCLUSION

Ticagrelor 60 mg for DAPT in intracranial stenting is safe and effective. Larger prospective studies may be required to validate these findings.

Efficacy and safety of anticoagulant and antiplatelet therapies in the medical management of carotid free-floating thrombus: A systematic review

BACKGROUND

The optimal treatment for carotid free-floating thrombus (CFFT) remains uncertain due to limited evidence, with no randomized clinical trials and scarce guidelines, such as ESVS 2023, favoring conservative management. Anticoagulation (ACT) and antiplatelet (APT) therapies are emerging as promising alternatives to high-risk surgical interventions. This systematic review aimed to evaluate the safety and efficacy of ACT and APT therapies for CFFT.

METHODS

A systematic search was performed across PubMed, Embase, Web of Science, and Cochrane databases. Safety and efficacy endpoints were assessed. A two-sample t-test compared baseline characteristics between groups, and a Chi-square test evaluated differences in categorical variables. Statistical significance was set at p < 0.05. Data were analyzed using R 4.3.0 with the meta package v.7.0-0.

RESULTS

Four studies met the inclusion criteria, involving 170 patients diagnosed with CFFT. The APT group included 96 patients (mean age 55.35 ± 13.52 years; 56.25% male), and the ACT group included 74 patients (mean age 58.57 ± 14.28 years; 51.35% male). Thrombus regression was slightly lower in APT (42%) compared to ACT (48%). Both groups showed similar rates of residual stenosis. Antiplatelet had fewer ischemic events within 30 days (none vs. 4% in ACT) and lower intracranial hemorrhage rates (3.3% vs. 5.4% in ACT) but higher mortality (6.3% vs. none in ACT).

CONCLUSION

Both ACT and APT are effective for managing CFFT, each with distinct efficacy and safety profiles. However, randomized trials are necessary to better assess these therapies in CFFT management.

Accelerated biological aging increases the risk of short- and long-term stroke prognosis in patients with ischemic stroke or TIA

BACKGROUND

Biological age (BA), an integrated measure of physiological aging, has a clear link to stroke. There is a paucity of long-term longitudinal studies about the association between accelerated biological age and stroke prognosis in patients with previous strokes, and the differences in the predictive ability of various BA indicators calculated from clinical biochemistry biomarkers for future stroke outcomes are still unknown. To evaluate the role of three accelerated BA indicators for short- and long-term prognosis of patients with ischemic stroke or transient ischemic attack (TIA), and to identify the most appropriate predictor.

METHODS

This study included 7396 patients from the Third China National Stroke Registry (CNSR-III), a prospective national registry of patients with acute ischemic stroke or TIA between August 2015 and March 2018 in China. We constructed accelerated BA using three widely recognized algorithms: PhenoAge, Klemera-Doubal, and HD method. To ascertain the association of accelerated BA with the risk of short- and long-term stroke outcomes, a Cox or logistic regression model was conducted for the analysis. The net reclassification index and integrated discrimination improvement were used to evaluate the added model improvement ability of BA acceleration.

FINDINGS

Compared to those with the lowest of PhenoAge acceleration, patients with the highest were more likely to have a higher risk of stroke (HR 1.98, 95% CI 1.49-2.63, P < 0.001), ischemic stroke (HR 1.88, 95% CI 1.41-2.53, P < 0.001), composite vascular events (HR 2.03, 95% CI 1.53-2.68, P < 0.001), all-cause death (HR 7.02, 95% CI 3.41-14.47, P < 0.001) and the modified Rankin scale of 3-6 (OR 2.55, 95% CI 2.05-3.16, P < 0.001) at three months, and the association observed within one year and five years was similar to that within three months. The risk of all stroke outcomes for HDAge was consistent with PhenoAge acceleration, but KDMAge acceleration was the same, except for stroke within one year (HR 1.24, 95% CI 1.00-1.53, P = 0.053). PhenoAge acceleration provided a better improvement in the model's predictive ability for stroke prognosis, compared to BA determined by other algorithms.

INTERPRETATION

In this prospective cohort study, BA acceleration, particularly PhenoAge, may help identify stroke patients with risks of short- and long-term poor outcomes, potentially enabling subclinical prevention and early intervention.

FUNDING

This work was supported by grants from Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (2019-I2M-5-029), the National Natural Science Foundation of China (U20A20358), Beijing Hospitals Authority Clinical Medicine Development of special funding support (ZLRK202312), the National Key R&D Program of China (No. 2022YFC3602500, 2022YFC3602505), Outstanding Young Talents Project of Capital Medical University (A2105), and Beijing High-Level Public Health Technical Personnel Construction Project (Discipline leader -03-12).

Clinical observation of 4 cases of cerebral infarction caused by left ventricular noncompaction

BACKGROUND

Cerebral infarction associated with myocardial hypertrabeculation is a rare condition that requires optimal management to reduce the risk of thromboembolism and stroke. As intravenous thrombolysis (IVT) is a standard treatment for acute ischemic stroke, it is important to investigate whether it is safe and effective in patients with this rare condition.

CASE REPORT

Four patients with cerebral infarction associated with myocardial hypertrabeculation were included. The clinical data of these patients were retrospectively analyzed to investigate the efficacy and safety of IVT in their treatment. The results showed that IVT was safe and effective for all the four adult patients. The treatment process and complications were summarized, and the prognosis was evaluated using the modified Rankin Scale (mRS). at 24 h after IVT, there was no evidence of hemorrhagic transformation on CT scan for any of the four patients in this case report.In addition, the results showed that IVT was effective in reducing the severity of the cerebral infarction in all four patients. The prognosis was evaluated using the modified Rankin Scale (mRS).

CONCLUSION

This case report provides evidence that IVT is safe and effective in the treatment of cerebral infarction associated with myocardial hypertrabeculation in adults.

Clinical Outcomes of Shifting from Transfemoral-First to Transradial-First Approach in Carotid Artery Stenting: A Retrospective Two-Timeframe Comparison at a Single Center

Objective: Carotid artery stenting (CAS) has traditionally been performed using the transfemoral approach (TFA). Recently, the transradial approach (TRA) has gained attention for its lower invasiveness and reduced complication risk. This study compares outcomes between two access strategy timeframes, TFA-first and TRA-first, to evaluate how this shift influences outcomes in a real-world setting. Methods: A retrospective analysis of 85 CAS procedures was conducted at our institution from October 2018 to September 2024, categorizing them into TFA-first (n = 42) and TRA-first (n = 43) periods. The primary endpoint was access-related complications and 30-day perioperative events, including stroke, myocardial infarction, and mortality. The secondary endpoints included target lesion access success rate, frequency of access route conversions, procedural time, and hospital length of stay. Results: Baseline characteristics, including age, sex, symptomatic status, stenosis severity, plaque characteristics, and anatomical considerations, were comparable between groups. In the TFA-first period, 88% of procedures utilized TFA, and TRA was not used at all, while the remaining 12% employed the transbrachial approach (TBA). In the TRA-first period, 23% of procedures employed TFA, 60% utilized TRA, and 16% relied on TBA (p < 0.01). Both groups achieved a similar rate of target lesion access success (98% each) with only one conversion per group. The primary endpoint was significantly lower in the TRA-first group (0%) compared to the TFA-first group (10%, p = 0.04), primarily due to reduced access-site complications. Additionally, the median hospital stay was shorter in the TRA-first group at 6 days compared to 10 days (p = 0.02). Conclusions: Adopting a TRA-first strategy over TFA in CAS leads to better outcomes by improving access-site safety and reducing hospital stays. Developing TRA-specific devices could further expand the applicability of TRA in CAS.

Cost-Minimization Model in Cryptogenic Stroke: ePatch vs Implantable Loop Recorder in Patients from the UK, Netherlands, and Sweden

Background

Patients who have experienced a cryptogenic stroke (CS) may benefit from extended monitoring and possible earlier detection of atrial fibrillation (AF), allowing for the timely initiation of appropriate pharmacotherapy.

Objective

This economic study aimed to evaluate the clinical and cost outcomes of using mid-term cardiac monitors (referred to as "ePatch") versus ILR-only in post-CS patients in the UK, Netherlands (NL) and Sweden.

Methods

An existing cost-minimization model was modified to fit healthcare settings in the UK, Netherlands and Sweden. The model's target population was composed of adult patients who had previously experienced a CS, but had no documented history of AF. The model compares the one-year direct medical costs between two groups: one group receiving wearable ePatch, the other group proceeding directly to ILR.

Results

When applied to a group of 1,000 patients, the ePatch versus ILR approach resulted in cost savings, due to combination of reduced expenses and decreased modelled occurrence of recurrent strokes in all three countries studied. In the base case analysis, the cost savings per patient with detected AF for ePatch ranged from 3.4-6.0 times, depending on the country.

Conclusion

Utilizing ePatch extended wear Holter for mid-term ECG monitoring in CS patients represents a cost-saving alternative to monitoring with ILR. The cost savings were achieved by reducing device expenses and by prevention of recurrent strokes via earlier anticoagulation initiation. Preventing recurrent strokes in this population is highly significant, as it can lead to improved long-term health outcomes and reduced overall healthcare costs.

Exploring the therapeutic utility of the factor XIa inhibitor asundexian

PURPOSE

Factor XIa inhibitors are a promising novel class of anticoagulants that attenuate pathological thrombosis with minimal interference with hemostasis. These effects contrast with those of conventional anticoagulants, which may exhibit adverse events of untoward bleeding precluding treatment in some patients. A variety of investigational pharmacological modalities have been developed and studied to target factor XIa.

SUMMARY

Asundexian is a small molecule inhibitor of factor XIa that has been evaluated in several clinical studies. It has been studied as an oral, once-daily medication and found to inhibit approximately 90% of factor XIa activity at doses of 20 to 50 mg. Phase 2 trials have demonstrated the potential for improved safety compared to standard of care in certain treatment settings, such as in atrial fibrillation. For other indications, such as noncardioembolic stroke and acute myocardial infarction, asundexian has been used in addition to background antiplatelet therapy. In these instances, asundexian did not show a difference in the incidence of bleeding events compared to placebo.

CONCLUSION

Phase 3 trials have recently been launched; however, the OCEANIC-AF trial was prematurely discontinued due to inefficacy of asundexian vs apixaban for stroke prevention in atrial fibrillation. Another phase 3 trial, OCEANIC-AFINA, is planned to compare asundexian to placebo in patients with atrial fibrillation at high risk for stroke who are deemed ineligible for anticoagulation.

Left atrial appendage closure in patients with failure of anticoagulation therapy: A multicenter comparative study on the hybrid strategy using DOACs and VKAs

BACKGROUND

Patients with non-valvular atrial fibrillation (nvAF) who experienced a cardioembolic (CE) event despite adequate oral anticoagulation (OAC) are at high risk of recurrence and the combination between percutaneous left atrial appendage closure (LAAC) and long-term OAC may be a valuable option. The aim of this study was to compare the safety and the efficacy of post-LAAC long-term assumption of direct oral anticoagulants (DOACs) vs. vitamin K antagonists (VKAs) in this population.

METHODS

Consecutive nvAF patients who experienced OAC failure despite adequate OAC therapy and underwent LAAC were retrospectively enrolled from three Italian centers. Patients were divided according to the anticoagulation strategy following LAAC: DOAC group and VKA group. The primary endpoint was a composite of all-cause death, CE event, and major bleeding, while secondary endpoint was a composite of CE event and major bleeding.

RESULTS

Overall, 132 patients (39 % females; mean age 69 ± 11 years), including 73 patients on DOAC and 59 patients on VKA, were enrolled. At a median follow up of 61 ± 23 months, the DOAC group reported lower rate of primary endpoint (HR 0.42, 95 %CI 0.18-0.99, p = 0.038) and lower rate of secondary endpoint (HR 0.28, 95 %CI 0.09-0.89, p = 0.02). No significant differences were detected regarding the type of DOAC assumed. Previous cerebrovascular events, CHA2DS2-VASc, CHADS2, HAS-BLED, and renal dysfunction were predictors of the primary endpoint.

CONCLUSION

Long-term DOAC assumption was associated with higher free from primary and secondary endpoint with respect to VKA in nvAF patients undergoing LAAC for OAC failure.

Drug-eluting stents versus bare-metal stents for intracranial atherosclerotic stenosis: a systematic review and meta-analysis

BACKGROUND

In-stent restenosis (ISR) is the primary cause of stroke recurrence after intracranial stenting. Drug-eluting stents (DES) have recently shown great potential for reducing restenosis. This systematic review aimed to evaluate the efficacy and safety of DES compared with bare-metal stents (BMS) for intracranial atherosclerotic stenosis (ICAS).

METHODS

We systematically searched the MEDLINE (Ovid), Cochrane Central Register of Controlled Trials, Embase (Ovid) and Web of Science databases for studies published from inception through 10 October 2023, comparing DES with BMS for the treatment of symptomatic severe ICAS. We included randomised controlled trials and cohort studies that compared DES and BMS in adult patients with ICAS. The primary outcomes were stroke or death within 30 days and ISR within 1 year. Secondary outcomes included procedure-related adverse events, technical success, functional evaluation findings, restenosis degree and other safety endpoints within 1 year. Subgroup analyses were conducted across different study types.

RESULTS

A total of 510 participants fulfilling all eligibility criteria were enrolled in four studies. DES had a similar rate of any stroke or death within 1 month (3 studies, 476 participants: risk ratio (RR): 1.00; 95% CI: 0.46 to 1.11; p=1.00; I2=31%) to that of the BMS group and had a significantly lower rate of ISR within 1 year (4 studies, 429 participants: RR: 0.23; 95% CI: 0.13 to 0.41; p<0.001; I2=0%). Moreover, a lower rate of stroke recurrence within 1 year was reported (3 studies, 436 participants: RR: 0.46; 95% CI: 0.24 to 0.88; p=0.02; I2=52%) in the DES group.

CONCLUSION

This review demonstrates that the application of DES for intracranial stenting is safe and can significantly reduce the rates of ISR and recurrent ischaemic events. Further research is required to validate these results.

PROSPERO REGISTRATION NUMBER

CRD42022338178.

Correlation between triglyceride-glucose index and atrial fibrillation in acute coronary syndrome patients: a retrospective cohort study and the establishment of a LASSO-Logistic regression model

BACKGROUND

Insulin resistance (IR) is an independent predictor of atrial fibrillation (AF), but the specific utility of the triglyceride-glucose (TyG) index as a predictive marker for the incidence of AF in the acute coronary syndrome (ACS) population has not yet been explored.

OBJECTIVE

To explore the correlation between TyG index and the risk of AF in ACS patients and to establish a predictive model.

METHODS

A retrospective study was conducted on 613 ACS patients admitted to the Department of Cardiovascular Medicine at the First Teaching Hospital of Tianjin University of Traditional Chinese Medicine from January 2022 to September 2024. Patients were divided into four groups based on quartiles of TyG index. Patients were further divided into two groups based on the occurrence of AF: the AF group and the non-AF group. Patient information was collected through the hospital's HIS system. Variable selection was completed using LASSO regression algorithms. Multivariate logistic bidirectional stepwise regression analysis was used to explore the correlation between the TyG index and the risk of AF in ACS patients and to construct a regression model. Three different models were constructed by adjusting for confounding factors and restricted cubic spline plots were drawn to validate the significance of the TyG index combined with AF further. The predictive value of the LASSO-multivariate logistic bidirectional stepwise regression model and the TyG index alone for predicting AF in ACS patients was analyzed using the receiver operating characteristic curve.

RESULTS

The LASSO-multivariate logistic bidirectional stepwise regression algorithm showed that coronary heart disease (CHD), valvular heart disease (VHD), TyG, age (AGE), and diastolic blood pressure (DBP) were risk factors for AF in ACS. The restricted cubic spline model demonstrated a significant linear relationship between a higher TyG index and an increased risk of AF in the ACS patient population. The area under the curve (AUC) for predicting AF in ACS patients using the TyG index and the LASSO-multivariate logistic bidirectional stepwise regression model was 0.65(95%CI = 0.58 ~ 0.73) and 0.71(95%CI = 0.65 ~ 0.77) respectively. Additionally, the correlation between the TyG index and AF was consistent across different subgroups.

CONCLUSION

In ACS patients, the TyG index is a stable and independent predictor of AF, with specific clinical value in identifying the occurrence of AF in this population.

Academic and Community Hospitals differ in stroke subtype classification and cardiac monitoring: the DiVERT multi-center cohort study

Background

Cardiac monitoring strategies to detect occult atrial fibrillation (AF) post-stroke differ among healthcare institutions. This may be related to discrepancies in stroke subtype classification/adjudication, and/or consultation of cardiology specialists at Community Hospitals (CoH) and Academic Centers (AcC). Identifying the degree of heterogeneity may encourage development of guideline-directed monitoring protocols, result in higher AF detection rates and treatments, and fewer strokes.

Methods

The DiVERT (SeconDary Stroke PreVEntion ThRough Pathway ManagemenT) study was designed to characterize post-stroke cardiac monitoring practices in a hospital setting. Care pathways were assessed with in-person stakeholder interviews; patient-level data were reviewed using electronic medical records.

Results

DiVERT identified 2,475 patients with diagnoses of cryptogenic (83.6% vs. 33.1%, p < 0.001), large vessel disease (LVD) (13.3% vs. 37.0%, p < 0.001), or small vessel disease (SVD) (3.1% vs. 29.9%, p < 0.001) stroke, at CoH and AcC, respectively. CoH consulted cardiology significantly less than AcC (12.3% vs. 34.7%, p < 0.001) and ordered significantly fewer short- or long-term cardiac monitors than AcC (6.8% vs. 69.2%, p < 0.001). CoH had shorter length of stay (5.3 vs. 9.4 days, p < 0.001) and patient demographics were significantly different (p < 0.001 for age, ethnicity and race).

Conclusion

Significant heterogeneity in cardiac monitoring post-stroke exists: CoH reported 2.5-times more cryptogenic stroke than AcC yet ordered 10-times fewer short/long-term cardiac monitors to look for AF. Significant differences in patient demographics among institutions may account for this discrepancy. Regardless, efforts to reduce heterogeneity are warranted to improve AF detection and treatment and prevent recurrent stroke.

Leveraging Mendelian randomization to inform drug discovery and development for ischemic stroke

Discovery and development of efficacious and safe pharmacological therapies is fraught with challenges. As proteins constitute the majority of drug targets and are encoded by genes, naturally occurring genetic variation within populations can provide valuable insights to inform drug discovery and development efforts. The drug target Mendelian randomization (MR) paradigm leverages these principles to investigate the causal effects of drug targets in humans. This review examines the application of drug target MR in informing the efficacy and development of therapeutics for ischemic stroke prevention and treatment. We consider applications of MR for existing and novel treatment strategies, including targeting blood pressure, lipid metabolism, coagulation, inflammation and glycemic control. Several of these genetically supported targets are under evaluation in late-stage clinical trials. Methodological limitations of drug target MR are addressed, followed by an outline of future research directions. We anticipate that careful application of drug target MR will enhance the efficiency of drug development for ischemic stroke, consequently accelerating the delivery of effective medications to patients.

The impact of chronic kidney disease on prognosis in acute stroke: unraveling the pathophysiology and clinical complexity for optimal management

BACKGROUND

Chronic kidney disease (CKD) significantly increases stroke risk and severity, posing challenges in both acute management and long-term outcomes. CKD contributes to cerebrovascular pathology through systemic inflammation, oxidative stress, endothelial dysfunction, vascular calcification, impaired cerebral autoregulation, and a prothrombotic state, all of which exacerbate stroke risk and outcomes.

METHODS

This review synthesizes evidence from peer-reviewed literature to elucidate the pathophysiological mechanisms linking CKD and stroke. It evaluates the efficacy and safety of acute reperfusion therapies-intravenous thrombolysis and endovascular thrombectomy-in CKD patients with acute ischemic stroke. Considerations, such as renal function, drug dosage adjustments, and the risk of contrast-induced nephropathy, are critically analyzed. Evidence-based recommendations and research priorities are drawn from an analysis of current practices and existing knowledge gaps.

RESULTS

CKD influences stroke outcomes through systemic and local pathophysiological changes, necessitating tailored therapeutic approaches. Reperfusion therapies are effective in CKD patients but require careful monitoring of renal function to mitigate risks, such as contrast-induced nephropathy and thrombolytic complications. The bidirectional relationship between stroke and CKD highlights the need for integrated management strategies to address both conditions. Early detection and optimized management of CKD significantly reduce stroke-related morbidity and mortality.

CONCLUSION

Optimizing stroke care in CKD patients requires a comprehensive understanding of their pathophysiology and clinical management challenges. This article provides evidence-based recommendations, emphasizing individualized treatment decisions and coordinated care. It underscores the importance of integrating renal considerations into stroke treatment protocols and highlights the need for future research to refine therapeutic strategies, address knowledge gaps, and consider tailored interventions to improve outcomes and quality of life for this high-risk population.

Artificial Microglia Nanoplatform Loaded With Anti-RGMa in Acoustic/Magnetic Feld for Recanalization and Neuroprotection in Acute Ischemic Stroke

Ischemic stroke is a leading cause of death and disability worldwide, and the main goals of stroke treatment are to destroy the thrombus to recanalize blood vessels and protect tissue from ischemia/reperfusion injury. However, current recanalization therapies have serious limitations and there are few neuroprotection methods. Hence, an artificial nanoplatform loaded with anti-Repulsive Guidance Molecule a monoclonal antibody (anti-RGMa) and coated with microglia membrane (MiCM) is reported for stroke treatment, namely MiCM@PLGA/anti-RGMa/Fe3O4@PFH (MiCM-NPs). Tail vein injection of MiCM-NPs targeted the ischemia-damaged endothelial cells because of the MiCM, then superparamagnetic iron oxide (Fe3O4) and anti-RGMa are released after external low-intensity focused ultrasound (LIFU) exposure. The thrombus is destroyed by LIFU-induced "liquid-to-gas" phase transition and cavitation of perfluorohexane (PFH) as well as Fe3O4 movements induced by an external magnetic field. Anti-RGMa protected the ischemic region from ischemia/reperfusion injury. The nanoplatform enabled visualization of the thrombus by ultrasound/photoacoustic imaging when the clot is in an extracranial artery. Importantly, in vivo animal studies revealed good safety for MiCM-NPs treatment. In conclusion, this nanoplatform shows promise as an ischemic stroke treatment strategy combining targeted delivery, recanalization, and neuroprotection.

Beyond Anticoagulation: Limitations of Oral Anticoagulants in Preventing Stroke Recurrence in Atrial Fibrillation

Background/Objectives: Despite the widespread use of oral anticoagulants (OACs), acute ischemic stroke (AIS) remains a significant risk for patients with atrial fibrillation (AF). The real-world effectiveness of OACs in preventing recurrent strokes, particularly following an initial stroke of cardioembolic (CE) origin, continues to be a major challenge for clinicians managing AF patients. This study evaluated the efficacy of OACs in secondary stroke prevention and investigated the influence of anticoagulation type and quality on recurrence risk. Methods: We analyzed data from 128 AF patients in the prospective Transzlációs Idegtudományi Nemzeti Laboratórium (TINL) STROKE-registry, admitted with CE stroke between February 2023 and September 2024. Patients were categorized by anticoagulation status at admission (OAC-users, n = 89; anticoagulation-naïve, n = 39). Recurrence rates were assessed using logistic regression models, adjusted for age, sex, hypertension, diabetes, and pre-stroke disability. Subgroup analyses explored the effects of anticoagulation type and quality. Results: Recurrence rates were similar between the OAC-treated and anticoagulation-naïve patients after adjusting for confounders (19.10% vs. 17.95%, p = 0.870). Among the anticoagulated patients, neither anticoagulation type nor quality alone significantly influenced the recurrence risk. However, their interaction was statistically significant (p = 0.049), suggesting that the effectiveness of anticoagulation in preventing strokes is strongly affected by treatment quality. Conclusions: Although OACs are a cornerstone of stroke prevention in patients with AF, their efficacy in reducing recurrence depends on optimal management. These findings highlight that adequate anticoagulation, not just its use, is critical to minimize recurrence risk. To effectively prevent strokes in high-risk AF patients, future strategies must focus on standardized protocols, tailored monitoring, and individualized dosing regimens.