An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association

Circulating PIWI-interacting RNAs in Acute Ischemic Stroke patients

Background

Stroke refers to an abrupt neurological deficit, caused by an acute focal injury of the central nervous system via infarction or hemorrhage due to impaired vascularity, and remains among the leading causes of disability and death worldwide. Stroke is often preceded by an episode of neuronal deficit termed transient ischemic attack (TIA), which presents an effective opportunity for mitigating the risk of an eminent acute ischemic stroke (AIS). Circulating non-coding RNAs (ncRNAs) have emerged as important biomarkers for stroke, but PIWI-interacting RNAs (piRNAs), a class of small regulatory ncRNAs, have not been previously explored as diagnostic or prognostic biomarkers for stroke.

Methods

We conducted comprehensive circulating piRNA profiling of AIS and TIA patients using RNA-seq on serum samples collected within 24 h of clinical diagnosis. The study cohort was divided into discovery and cross-validation datasets to identify replicated piRNAs using stringent analysis cut-offs. The expression levels of the panel of differentially regulated piRNAs between AIS and TIA patients were also compared with healthy controls.

Results

We identified a panel of 10 differentially regulated piRNAs between AIS and TIA patients; hsa-piR-28272, -piR-32972, -piR-28247, -piR-24553, -piR-24552, -piR-28275, -piR-28707 and -piR-32882 were upregulated, while hsa-piR-23058 and -piR-23136 were downregulated in AIS patients. Moreover, these 10 piRNAs were also differentially expressed in AIS patients compared to healthy controls. In addition, we investigated the potential gene targets of the dysregulated piRNAs and their plausible involvement in pathophysiological processes affected in stroke.

Conclusions

The imbalances in the circulating piRnome of AIS and TIA patients presented herein provide important insights into the roles of piRNAs following ischemic brain injury and potentially provide opportunities to mitigate stroke-induced mortality and morbidity.

Eligibility for and practical implications of Semaglutide in overweight and obese patients with acute coronary syndrome

AIMS

Semaglutide has been shown to reduce cardiovascular events in non-diabetic patients with preexisting cardiovascular disease and overweight/obesity in the SELECT trial. Data on the applicability of these results to clinical practice are limited. We evaluated the eligibility for and practical implications of semaglutide in overweight/obese non-diabetic patients with recent acute coronary syndrome (ACS) from a contemporary real-world registry.

METHODS

Patients from the multicenter START-ANTIPLATELET registry (NCT02219984) were stratified to investigate the proportion of patients eligible for semaglutide >60 days after discharge for ACS (post-acute phase), according to the SELECT trial eligibility criteria: age ≥ 45 years; body mass index ≥27 kg/m2; history of myocardial infarction (MI), stroke, or peripheral artery disease; no diabetes. Major adverse cardiovascular events (MACE), defined as a composite of all-cause death, MI, target vessel revascularization, or stroke, and net adverse clinical events (NACE), a composite of all-cause death, MI, stroke, or major bleeding, were assessed at 1-year follow-up.

RESULTS

The study population comprised 2940 consecutive ACS patients. At 60 days after discharge, 807 patients (27.4 %) met the SELECT eligibility criteria (SELECT-like group) and 2133 patients were ineligible (not-eligible group). At 1 year, incidence of MACE (4.6 % vs. 8.2 %; p = 0.004) and NACE (3.6 % vs. 7.6 %; p < 0.001) was lower in the SELECT-like group compared to the not-eligible group.

CONCLUSIONS

In a contemporary real-world registry, a significant proportion of post-ACS patients were eligible for semaglutide according to the SELECT trial criteria. Future studies are needed to evaluate the potential implications of semaglutide for secondary prevention.

Stroke Incidence, Case Fatality, and Mortality Using the WHO International Classification of Diseases 11: The Geneva Stroke Study

BACKGROUND AND OBJECTIVES

In the field of stroke epidemiology, one of the major advances in the recently implemented International Classification of Diseases, 11th revision (ICD-11) relates to the definition of ischemic stroke, which now includes events shorter than 24 hours when ischemia can be proven on brain imaging. However, data are scarce to ascertain the incidence of strokes of short duration with tissue evidence of ischemia. In this study, we determined the incidence, 30-day case fatality, and mortality rate of stroke in the Geneva population using the new ICD-11 criteria, taking advantage of the organization of stroke service in the area.

METHODS

In this population-based observational cohort study, we used data from the Swiss Stroke Registry, supplemented by hospital records, outpatient medical files, and autopsy, to identify residents of the canton of Geneva, Switzerland, meeting the ICD-11 criteria for first-ever stroke, including ischemic strokes, nontraumatic intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH), from January 1, 2018, to December 31, 2019.

RESULTS

We identified 1,186 first-ever strokes (75.8 years [interquartile range 63.4-84.5]; 571 women [48.1%]). MRI was performed in 90.9% of patients with ischemic strokes. The annual incidence of first-ever stroke, age-adjusted to the European Standard Population, was 127.0/100,000 (95% CI 119.8-134.3) (107.3 [100.7-114.0] for ischemic stroke, 13.2 [10.9-15.5] for ICH, and 6.0 [4.4-7.5] for SAH [3.1 {2.0-4.2} for aneurysmal SAH]). Overall, the 30-day case fatality was higher in ICH (32.5% [95% CI 19.7-38.8], compared with SAH (17.2% [6.6-27.9] and ischemic strokes 10.8% [8.4-12.4]). The incidence of ischemic stroke was 107.3 (100.7-114.0) according to ICD-11 and 90.4 (84.3-96.5) according to ICD-10 (excluding patients with radiologic infarct and symptoms lasting <24 hours). Compared with ICD-10, ICD-11 increased the number of ischemic stroke cases by 18.3%. Patients with ischemic strokes identified with ICD-11 but not under ICD-10 (i.e., patients with symptoms lasting <24 hours and a brain lesion) were younger and presented with a lower National Institutes of Health Stroke Scale (NIHSS) score on admission compared with those identified by ICD-10 and ICD-11.

DISCUSSION

The new ICD-11 clinicoradiologic definition of ischemic stroke increased the number of ischemic stroke cases by 18.3% in our Western European population. Future studies will evaluate the impact of ICD-11 on the human, organizational, and economic needs allocated to the management of the disease.

Early reperfusion in patients with acute retinal artery occlusion: A multicenter prospective study

BACKGROUND

The visual outcome after central retinal artery occlusion (CRAO) is poor, but its relationship with early reperfusion (ER) is poorly known. We evaluated the incidence of ER in acute CRAO or branch retinal artery occlusion (BRAO), and its association with clinical outcome.

METHODS

In this prospective observational multicenter study, we included patients with acute CRAO or macula-involving BRAO presenting within 24 hours from symptom onset. ER was evaluated within 24 hours after the initial clinical evaluation using indocyanine green angiography (ICGA). The primary outcome was the best-corrected visual acuity (BCVA) at 1 month.

RESULTS

In all, 70 patients were enrolled, of whom 63 (90%) had CRAO. Median age was 71 years (interquartile range: 67-77), 63% were male, median time from symptom onset to presentation was 5.3 hours (interquartile range: 3.1-15.1), and 17% received intravenous fibrinolysis. ER was identified in 34 patients (49%), of whom 21 (30%) achieved complete reperfusion (100% filling of the 55° ICGA field). Patients with ER were less likely to have hypertension and diabetes mellitus (p < 0.001 and p = 0.046, respectively). At the 1-month follow-up, BCVA was significantly better in ER patients (median BCVA 1.3 logMAR vs 1.7 logMAR, p = 0.001), with greater benefit with complete reperfusion (p for trend < 0.001). ER was also associated with improved visual field and quality of life at the 1-month follow-up (both p < 0.05).

CONCLUSION

ER occurred in almost 50% of the patients and was associated with improved visual outcomes and quality of life. Therapies that increase ER in CRAO will likely improve clinical outcomes.

CLINICAL TRIAL REGISTRATION

This study was registered on ClinicalTrials.gov (identifier NCT03049514); https://classic.clinicaltrials.gov/ct2/show/NCT03049514.

Covert Perioperative Strokes in Older Patients Having Noncardiac Surgery (PRECISION): A Prospective Cohort Analysis

BACKGROUND

Perioperative strokes may promote postoperative neurocognitive dysfunction. This study thus evaluated the incidence of postoperative strokes and the association between strokes and postoperative neurocognitive outcomes in older patients recovering from noncardiac surgery.

METHODS

The Postoperative Covert Stroke and Cognitive Dysfunction among Elderly Patients Undergoing Noncardiac Surgery study (PRECISION) was a two-center prospective cohort study evaluating patients aged 60 yr or older who had elective, noncardiac inpatient surgery at two Chinese academic centers. Postoperative strokes were evaluated by scheduled magnetic resonance brain imaging within 7 days. The primary outcome was the cumulative incidence of postoperative stroke. Secondary outcomes included postoperative delirium within the first 5 days after surgery, neurocognitive decline at 12 months, and the association between stroke and neurocognitive dysfunction.

RESULTS

Among 934 patients (mean age, 67 yr; 45% male) included in the analyses, two thirds had neurosurgical craniotomies. There were 111 (11.9%; 95% CI, 9.8 to 14.0%) covert strokes within 7 days after surgery and no overt strokes. Postoperative delirium was observed in 117 patients (12.5%; 95% CI, 10.4 to 14.7%) within 5 days, and neurocognitive decline was observed in 147 patients (18.8%; 95% CI, 16.0 to 21.5%) at 1 yr after surgery. Postoperative covert strokes were significantly associated with delirium (adjusted odds ratio, 2.18; 95% CI, 1.31 to 3.62; P = 0.003) and 1-yr neurocognitive decline (adjusted odds ratio, 2.33; 95% CI, 1.31 to 4.13; P = 0.004) in overall participants.

CONCLUSIONS

Among patients aged 60 yr and older who had major noncardiac surgery, mainly intracranial, one in nine patients experienced a perioperative covert stroke. Covert strokes more than doubled the risk of postoperative delirium and long-term neurocognitive decline. Covert perioperative strokes are common and clinically meaningful.

Machine learning-based predictive models for perioperative major adverse cardiovascular events in patients with stable coronary artery disease undergoing noncardiac surgery

BACKGROUND AND OBJECTIVE

Accurate prediction of perioperative major adverse cardiovascular events (MACEs) is crucial, as it not only aids clinicians in comprehensively assessing patients' surgical risks and tailoring personalized surgical and perioperative management plans, but also for information-based shared decision-making with patients and efficient allocation of medical resources. This study developed and validated a machine learning (ML) model using accessible preoperative clinical data to predict perioperative MACEs in stable coronary artery disease (SCAD) patients undergoing noncardiac surgery (NCS).

METHODS

We collected data from 9171 adult SCAD patients who underwent NCS and extracted 64 preoperative variables. First, the optimal data imputation, resampling, and feature selection methods were compared and selected to deal with missing data values and imbalances. Then, nine independent machine learning models (logistic regression (LR), support vector machine, Gaussian Naive Bayes (GNB), random forest, gradient boosting decision tree (GBDT), extreme gradient boosting (XGBoost), light gradient boosting machine, categorical boosting (CatBoost), and deep neural network) and a stacking ensemble model were constructed and compared with the validated Revised Cardiac Risk Index's (RCRI) model for predictive performance, which was evaluated using the area under the receiver operating characteristic curve (AUROC), the area under the precision-recall curve (AUPRC), calibration curve, and decision curve analysis (DCA). To reduce overfitting and enhance robustness, we performed hyperparameter tuning and 5-fold cross-validation. Finally, the Shapley additive interpretation (SHAP) method and a partial dependence plot (PDP) were used to determine the optimal ML model.

RESULTS

Of the 9,171 patients, 514 (5.6 %) developed MACEs. 24 significant preoperative features were selected for model development and evaluation. All ML models performed well, with AUROC above 0.88 and AUPRC above 0.39, outperforming the AUROC (0.716) and AUPRC (0.185) of RCRI (P < 0.001). The best independent model was XGBoost (AUROC = 0.898, AUPRC = 0.479). The calibration curve accurately predicted the risk of MACEs (Brier score = 0.040), and the DCA results showed that XGBoost had a high net benefit for predicting MACEs. The top-ranked stacking ensemble model, consisting of CatBoost, GBDT, GNB, and LR, proved to be the best (AUROC 0.894, AUPRC 0.485). We identified the top 20 most important features using the mean absolute SHAP values and depicted their effects on model predictions using PDP.

CONCLUSIONS

This study combined missing-value imputation, feature screening, unbalanced data processing, and advanced machine learning methods to successfully develop and verify the first ML-based perioperative MACEs prediction model for patients with SCAD, which is more accurate than RCRI and enables effective identification of high-risk patients and implementation of targeted interventions to reduce the incidence of MACEs.

IPNA consensus definitions for clinical trial outcomes in steroid-resistant nephrotic syndrome

Assessment of the true impact of therapeutic interventions is a challenge in the absence of universal, standardized definitions for clinical trial endpoints in children with kidney diseases. Steroid-resistant nephrotic syndrome (SRNS) is a difficult kidney disease to treat, with unremitting disease progressing to kidney failure. Currently, available therapies result in suboptimal cure rates. Clinical trials with innovative, targeted treatments will likely be conducted for this disease in the foreseeable future. An international consortium of the IPNA Best Practices and Standards Committee and the Pediatric Nephrology Expert Group of the conect4children (c4c) network developed through consensus, standardized, internationally acceptable definitions for trial outcomes for SRNS. The endpoint definitions were formulated for use with urine protein to creatinine ratios and estimated glomerular filtration rates. Definitions of complete remission, partial remission, non-remission of disease, reduction in proteinuria, kidney disease progression, kidney failure, and composite kidney outcome were refined using an iterative process until a consensus was achieved.

Examining the influence of PM2.5-bound metallic elements and potential sources on stroke emergency department visits: A case-crossover study in Taiwan

This study aimed to investigate the impact of short-term exposure PM2.5 and PM2.5-bound metallic elements on stroke-related emergency department visits. Using a case-crossover design, data from the National Health Insurance Research Database (NHIRD) identified 25,055 stroke-related emergency department visits and matched them with 50,110 control days from 2017 to 2020 in six selected study areas in Taiwan. Environmental exposure data included PM2.5 monitoring date and 35 PM2.5-bound metallic elements from these areas. Conditional logistic regression models were employed for the analysis. The association between overall PM2.5 exposure and stroke emergency department visits varied by season. Significant positive associations were observed in autumn and winter across lag periods. In autumn, adjusted odds ratios (ORs) from lag 0-3 were 1.086 (95% CI: 1.078-1.095), 1.087 (95% CI: 1.078-1.096), 1.086 (95% CI: 1.077-1.095), 1.094 (95% CI: 1.085-1.103), respectively. Furthermore, during autumn, a variety of 25 PM2.5-bound metallic elements showed a positive association with stroke, particularly PM2.5-bound cadmium (Cd). Adjusted ORs for PM2.5-bound Cd were 1.486 (95% CI:1.385-1.594) at lag 0, 1.500 (95% CI: 1.397-1.611) at lag 1, 1.458 (95% CI: 1.359-1.565) at lag 2, and 1.465 (95% CI: 1.366-1.571) at lag 3. Conversely, specific elements (Sr, Y, Pb, Ga, Cu, Ba, K, Cs, Rb, Nd, and Al) associated with burning sources exhibited notable positive associations in winter. Our study highlights the importance of monitoring PM2.5 composition changes and mitigate stroke risks posed by diverse metallic elements. Seasonal variability is evident, with autumn and winter showing sustained associations between stroke and PM2.5 exposure. Notably, winter, especially during celebrations, showed a significant contribution of PM2.5-bound metallic elements from burning sources.

Automated Detection of Central Retinal Artery Occlusion Using OCT Imaging via Explainable Deep Learning

Objective

To demonstrate the capability of a deep learning model to detect central retinal artery occlusion (CRAO), a retinal pathology with significant clinical urgency, using OCT data.

Design

Retrospective, external validation study analyzing OCT and clinical baseline data of 2 institutions via deep learning classification analysis.

Subjects

Patients presenting to the University Medical Center Tübingen and the University Medical Center Hamburg-Eppendorf in Germany.

Methods

OCT data of patients suffering from CRAO, differential diagnosis with (sub) acute visual loss (central retinal vein occlusion, diabetic macular edema, nonarteritic ischemic optic neuropathy), and from controls were expertly graded and distinguished into 3 groups. Our methodological approach involved a nested multiclass five fold cross-validation classification scheme.

Main Outcome Measures

Area under the curve (AUC).

Results

The optimal performance of our algorithm was observed using 30 epochs, complemented by an early stopping mechanism to prevent overfitting. Our model followed a multiclass approach, distinguishing among the 3 different classes: control, CRAO, and differential diagnoses. The evaluation was conducted by the "one vs. all" area under the receiver operating characteristics curve (AUC) method. The results demonstrated AUC of 0.96 (95% confidence interval [CI], ± 0.01); 0.99 (95% CI, ± 0.00); and 0.90 (95% CI, ± 0.03) for each class, respectively.

Conclusions

Our machine learning algorithm (MLA) exhibited a high AUC, as well as sensitivity and specificity in detecting CRAO and the differential classes, respectively. These findings underscore the potential for deploying MLAs in the identification of less common etiologies within an acute emergency clinical setting.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A New Perspective on the Prediction and Treatment of Stroke: The Role of Uric Acid

Stroke, a major cerebrovascular disease, has high morbidity and mortality. Effective methods to reduce the risk and improve the prognosis are lacking. Currently, uric acid (UA) is associated with the pathological mechanism, prognosis, and therapy of stroke. UA plays pro/anti-oxidative and pro-inflammatory roles in vivo. The specific role of UA in stroke, which may have both neuroprotective and damaging effects, remains unclear. There is a U-shaped association between serum uric acid (SUA) levels and ischemic stroke (IS). UA therapy provides neuroprotection during reperfusion therapy for acute ischemic stroke (AIS). Urate-lowering therapy (ULT) plays a protective role in IS with hyperuricemia or gout. SUA levels are associated with the cerebrovascular injury mechanism, risk, and outcomes of hemorrhagic stroke. In this review, we summarize the current research on the role of UA in stroke, providing potential targets for its prediction and treatment.

Global, regional and national trends in the burden of intracranial hemorrhage, 1990-2021: Results from the Global Burden of Disease study

Intracerebral hemorrhage (ICH) is a significant global public health issue that is characterized by a rapid start, severe symptoms, and a poor prognosis. It is the most common type of hemorrhagic stroke. We analyzed global intracranial hemorrhage incidence, mortality, disability-adjusted life years (DALYs), and corresponding age-standardized rates (ASRs) and estimated annual percentage changes (EAPCs) by using GBD 2021 data. The data were further stratified by age, sex, and region to assess the global burden of ICH from 1990 to 2021, providing the most up-to-date epidemiologic reference data for public health prevention and treatment strategies. In 2021, there were 3,444,300 (95 % UI, 305.30 to 381.20) new cases, 3,308,400 (302.11-359.47) deaths and 79,457,400 (7230.45-8548.02) DALYs. The burden of intracranial hemorrhage was higher in Oceania and Southeast Asia (Age-standardized DALY rates of 2582.46 per 100,000 and 1976.78 per 100,000), but lower in Australasia (126.59), high-income North America (221.19), and Western Europe (161.23). Of the 204 countries and territories globally, the burden of intracranial hemorrhage is higher in countries such as Nauru, Solomon Islands and Marshall Islands. From 1990 to 2021, global age-standardized incidence rates (ASIR), age-standardized mortality rates (ASMR), and age-standardized DALY rates (ASDR) declined, corresponding to EAPCs of -1.52, -1.63 and -1.75, with females declining more than males. In 2021, the most significant risk factor for ICH was high systolic blood pressure, accounting for 56.4 % of total DALYs for intracranial hemorrhage. Other major risk factors include: ambient particulate matter pollution, smoking, solid fuel pollution of household air, high sodium diet, and renal dysfunction. We need to target interventions at relevant risk factors, such as hypertension management, environmental particulate management, smoking cessation campaigns, focusing on high-risk groups and high-burden areas, and continue to deepen the implementation of the universal primary prevention strategy.

Distinctive cerebral small vessel disease patterns are associated with ischemic stroke in systemic lupus erythematosus

BACKGROUND

Systemic lupus erythematosus (SLE) increases the risk of ischemic stroke (IS) and cerebral small vessel disease (CSVD) through a unique interplay of cardiovascular and immune-mediated mechanisms. There is an unmet need of predictors of IS risk and of characterization of the distinctive features of CSVD in patients with SLE.

OBJECTIVES

To assess if CSVD is more extensive in patients with SLE and ischemic stroke (IS+) than in those without (IS-); to identify distinctive neuroimaging features of CSVD in patients with SLE.

METHODS

This observational study, conducted at an academic referral center in São Paulo, Brazil, included SLE patients who underwent brain MRI between 2010 and 2021. Two neuroradiologists, blinded to clinical data, reached a consensus on the summary CSVD score, that consists of microbleeds, lacunes of presumed vascular origin, enlarged perivascular spaces, and white matter hyperintensities of presumed vascular origin. Logistic regression was performed with IS as the dependent variable.

RESULTS

We included 106 patients, 53 IS+ and 53 IS- (median age: 41; interquartile range, 34;51 years; 92% women). The summary CSVD score was independently associated with the IS + group (OR 3.83, 95% CI 1.73 - 9.87, p = 0.002), even after adjusting for age, hypertension, secondary antiphospholipid syndrome, and use of antimalarial drugs. Microbleeds predominated in cortical regions (23/24, 92%), lacunes in the basal ganglia (10/16, 63%) and white matter hyperintensities in the deep white matter (47/59, 80%).

CONCLUSION

CSVD was more frequent in IS+ than in IS-, highlighting the need for prospective studies in SLE to test CSVD as a biomarker of IS risk. Microbleeds predominated in the cortical region, different from reports of age-related and hypertension-associated CSVD.

The role of triglyceride-glucose index in central retinal artery occlusion

PURPOSE

To evaluate the correlation between the Triglyceride-Glucose (TyG) index and newly diagnosed cases of central retinal artery occlusion (CRAO) in patients.

METHODS

The research involved 51 patients diagnosed with central retinal artery occlusion (CRAO) and a control group consisting of 50 healthy volunteers matched for age and sex. Following a thorough ocular examination, various blood biochemistry and hematological parameters were documented. The TyG index was derived from fasting plasma glucose and triglyceride values.

RESULTS

The average age was 66.1 ± 8.9 years for individuals with CRAO and 64.9 ± 7.6 years for those in the control group. Significant differences in TyG values were observed between the CRAO and control groups, with the CRAO group exhibiting higher values (8.74 ± 0.17 vs. 8.49 ± 0.22, p<0.001). Upon multivariate analysis, the TyG index emerged as an independent predictor of CRAO (Odds Ratio= 1.84, 95% confidence interval = 1.19 - 4.23; p < 0.001). In receiver operating characteristics analysis, the area under the curve for the TyG index was 0.789. A TyG index exceeding 8.58 predicted CRAO with 78% sensitivity and 68% specificity.

CONCLUSION

The current study demonstrated a notable association between increased TyG index and central retinal artery occlusion (CRAO). Thus, the TyG index could serve as a valuable predictive marker for assessing the risk of CRAO.

THBS1 in macrophage-derived exosomes exacerbates cerebral ischemia-reperfusion injury by inducing ferroptosis in endothelial cells

Macrophages play a critical role in the development of acute ischemic stroke (AIS). Cerebral ischemia-reperfusion injury (CIRI) is a pivotal pathological process that exacerbates AIS, with exosomes act as crucial mediators. However, the effects and mechanisms of action of macrophage-derived exosomes on CIRI remain unclear. This study demonstrated that macrophage-derived exosomes induce endothelial ferroptosis and barrier disruption during CIRI. Through proteomic sequencing and the reanalysis of transcriptomic and single-cell sequencing data, thrombospondin-1 (THBS1) was identified as a key exosomal molecule. Elevated THBS1 was observed in exosomes and monocytes from the peripheral blood of patients with AIS in oxygen-glucose deprivation/reoxygenation (OGD/R)-stimulated THP-1 and RAW264.7, in their secreted exosomes, and in macrophages within the brains of transient middle cerebral artery occlusion (tMCAO) mice. Additionally, THBS1 expression in exosomes was positively correlated with vascular barrier injury biomarkers, including MMP-9 and S100B. Modulation of THBS1 in macrophage-derived exosomes affected exosome-induced ferroptosis in endothelial cells. The mechanism by which THBS1 binds directly to OTUD5 and promotes GPX4 ubiquitination was elucidated using RNA interference, adeno-associated virus transfection, and endothelial-specific Gpx4 knockout mice. High-throughput screening of small-molecule compounds targeting THBS1 was performed. Molecular docking, molecular dynamics simulations, and cellular thermal shift assays further confirmed that salvianolic acid B (SAB) has a potent binding affinity for THBS1. SAB treatment inhibited the interaction between THBS1 and OTUD5, leading to reduced GPX4 ubiquitination. Further research revealed that SAB treatment enhanced the cerebral protective effects of THBS1 inhibition. In conclusion, this study explored the role of exosome-mediated signaling between macrophages and cerebral vascular endothelial cells in CIRI, highlighting the THBS1-OTUD5-GPX4 axis as a driver of endothelial ferroptosis and brain injury. Targeting this signaling axis represents a potential therapeutic strategy for treating CIRI.

Association between Triglyceride-Glucose indices and ischemic stroke risk across different glucose metabolism statuses

BACKGROUND

Triglyceride-glucose (TyG) related indices, including TyG, TyG-body mass index (TyG-BMI), and TyG-waist circumference (TyG-WC), have been identified as promising biomarkers for assessing insulin resistance (IR), a known risk factor for ischemic stroke. While previous research has highlighted the relevance of these indices in various metabolic disorders, their predictive utility for ischemic stroke across different glucose metabolic statuses has not been extensively explored.

METHOD

This study utilized data from the UK Biobank, analyzing 392,733 participants free from ischemic stroke at baseline, categorized into normal glucose, prediabetes, and diabetes groups based on American Diabetes Association criteria. TyG-related indices were computed using baseline measures of fasting blood glucose and triglycerides. Participants were followed for a median of 14.68 years to assess the incidence of ischemic stroke. Cox proportional hazards models adjusted for demographic and clinical covariates were used to explore the associations between TyG indices and stroke risk.

RESULTS

Over the follow-up period, 8033 participants experienced an ischemic stroke. Higher TyG-related indices were associated with an increased stroke risk in all glucose metabolism groups, with the strongest associations observed in the prediabetes and normal glucose groups. The risk of stroke increased progressively across quartiles of TyG, TyG-BMI, and TyG-WC indices. The analysis revealed that each unit increase in the TyG index significantly elevated stroke risk in diabetic individuals, while TyG-BMI and TyG-WC indices showed significant predictive power in the prediabetes and normal glucose groups.

CONCLUSION

TyG-related indices, particularly TyG-BMI and TyG-WC, are effective in predicting the risk of ischemic stroke, especially among individuals with prediabetes and normal glucose levels. These findings underscore the utility of TyG indices as tools for early detection and preventive strategies in stroke risk management across various states of glucose metabolism.

Cumulative impact of procedural and anatomical factors on in-hospital bleeding complications in endovascular therapy for lower-extremity artery disease: A nationwide registry study in Japan

Background: Although bleeding is a common procedure-related adverse event following endovascular therapy (EVT), limited data exist regarding the procedural and anatomical factors associated with its complications in patients with lower-extremity artery disease (LEAD) undergoing EVT. Methods: Data were extracted from a nationwide Japanese EVT registry of 73,990 patients who underwent EVT for symptomatic LEAD between January 2021 and December 2022. The primary outcome measure was in-hospital bleeding complications, including access site bleeding, nonaccess site bleeding, and hemorrhagic stroke. Results: The mean age of the patients was 75 ± 9 years, and 69% were men. In-hospital bleeding complications were observed in 613 (0.8%) patients. Logistic regression analysis demonstrated significant associations between bleeding complications and the following procedural, anatomical, and pharmacological variables: emergent revascularization (odds ratio [OR]: 1.90, 95% CI: 1.29-2.79), multiple approach sites (OR: 2.46, 95% CI: 2.00-3.01), bilateral arterial calcification (OR: 1.46, 95% CI: 1.19-1.79), chronic occlusion (OR: 1.53, 95% CI: 1.28-1.83), dual antiplatelet therapy (OR: 1.70, 95% CI: 1.27-2.28), and oral anticoagulant (OR: 1.63, 95% CI: 1.31-2.03). The adjusted incidence of in-hospital bleeding was 0.59% (95% CI: 0.51-0.68%) in patients with one of the identified procedural and anatomical risk factors, 0.96% (95% CI: 0.82-1.13%) in patients with two factors, and 2.40% (95% CI: 1.88-3.05%) in patients with three or four factors. Conclusions: Procedural and anatomical factors as well as antithrombotic strategies were significantly associated with an increased risk of in-hospital bleeding in patients with LEAD who underwent EVT.

Are standing balance and walking ability deficits poststroke related to the integrity of the corticospinal and non-corticospinal tracts? A meta-analysis

BACKGROUND

The importance of corticospinal tract (CST) integrity in upper limb recovery poststroke is well established, but its association with standing balance and walking remains unclear. This meta-analysis aimed to establish the relationship between CST and non-CST motor tract integrity, and clinical scores of standing balance and walking poststroke.

METHODS

In July 2024, five databases were searched for studies, focusing on diffusion MRI metrics and clinical scores of standing balance and/or walking independence poststroke. Meta-analyses were conducted to pool correlation coefficients (r) and group differences (d) based on CST integrity.

RESULTS

Twenty-two studies were included. Cross-sectional analysis showed no correlation (r < .25) between CST metrics and the functional ambulation category (FAC) in the sub-acute phase. Weak prognostic associations were found for CST-FA and CST-FN with FAC. Significant FAC score differences were found between preserved- and disrupted CST groups in the sub-acute (d = .79) and chronic (d = 1.07) phase and for prognostic analysis (d = 1.40). Non-CST metrics showed no cross-sectional associations and mixed prognostic associations.

CONCLUSIONS

CST integrity was not significantly associated with standing balance or walking independence in the sub-acute phase. Early CST integrity showed weak prognostic value for walking at 6 months. Multimodal longitudinal research is needed to improve lower limb recovery prognostics.

Silent Myocardial Infarction and Risk of Stroke Recurrence: A Post Hoc Analysis of the IRIS Trial

BACKGROUND

Unrecognized or silent myocardial infarction (MI) detected on an ECG is associated with first-ever stroke, but the impact on stroke recurrence is unknown. We aimed to determine the association of silent MI with stroke recurrence in patients with a recent ischemic stroke.

METHODS AND RESULTS

Subjects from the IRIS (Insulin Resistance Intervention After Stroke) trial with an available ECG were included. Clinical MI was defined as a history of hospitalization for MI. Silent MI was defined as ECG evidence of MI in the absence of clinical MI. The primary outcome was recurrent stroke. Ischemic stroke and subtype were assessed as secondary outcomes. Multivariable Cox regression analysis adjusted for demographics, pioglitazone, and vascular risk factors was used to examine the association between MI and stroke recurrence. A total of 2282 participants met the inclusion criteria. Clinical and silent MI were identified in 161 (7.1%) and 94 (4.1%) subjects, respectively. Over the study period, 209 recurrent strokes occurred, with 191 classified as ischemic. In the fully adjusted model, silent MI was significantly associated with any stroke (hazard ratio [HR], 2.29 [95% CI, 1.34-3.90]) and ischemic stroke (HR, 2.09 [95% CI, 1.18-3.70]) recurrence. Clinical MI was associated with stroke recurrence in the unadjusted analysis but not in the fully adjusted model (HR, 1.31 [95% CI, 0.81-2.11]). Silent MI was not associated with potential cardioembolic subtypes (HR, 1.50 [95% CI, 0.70-3.22]).

CONCLUSIONS

Among patients with a recent ischemic stroke, silent MI was associated with stroke recurrence. Tailored prevention strategies in this population warrant future investigation.

REGISTRATION

URL: https://clinicaltrials.gov. Unique Identifier: NCT00091949.

One-Year Functional Outcome of Patients After Surgery for Acute Stanford Type A Aortic Dissection

BACKGROUND

Our aim was to report the functional outcome of Stanford type A aortic dissection (TAAD) after 1 year as well as morbidity and mortality.

METHODS AND RESULTS

This is a retrospective analysis including 642 patients with TAAD from January 2005 to December 2021. Mean age at TAAD was 62 years (95% CI, 61-63), and 30% of the population were women. One year after surgery for TAAD, 75% of patients were living at home with New York Heart Association functional class I. No patients were observed with New York Heart Association functional class IV. Less than 2% resided in an assisted-living facility. Eighty-five percent of nonretired patients had returned to work. Two hundred twelve (33%) patients were retired after 1 year at a mean age of 73 years (95% CI, 72-74). Stroke (defined as any kind of neurological symptoms) occurred in 148 (23%) patients and was the cause of death in 33 patients. Of the remaining patients with stroke, 115 (30%) had no residual limitations 1 year after TAAD. The cross-clamp time was significantly higher in patients with stroke (98 minutes [95% CI, 94.0-101.1] in patients without stroke versus 106 minutes [95% CI, 98.5-114.1] in patients with stroke; P=0.026). Sixty-nine percent of patients with stroke lived at home, 28% lived at home with support, and 3% lived in an assisted-living facility. One year after stroke, 77% of the patients achieved a modified Rankin Scale score ≤2, whereas no patient had a modified Rankin Scale score of 5. There was no significant correlation between sex and recovery rate (P=0.48). However, experiencing a stroke significantly increased the likelihood of residing in an assisted-living facility or receiving support at home 1 year after TAAD (odds ratio, 9.46 [95% CI, 5.06-17.70]; P<0.001). Thirty-day mortality was 11.8%, and 92 patients (14%) died within the first year after TAAD. There was no significant sex difference in mortality (P=0.101).

CONCLUSIONS

One year after surgery for Stanford acute type A aortic dissection, almost 3 out of 4 patients lived unassisted at home. Stroke survivors have a favorable outcome, with the majority having mild or no residual neurological deficits at 1 year.

Stroke in adults with primary intracranial tumours

BACKGROUND

We investigated stroke in patients with either benign or malignant primary intracranial tumours to give insights into how malignant and non-malignant intracranial tumours affect stroke and to provide evidence for stroke guidelines for these patients.

METHODS

We conducted a retrospective cohort study of patients with benign or malignant primary intracranial tumours admitted with stroke (2011-2022) to a single centre with regional stroke and neuro-oncology units. Data collected included: stroke aetiology, stroke timing relative to tumour diagnosis, pre-stroke disability, post-stroke disability, stroke recurrence and treatment.

RESULTS

We identified 258 patients who had an index stroke (120 haemorrhagic, 135 ischaemic, three coincident haemorrhagic/ischaemic) at or after the diagnosis of their primary intracranial tumour (71% benign, 29% malignant). Stroke incidence spiked at tumour diagnosis and subsequent months. Symptomatic intracranial haemorrhage was more commonly associated with malignant primary intracranial tumours. In-hospital mortality and level of disability at hospital discharge (median modified Rankin scale score, 4) were similar for patients with benign or malignant primary intracranial tumours. Stroke recurrence was 22% at one year. Statins were associated with reduced stroke recurrence (HR = 0.35 [95% CI 0.13-0.96]). The probability of patients with malignant tumours receiving chemotherapy was inversely related to disability at hospital discharge (ratio OR per unit increase modified Rankin scale = 0.65 [95% CI 0.42-0.96]).

CONCLUSION

Stroke has wider consequences for patients with primary intracranial tumours than commonly recognised. Our data indicated that statins may help to prevent stroke recurrence. Despite concerns about intracranial haemorrhage, antiplatelet agents should be considered after ischaemic stroke.

First experience in employing a complex digital support system accompanied by personal assistance to improve aftercare in patients with stroke or transient ischemic attack - results of the PostStroke-Manager feasibility study

Stroke aftercare is widely acknowledged as crucial yet challenging. Digital tools offer a promising strategy to improve aftercare and, thus, patients' quality of life. However, it has not yet been investigated whether digital tools addressing different aspects of aftercare at the same time can be utilized in stroke patients. This study was intended to gain first experience in employing a complex patient-centered digital support system (i.e., the PostStroke-Manager) in individuals with stroke or transient ischemic attack (TIA) and thus examined its feasibility accompanied by personal assistance. This cohort study was carried out to enroll patients with stroke or TIA. Digital support was realized through an application installed on a tablet, a smartwatch, and a blood pressure monitor. Trained nurses, referred to as stroke pilots, provided personal assistance. After 6 or 12 months, patients were asked to evaluate the concept with digital and personal support as a whole and concerning single components of the program for individually experienced beneficial effects. Additional descriptive analyses comprised temporal courses of stroke-related impairments, quality of life, anxiety, depression, adherence, empowerment, blood pressure, LDL cholesterol, and HbA1c levels. Between January 2022 and December 2022, 815 patients were screened, and 43 were included in the study, of whom 36 completed follow-up assessments. The study met its predefined feasibility criterion, with at least 50% of program components receiving positive ratings from at least 75% of patients. The digital system as a whole (77.8%), personal assistance (75.0%), and interactions with stroke pilots (77.8%) received particularly positive ratings. Additionally, aspects such as vital sign monitoring, platforms for communication and medical records were rated positively. Longitudinal analyses revealed improvements in patients' impairments, blood pressure, and LDL cholesterol levels, while most psychometric measurements remained stable. These findings indicate the feasibility of employing complex digital support systems for patient-centered aftercare in selected individuals with stroke or TIA. The challenge remains in extending benefits to those patients with more severe neurological impairments, highlighting the necessity for ongoing advancement in this field.

High-sensitivity C-reactive protein and risk of retinal artery occlusion and ischaemic stroke: a cross-cohort study

AIMS

Previous studies have suggested an association between retinal artery occlusion (RAO) and ischaemic stroke (IS), both associated with elevated inflammatory factors. However, the role of high-sensitivity C-reactive protein (hs-CRP) in the sequential onset of these two diseases is still unclear. Based on this evidence, we evaluated the association of hs-CRP with RAO and IS.

METHODS

We examined hs-CRP from both the large multicentre cohort study UK Biobank and Chinese Retinal Artery Occlusion study. Cox proportional hazard models were used to study the association of hs-CRP with incident RAO and IS during the long-term follow-up in the UK Biobank. Logistic regression analysis was employed to assess the cross-sectional relationship between hs-CRP with RAO and IS in the Chinese cohort. A restricted cubic spline (RCS) approach was employed to evaluate potential non-linear associations of hs-CRP with IS.

RESULTS

After exclusions, the analysis included 459 188 participants from the UK and 338 participants from China. Over a median follow-up of 12.2 years, 136 cases of incident RAO and 3206 cases of incident IS events were recorded in the UK Biobank. After multivariable adjustment, higher hs-CRP (per 10 mg/L) level was associated with increased risks of RAO (HR: 1.34, 95% CI: 1.01 to 1.76) and IS (HR: 1.24, 95% CI: 1.17 to 1.33). RCS analysis revealed a significant non-linear relationship between hs-CRP levels and incident IS (Pnon-linear<0.001). Furthermore, RAO patients with higher hs-CRP levels were more likely to be combined with IS (2.81 mg/L vs 10.14 mg/L, p<0.001). In the Chinese cohort, the association between hs-CRP with RAO and IS was further confirmed. Higher hs-CRP (per 1 mg/L) level was associated with increased risks of RAO (OR: 1.43, 95% CI: 1.15 to 1.78) and IS (OR: 1.13, 95% CI: 1.03 to 1.24).

CONCLUSIONS

Our findings underscore hs-CRP as a robust risk factor for both RAO and IS. Controlling hs-CRP levels might reduce the incidence of RAO and secondary stroke.

Unveiling synergies: Integrating TCM herbal medicine and acupuncture with conventional approaches in stroke management

This review explores the mechanisms and treatment strategies of ischemic stroke, a leading cause of morbidity and mortality worldwide. Ischemic stroke results from the obstruction of blood flow to the brain, leading to significant neurological impairment. The paper categorizes ischemic stroke into subtypes based on etiology, including cardioembolism and large artery atherosclerosis, and discusses the challenges of current therapeutic approaches. Conventional treatments like tissue plasminogen activator (tPA) and surgical interventions are limited by narrow windows and potential complications. The review highlights the promise of acupuncture, which offers neuroprotective benefits by promoting cerebral ischemic tolerance and neural regeneration. Integrating acupuncture with conventional treatments may enhance patient outcomes. Emphasis is placed on understanding the pathophysiology to develop targeted therapies that mitigate neuronal damage and enhance recovery.

Spinal Cord Infarction: Clinical and Neuroradiological Clues of a Rare Stroke Subtype

Spinal cord infarction (SCI) of arterial origin is a rare vascular event, and its incidence is probably underestimated. There are no strong epidemiological data, and the diagnostic pathway is complex and sometimes incomplete. Furthermore, many cases may be misdiagnosed as other forms of acute and subacute myelopathies. The focus of this review is the clinical and neuroradiological issues in diagnosing SCI and their respective reliability in a clinical setting. The new proposed diagnostic criteria of SCI, although not covering all aspects, highlight the need for a comprehensive approach, including even atypical cases, as the lack of cord compression on Magnetic Resonance Imaging (MRI) is the only mandatory feature for diagnosis. Some MRI features are supportive of the diagnosis, particularly when the anterior spinal artery territory is involved and diffusion-weighted imaging (DWI) is used. Several etiologies can be considered, considering traditional vascular risk factors and diseases affecting the aorta and its main branches, yet a significant proportion of cases remain without a definite etiology. The strongest predictor of SCI diagnosis is a clinical variable, i.e., a time to nadir of severe deficits < 12 h.

Research trends and hotspots in post-stroke speech rehabilitation: A bibliometric analysis

BACKGROUND

With the global population aging, the incidence of stroke is rising, often resulting in motor dysfunction, speech disorders, and swallowing difficulties, significantly affecting daily life and social participation. Speech and language disorders notably impair communication and restrict social engagement, making speech rehabilitation a critical intervention. However, comprehensive bibliometric analyses on post-stroke language rehabilitation are limited, restricting understanding of progress in this field.

OBJECTIVE

This study aimed to identify hotspots and trends in post-stroke speech rehabilitation research from 2003 to 2023 to guide future studies.

METHODS

Articles on post-stroke speech rehabilitation from 2003 to 2023 were retrieved from the Web of Science Core Collection. Analyses included annual publications, key authors, countries, institutions, journals, co-citations, and keywords.

RESULTS

Among 1077 articles, publication volume showed an upward trend, with the United States leading in contributions. The Aphasiology journal published the most articles, and prominent institutions like the University of Queensland demonstrated significant publication and citation impact. Key trends included "communication disorders," "functional connectivity," and "melodic intonation therapy," with "stroke" and "aphasia" emerging as central keywords.

CONCLUSION

Research in post-stroke speech rehabilitation is increasing, with significant contributions from the United States and key institutions. Trends highlight the importance of communication-focused therapies and innovative techniques like melodic intonation therapy. This study provides insights into research directions.

Neuroticism and cerebral small vessel disease: A genetic correlation and Mendelian randomization analysis

OBJECTIVES

The association of neuroticism and cerebral small vessel disease (CSVD) development remains unclear. In this study, we used Mendelian randomization (MR) to explore the potential role of neuroticism in CSVD development.

METHODS

We collected data on ischemic stroke (IS); small vessel stroke (SVS); three neuroimaging markers altered in CSVD, including white matter hyperintensity (WMH), fractional anisotropy (FA), and mean diffusivity (MD); and three neuroticism clusters, including depressed affect, worry, sensitivity to environmental stress and adversity (SESA), from large-scale genome-wide association studies (GWAS). Bidirectional MR analyses were used to evaluate the association between neuroticism and CSVD, primarily estimated using the inverse variance weighted (IVW) method. The linkage disequilibrium score (LDSC) regression was employed to assess the association between various phenotypes.

RESULTS

LDSC analysis unveiled a noteworthy genetic correlation between depressed affect and IS (rg = 0.111, p = 0.001) as well as between worry and SVS (rg = -0.111, p = 0.032). Our study revealed a causal correlation between SESA and FA using both forward and reverse MR analyses (SESA on FA, odds ratio (OR) = 0.186 (0.071 to 0.483), p = 5.50 × 10-4; FA on SESA, OR = 0.996 (0.9916 to 0.9997), p = 0.035). Meanwhile, FA also exerted a statistical causal influence on depressed affect cluster (OR = 0.992 (0.987 to 0.997), p = 0.001).

INTERPRETATION

This research suggests a potential correlation between certain aspects of neuroticism and CSVD, with further studies needed to better understand the causal relationship and its implications for patient intervention.

Early Experience With the Nexus Aortic Arch Endograft for Endovascular Treatment of Complex Aortic Arch Pathologies Beyond Standard Indications

BACKGROUND

The Nexus stent graft offers a minimally-invasive option for treating aortic arch aneurysms (AArA). Despite strict instructions for use (IFU), it is sometimes applied in complex anatomies for patients who are surgically inoperable or unsuitable for other devices. This study evaluates outcomes in patients treated outside the IFU, providing real-world insights.

METHODS

We analyzed patients treated with the Nexus endograft outside its IFU between January 2022 and August 2024. The primary endpoint was the occurrence of major adverse cardiovascular and cerebral events (MACCE) such as death, stroke, or myocardial infarction. Secondary endpoints included the reasons for outside-IFU implantation, technical success, any aortic-related adverse events and postoperative endoleaks.

RESULTS

Thirteen patients underwent endovascular treatment for AArA outside IFU. Five (38.5%) had a post-type A dissection, 5 had de novo AArA (38.5%), and 3 (23%) lacked a landing zone in zones 1 to 3 of the aortic arch for thoracoabdominal aortic repair. Seven patients (54%) received the Nexus One device, while 6 (46%) received the Nexus Duo endograft. No perioperative MACCE occurred. Mean follow-up was 17 ± 12 months, with a 79% survival rate at 1 year. Primary reasons for outside IFU use included an inner ascending length <30 mm and a descending aortic diameter >40 mm in 46% of patients accordingly. Technical success was achieved in all cases. A type Ic endoleak (7%) due to aneurysmatic degeneration of the brachiocephalic artery was identified at 2 years. No further aortic-related adverse events were reported.

CONCLUSIONS

The Nexus endograft demonstrated a favorable safety profile and promising clinical outcomes at 1 year, even in patients treated outside IFU criteria, with high technical success and no evidence of stroke. Reassessment of certain IFU criteria could enhance the device's applicability.

CLINICAL IMPACT

Our findings highlight the potential for expanding the clinical use of the Nexus stent-graft beyond its current IFU, offering a safe and effective alternative for complex aortic arch anatomies. With high technical success and no perioperative cerebrovascular events, these results suggest that carefully selected patients who are otherwise ineligible for surgery may still benefit from endovascular repair. This study provides real-world evidence supporting the reconsideration of IFU criteria, potentially broadening treatment options. The innovation lies in demonstrating that even outside IFU conditions, the Nexus endograft maintains a strong safety profile, paving the way for more inclusive patient selection.

Salt Substitution and Recurrent Stroke and Death: A Randomized Clinical Trial

Importance

The direct effect of consumption of salt substitutes on recurrent stroke and mortality among patients with stroke remains unclear.

Objective

To evaluate the effects of salt substitutes vs regular salt on the incidence of recurrent stroke and mortality among patients with stroke.

Design, Setting, and Participants

The Salt Substitute and Stroke Study (SSaSS), an open-label, cluster randomized clinical trial, was conducted in 600 northern Chinese villages (clusters). Patients who self-reported a hospital diagnosis of stroke were included in this prespecified subgroup analysis. Data were analyzed from November 2023 to August 2024.

Interventions

Participants were assigned to use either a salt substitute, consisting of 75% sodium chloride and 25% potassium chloride by mass, or regular salt.

Main Outcomes and Measures

The primary outcome was recurrent stroke.

Results

After excluding 5746 persons without a baseline history of stroke, 15 249 patients with stroke (mean [SD] age, 64.1 [8.8] years; 6999 [45.9%] female; 8250 male [54.1%]) were included. Over a median (IQR) follow-up of 61.2 (60.9-61.6) months, the mean difference in systolic blood pressure was -2.05 mm Hg (95% CI, -3.03 to -1.08 mm Hg). A total of 2735 recurrent stroke events (691 fatal and 2044 nonfatal) and 3242 deaths were recorded. Recurrent stroke was significantly lower in the salt substitute vs regular salt group (rate ratio [RR], 0.86; 95% CI, 0.77-0.95; P = .005), with larger effects on hemorrhagic stroke (relative reduction, 30%; P = .002). Death rates were also significantly lower (RR, 0.88; 95% CI, 0.82-0.96; P = .003), with larger effects on stroke-related deaths (relative reduction 21%; P = .01). No significant difference was observed for hyperkalemia (RR, 1.01; 95% CI, 0.74-1.38; P = .96).

Conclusions and Relevance

Results of this cluster trial demonstrate that salt substitution was safe, along with reduced risks of stroke recurrence and death, which underscores large health gains from scaling up this low-cost intervention among patients with stroke.

Trial Registration

ClinicalTrials.gov Identifier: NCT02092090.

Early Neurologic Deterioration and Efficacy of Dual Antiplatelet in Anterior Versus Posterior Circulation Stroke

BACKGROUND

Anterior circulation stroke (ACS) differs from posterior circulation stroke (PCS) in several aspects. We hypothesize that the risk of early neurologic deterioration (END) and its responses to clopidogrel plus aspirin versus aspirin alone may be different between stroke territories.

METHODS AND RESULTS

This was a prespecified post hoc analysis of ATAMIS (Antiplatelet Therapy in Acute Mild to Moderate Ischemic Stroke) trial and included patients with definite infarct location who were classified into ACS and PCS according to stroke territory. Primary outcome was occurrence of END at 7 days, defined as ≥2-point increase in National Institutes of Health Stroke Scale score compared with baseline. We compared the treatment effects of clopidogrel plus aspirin versus aspirin alone in each stroke territory. From 3000 patients, 2431 eligible patients (1780 with ACS [910 assigned into clopidogrel plus aspirin and 870 assigned into aspirin alone] and 651 with PCS [371 assigned into clopidogrel plus aspirin and 280 assigned into aspirin alone]) were included. Median age was 66 years and 35.1% were women. The occurrence of END was higher in ACS than PCS (6.8% versus 3.8%, P=0.007). clopidogrel plus aspirin was associated with lower risk of END in ACS (risk difference [95% CI]: -2.4% [-4.1% to -0.8%], P=0.004), but not in PCS (risk difference [95% CI]: -0.6% [-2.7% to 1.5%], P=0.57). No significant interaction was found (P=0.69).

CONCLUSIONS

Our study demonstrated END was higher in acute mild-to-moderate ischemic stroke with anterior circulation, who derived more benefit from clopidogrel plus aspirin than aspirin alone.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02869009.

Emergency Department Workflow Times of Intravenous Thrombolysis with Tenecteplase versus Alteplase in Acute Ischemic Stroke: A Prospective Cohort Study before and during the COVID-19 Pandemic

INTRODUCTION

Tenecteplase (TNK) has demonstrated to be non-inferior to alteplase (ALT) for intravenous thrombolysis (IVT) in acute ischemic stroke (AIS). There are potential workflow benefits associated with TNK use, aiming to reduce patient length of stay in the emergency department. Our aim was to investigate whether the routine use of TNK during the COVID-19 pandemic influenced workflow times compared to historical use of ALT, while maintaining non-inferior clinical outcomes in a non-drip and ship scenario of a comprehensive stroke center.

METHODS

We included patients with AIS admitted from September 2019 to September 2022 and compared those treated with TNK during the COVID-19 pandemic to those treated with ALT in the period immediately before. We compared emergency department length of stay (EDLOS), door-to-needle time (DTN), door-to-groin puncture time (DTG), clinical and safety outcomes with adjusted general linear regression models.

RESULTS

110 patients treated with TNK and 111 with ALT were included in this study. Mean EDLOS was 251 (SD = 164) min for TNK users versus 240 (SD = 148) min for ALT (p = 0.62). Mean DTN was 43 (SD = 25) min for TNK versus 46 (SD = 27) min for ALT users (p = 0.39). Mean DTN under 60 min was achieved in 86 (78.2%) patients and in 85 (76.5%) patients of the TNK and ALT groups, respectively (p = 1.0). DTN under 45 min was achieved in 65.4% and 58.6% (p = 0.65) of the TNK and ALT groups, respectively. DTG time was 114 (SD = 43) min for TNK versus 111 (58 = SD) min in the ALT group (p = 0.88). DTG under 90 min was achieved in 32% of the TNK group and 35% of the ALT group (p = 0.69). There were no differences in any of the clinical or safety outcomes between groups at 90 days.

CONCLUSIONS

The adoption of TNK during COVID-19 pandemic did not result in a change in EDLOS, DTN, or DTG times when compared to ALT in this cohort. Safety and clinical outcomes were similar between groups. Probably a greater benefit could have been seen in a drip and ship thrombolysis setting. Further research is needed to assess the potential advantages of TNK in drip and ship scenarios of IVT.

INTRODUCTION

Tenecteplase (TNK) has demonstrated to be non-inferior to alteplase (ALT) for intravenous thrombolysis (IVT) in acute ischemic stroke (AIS). There are potential workflow benefits associated with TNK use, aiming to reduce patient length of stay in the emergency department. Our aim was to investigate whether the routine use of TNK during the COVID-19 pandemic influenced workflow times compared to historical use of ALT, while maintaining non-inferior clinical outcomes in a non-drip and ship scenario of a comprehensive stroke center.

METHODS

We included patients with AIS admitted from September 2019 to September 2022 and compared those treated with TNK during the COVID-19 pandemic to those treated with ALT in the period immediately before. We compared emergency department length of stay (EDLOS), door-to-needle time (DTN), door-to-groin puncture time (DTG), clinical and safety outcomes with adjusted general linear regression models.

RESULTS

110 patients treated with TNK and 111 with ALT were included in this study. Mean EDLOS was 251 (SD = 164) min for TNK users versus 240 (SD = 148) min for ALT (p = 0.62). Mean DTN was 43 (SD = 25) min for TNK versus 46 (SD = 27) min for ALT users (p = 0.39). Mean DTN under 60 min was achieved in 86 (78.2%) patients and in 85 (76.5%) patients of the TNK and ALT groups, respectively (p = 1.0). DTN under 45 min was achieved in 65.4% and 58.6% (p = 0.65) of the TNK and ALT groups, respectively. DTG time was 114 (SD = 43) min for TNK versus 111 (58 = SD) min in the ALT group (p = 0.88). DTG under 90 min was achieved in 32% of the TNK group and 35% of the ALT group (p = 0.69). There were no differences in any of the clinical or safety outcomes between groups at 90 days.

CONCLUSIONS

The adoption of TNK during COVID-19 pandemic did not result in a change in EDLOS, DTN, or DTG times when compared to ALT in this cohort. Safety and clinical outcomes were similar between groups. Probably a greater benefit could have been seen in a drip and ship thrombolysis setting. Further research is needed to assess the potential advantages of TNK in drip and ship scenarios of IVT.

Severity of Chronic Kidney Disease as Assessed by the Kidney Failure Risk Equation Is Associated With Incident Acute Ischemic Stroke

AIM

Stroke is a leading cause of death and disability, with substantial healthcare implications. Chronic kidney disease (CKD) is similarly impactful, and emerging evidence links CKD to a higher stroke risk. Despite this, stroke risk assessment in CKD patients remains limited. This study explores the kidney failure risk equation (KFRE) as a predictive tool for ischaemic stroke in CKD patients.

METHODS

This retrospective cohort study analysed CKD patients from a healthcare registry, excluding those with prior stroke, end-stage kidney disease, or kidney transplants. Acute ischemic stroke was the primary outcome, with deaths censored. Cox proportional hazards models evaluated associations between the 2-year and 5-year 4-variable KFRE scores and stroke risk.

RESULTS

A total of 14,794 consecutive patients were included, with a median follow-up of 509 days. The median age of the cohort was 73 years (IQR:14 years), with 6251 females(42.3%), and the majority being of Chinese ethnicity (n = 10 759,73.5%). During the follow-up period, 155 patients (1.05%) experienced an ischemic stroke event, with a median time to stroke of 265 days (IQR:242 days). The 2-year (HR: 1.38 per 10% increase, 95% CI: [1.17-1.63], p < 0.001) and 5-year (HR:1.20 per 10% increase, 95% CI: [1.10-1.31], p < 0.001) 4-variable KFRE scores were significantly associated with an increased risk of ischemic stroke. These associations remained significant after adjusting for patient demographics, comorbidities, advanced CKD stage, glycated haemoglobin and lipid parameters.

CONCLUSION

CKD patients at elevated risk of kidney failure also face a significantly increased risk of acute ischaemic stroke. The KFRE could potentially be integrated into CKD management to assess this risk. Future large prospective cohort studies are necessary to validate these findings.

Editor's Choice - Role of Antiplatelet Therapy in Patients Managed for Complex Aortic Aneurysms using Fenestrated or Branched Endovascular Repair

OBJECTIVE

Despite the increasing number of fenestrated and branched endovascular aortic repair (F/B-EVAR) procedures, evidence on post-operative antiplatelet therapy is very limited. This study aimed to investigate the role of single antiplatelet therapy (SAPT) vs. double antiplatelet therapy (DAPT) after F/B-EVAR in 30 day and follow up outcomes.

METHODS

A multicentre retrospective analysis was conducted, including F/B-EVAR patients managed from 1 January 2018 to 31 December 2022. Comparative outcomes were assessed according to post-operative antiplatelet therapy. The cohort was divided into the SAPT group (acetylsalicylic acid [ASA] or clopidogrel) and DAPT group (ASA and clopidogrel). The duration of SAPT or DAPT was one to six months. Primary outcomes were 30 day death, and cardiovascular ischaemic and major haemorrhagic events. Secondary outcomes were survival and target vessel (TV) patency during follow up.

RESULTS

A total of 1 430 patients were included: 955 under SAPT and 475 under DAPT. The 30 day mortality rate was similar (SAPT 2.1% vs. DAPT 1.5%; p = .42). Cardiovascular ischaemic events were lower in the DAPT group (SAPT 11.9% vs. DAPT 8.2%; p = .040), with DAPT being an independent protector for acute mesenteric (p = .009) and lower limb ischaemia (p = .020). No difference was found in 30 day major haemorrhagic events (SAPT 7.5% vs. DAPT 6.3%; p = .40). The mean follow up was 21.8 ± 2.9 months. Cox regression showed no survival confounders, with similar rates between groups (log rank p = .71). DAPT patients enjoyed higher TV patency (SAPT 93.4%, standard error [SE] 0.7% vs. DAPT 97.0%, SE 0.6%; log rank p = .007) at thirty six months. Cox regression revealed B-EVAR as a predictor of worse TV patency (hazard ratio 2.03, 95% confidence interval 1.36 - 3.03; p < .001). DAPT was related to higher patency within B-EVAR patients (SAPT 87.2%, SE 2.1% vs. DAPT 94.9%, SE 1.9%; p < .001).

CONCLUSION

DAPT after F/B-EVAR was associated with lower risk of cardiovascular ischaemic events and higher TV patency, especially in B-EVAR cases. No difference in major haemorrhagic events was observed at 30 days.

Effect of artificial intelligence-based video-game system on dysphagia in patients with stroke: A randomized controlled trial

BACKGROUND AND AIMS

Post-stroke dysphagia is highly prevalent and causes complication. While video games have demonstrated potential to increase patient engagement in rehabilitation, their efficacy in stroke patients with dysphagia remains unclear. This aim of this study was to explore the effectiveness of the artificial intelligence-based video-game (AI-VG) intervention in improving swallowing function among stroke patients with dysphagia.

METHODS

A prospective, single blinded, randomized controlled trial (RCT) was conducted in a rehabilitation hospital from October 2023 to July 2024. Participants were randomly assigned to either the AI-VG system group or the usual care group. All participants received training for 30 min per session per day, five times per week for 4 weeks. The primary outcome was change in swallowing function from baseline (T0) to post-intervention (T1) and 1 month follow-up (T2). Secondary outcomes included changes in laryngeal function, oral intake function, nutritional status, and swallowing-related quality of life. The adherence, satisfaction, and acceptance of the two groups were evaluated. Changes in outcomes over time were compared using generalized estimating equation modeling.

RESULTS

A total of 84 participants (AI-VG group = 42, age = 65.00 ± 9.70 years, 57.10 % male; usual care group = 42, age = 66.40 ± 13.10 years, 69.00 % male) were included in this study. Compared with the usual care group, the AI-VG group showed significantly improved swallowing function, with a mean group difference of 4.02 (95 % CI = from -6.16 to -1.89, P < 0.001) at T1 and 4.14 (95 % CI = from -6.16 to 2.12, P < 0.001) at T2. Oral intake function, nutritional status, and swallowing-related quality of life improved significantly (P < 0.001 for overall group × time interaction). Adherence was significantly higher in the intervention group than in the control group (median [IQR], 18.00 [17.00-20.00] vs. 16.00 [15.00-17.00], P < 0.001). The intervention group had higher levels of acceptance and satisfaction of AI-VG (103.00 [100.50-104.00] and 73.00 [72.00-74.00], respectively). No significant difference was observed in laryngeal function (P > 0.05).

CONCLUSIONS

The AI-VG intervention is an effective method for enhancing swallowing function in patients with post-stroke dysphagia. Future validation through multicenter, large-sample RCTs are warranted to confirm the findings and explore broader clinical applications.

CLINICAL TRIAL REGISTRATION

ClinicalTrials. Gov Identifier: NCT05978700, https://clinicaltrials.gov/study/NCT05978700.

The complementary dominance hypothesis: a model for remediating the 'good' hand in stroke survivors

The complementary dominance hypothesis is a novel model of motor lateralization substantiated by decades of research examining interlimb differences in the control of upper extremity movements in neurotypical adults and hemisphere-specific motor deficits in stroke survivors. In contrast to earlier ideas that attribute handedness to the specialization of one hemisphere, our model proposes complementary motor control specializations in each hemisphere. The dominant hemisphere mediates optimal control of limb dynamics as required for smooth and efficient movements, whereas the non-dominant hemisphere mediates impedance control, important for countering unexpected mechanical conditions and achieving steady-state limb positions. Importantly, this model proposes that each hemisphere contributes its specialization to both arms (though with greater influence from either arm's contralateral hemisphere) and thus predicts that lesions to one hemisphere should produce hemisphere-specific motor deficits in not only the contralesional arm, but also the ipsilesional arm of stroke survivors - a powerful prediction now supported by a growing body of evidence. Such ipsilesional arm motor deficits vary with contralesional arm impairment, and thus individuals with little to no functional use of the contralesional arm experience both the greatest impairments in the ipsilesional arm, as well as the greatest reliance on it to serve as the main or sole manipulator for activities of daily living. Accordingly, we have proposed and tested a novel intervention that reduces hemisphere-specific ipsilesional arm deficits and thereby improves functional independence in stroke survivors with severe contralesional impairment.

Argatroban plus alteplase in posterior versus anterior circulation stroke

OBJECTIVE

ARAIS trial failed to demonstrate benefit of argatroban as an adjunct to alteplase for stroke. Given differences between anterior circulation stroke (ACS) and posterior circulation stroke (PCS), we performed prespecified secondary analysis to investigate whether benefit of argatroban was different between ACS and PCS.

METHODS

In secondary analysis of ARAIS, patients with definite stroke territories based on responsible vessel examination were classified into ACS and PCS. The primary outcome was a 90-day excellent functional outcome (modified Rankin Scale score of 0 to 1). The efficacy was compared between argatroban plus alteplase and alteplase alone.

RESULTS

This study included 356 patients from the full analysis set of ARAIS trial: 283 in the ACS group and 73 in the PCS group. Compared with alteplase alone, a higher likelihood of 90-day excellent functional outcome was associated with argatroban plus alteplase in PCS group (78.1% versus 61.0%; adjusted RD, 14.4%; 95% CI, 1.6% to 27.2%; p = 0.03), but similar in ACS group (61.7% versus 62.7%; adjusted RD, -2.4%; 95% CI, -10.1% to 5.2%; p = 0.54). After controlling unbalanced sample size bias by propensity score matching, significant interaction between efficacy and stroke territories was found (p = 0.01). The risk of symptomatic intracranial hemorrhage was higher following argatroban plus alteplase than alteplase alone in ACS group (p = 0.02).

INTERPRETATION

Argatroban plus alteplase, compared with alteplase alone, was associated with improved functional outcomes in PCS. This study first demonstrated better benefits of argatroban plus alteplase in PCS, which deserves to be confirmed.

The neurorehabilitation of post-stroke dysphagia: Physiology and pathophysiology

Swallowing is a complex process involving the precise contractions of numerous muscles of the head and neck, which act to process and shepherd ingested material from the oral cavity to its eventual destination, the stomach. Over the past five decades, information from animal and human studies has laid bare the complex network of neurones in the brainstem, cortex and cerebellum that are responsible for orchestrating each normal swallow. Amidst this complexity, problems can and often do occur that result in dysphagia, defined as impaired or disordered swallowing. Dysphagia is common, arising from multiple varied disease processes that can affect any of the neuromuscular structures involved in swallowing. Post-stroke dysphagia (PSD) remains the most prevalent and most commonly studied form of dysphagia and, as such, provides an important disease model to assess dysphagia physiology and pathophysiology. In this review, we explore the complex neuroanatomical processes that occur during normal swallowing and PSD. This includes how strokes cause dysphagia, the mechanisms through which natural neuroplastic recovery occurs, current treatments for patients with persistent dysphagia and emerging neuromodulatory treatments.

Effectiveness and safety of the Trevo® Retriever for mechanical thrombectomy in Chinese patients with acute ischemic stroke: Trevo Retriever China Registry

BACKGROUND

To quantify the effectiveness and safety of the Trevo® Retriever for endovascular treatment of acute ischemic stroke (AIS) patients in China.

METHODS

Trevo Retriever Registry (China) was a prospective, multicenter, non-comparative, open-label study of patients with AIS treated with the Trevo Retriever. The primary outcome was the proportion of patients achieving an expanded Thrombolysis in Cerebral Infarction (eTICI) score ≥2b at the end of endovascular treatment. Secondary outcomes included first-pass eTICI score ≥2b and 90-day modified Rankin Scale (mRS) score ≤2.

RESULTS

The Trevo Retriever Registry (China) enrolled and followed 201 patients (62.1 ± 12.5 years-old; 70.6% male) at 11 centers. The pre-procedure NIHSS score and ASPECTS were 16 (interquartile range (IQR), 13-21) and 7 (IQR, 6-9), respectively, and 188 (93.5%) patients had an mRS score of 0 prior to the stroke. The main stroke etiology was large artery atherosclerosis, accounting for 71.6% (144/201) of patients. Post-procedure eTICI ≥2b was 98.4% (187/190). First-pass eTICI ≥2b was 74.7% (136/182). The 90-day good outcome (mRS ≤2) rate was 73.6% (148/201). The 90-day all-cause mortality was 5.5% (11/201). Neurological deterioration at 24 h post-procedure was observed in 7.7% (15/195) patients. Embolism in a new territory was seen in one patient (0.5%). Two (1.0%) procedure-related adverse events (AEs) occurred, which were intra-procedure cerebral artery embolism. No Trevo related AEs occurred.

CONCLUSIONS

This real-world study of the Trevo Retriever in China demonstrated a high rate of revascularization and first-pass success that resulted in an overall high good function outcome rate and low mortality.

Upper normal serum magnesium is associated with a reduction in incident death from fatal heart failure, coronary heart disease and stroke in non-dialysis patients with CKD stages 4 and 5

Background

Serum magnesium disturbances are common in patients with cardiovascular disease (CVD). However, the well-established link between low serum magnesium and nutritional or inflammatory disorders has limited its consideration as a non-traditional risk factor for mortality. This study aims to elucidate the relationship between serum magnesium concentrations and mortality due to fatal heart failure (HF), coronary heart disease (CHD) and stroke in non-dialysis patients with chronic kidney disease (CKD) stages 4 and 5.

Methods

A cohort of 1271 non-dialysis patients with CKD stages 4 and 5 was followed from 2008 to 2018. Patients with prior major adverse cardiovascular events (MACE) were excluded. Serum magnesium levels were stratified into tertiles and the primary outcomes were incidence rates of fatal HF, CHD and stroke. Secondary outcomes included composite MACE and all-cause mortality. Hazard ratios (HRs) were calculated using multivariate Cox regression, adjusting for demographics, comorbidities and biochemical parameters. E-values were used to assess the robustness of the results.

Results

Over the 10-year follow-up, 186 patients died. Higher serum magnesium levels were significantly associated with reduced mortality risk from HF [HR 0.49 (95% CI 0.27-0.89) for T2; HR 0.31 (95% CI 0.16-0.60) for T3] compared with the lowest tertile. Similar trends were observed for CHD and stroke mortality. The incidence rate of MACE per 1000 person-years was reduced from 68.2 in tertile 1 to 26.2 in tertile 2 and 16.8 in tertile 3. Secondary endpoints, including all-cause mortality and composite MACE, followed trends similar to the primary outcomes.

Conclusions

Higher serum magnesium concentrations were associated with lower risks of death from fatal HF, CHD and stroke in non-dialysis patients with CKD stages 4 and 5.

Association of the panimmune-inflammatory value (PIV) with all-cause and cardiovascular mortality in maintenance hemodialysis patients: a propensity score matching retrospective study

PURPOSE

The panimmune-inflammatory value (PIV) is a novel inflammatory indicator. However, its role in maintenance hemodialysis (MHD) remains unclear. Our goal was to explore the predictive value of PIV for cardiovascular and all-cause mortality in MHD patients.

METHODS

In this retrospective cohort study, 507 patients receiving MHD between November 2017 and December 2022 were enrolled. The PIV value was calculated as follows: neutrophil count × monocyte count × platelet count/lymphocyte count. Patients were divided into two groups on the basis of the median PIV. Propensity score matching (PSM) was used to adjust for imbalances in baseline information between groups. Kaplan‒Meier curves, Cox regression, the Fine‒Gray competing risk model, and restricted cubic spline (RCS) curves were used to analyze the relationship between PIV and mortality.

RESULTS

By the end of follow-up, 126 deaths had occurred, 91 of which were due to cardiovascular disease. The Kaplan‒Meier curves demonstrated that MHD patients with higher PIV levels had a poorer prognosis for all-cause death (p = 0.019). PIV levels were linked to all-cause death in multivariate Cox proportional risk regression (HR = 1.76; 95% CI 1.14, 2.72; p = 0.011). The Fine‒Gray model revealed a greater cumulative incidence of cardiovascular death in the higher PIV group (p = 0.035). PIV levels were linked to cardiovascular mortality in the Fine‒Gray competing risk model (HR = 2.06; 95% CI 1.25, 3.42; p = 0.005). The RCS revealed a nonlinear relationship between PIV and mortality risk (p < 0.05). Using 63 years of age as the threshold, we observed a multiplicative interaction effect between age and PIV for all-cause mortality (p = 0.006).

CONCLUSION

In MHD patients, PIV is an independent hazard factor for cardiovascular-related mortality and all-cause mortality.

Noninvasive imaging biomarker reveals invisible microscopic variation in acute ischaemic stroke (≤ 24 h): a multicentre retrospective study

To develop and validate non-contrast computed tomography (NCCT)-based radiomics method combines machine learning (ML) to investigate invisible microscopic acute ischaemic stroke (AIS) lesions. We retrospectively analyzed 1122 patients from August 2015 to July 2022, whose were later confirmed AIS by diffusion-weighted imaging (DWI). However, receiving a negative result was reported by radiologists according to the NCCT images. Patients in five institutions (n = 592) were combined to generate training and internal validation sets, remaining in three institutions as external validation sets (n = 204, 53 and 273). Through a series of procedures: head alignment, co-registration of NCCT and DWI, the volume of interest delineation and feature extraction. Multiple ML models (random forest, RF; support vector machine, SVM; logistic regression, LR; multilayer perceptron, MLP) were used to discriminate microscopic AIS and non-AIS. Among 1122 patients included (760 men [67.7%]; median [range] age, 64 [21-96] years). After least absolute shrinkage and selection operator (LASSO) algorithm, 44 optimal features were remained. The radiomics combined ML models were yielded similar mean areas under the receiver operating characteristic curve of 0.808 (95% CI 0.754 to 0.861) for RF, 0.802 (95% CI 0.748 to 0.856) for radial basis kernel function-based SVM, 0.792 (95% CI 0.737 to 0.847) for MLP, 0.792 (95% CI 0.736 to 0.848) for Linear-SVM and 0.787 (95% CI 0.730 to 0.844) for LR, respectively. Combining radiomics with ML models can be an efficient, noninvasive, economical, and reliable technique for evaluating invisible microscopic AIS on NCCT and assisting radiologists to make clinical decisions.

Effects of calcium channel blockers on perioperative ischemic events in hypertensive patients with intracranial aneurysms undergoing neurointervention

BACKGROUND

Although calcium channel blockers (CCBs) are useful in stroke prevention, their specific role in preventing stroke in hypertensive patients with intracranial aneurysms undergoing endovascular stent placement remains unclear.

METHODS

We retrospectively examined 458 hypertensive patients with intracranial aneurysms who underwent stent treatment, drawn from a larger multicenter cohort comprising 1326 patients across eight centers. Patients were dichotomized into two groups according to use of a CCB. Propensity score matching (PSM) was performed to balance group differences in patient and aneurysm characteristics. We conducted a comparison of patient and aneurysm characteristics, ischemic complications, and clinical outcomes between the two groups.

RESULTS

The CCB and non-CCB groups comprised 279 and 179 patients, respectively. PSM resulted in 165 matched pairs. After PSM, the incidence of ischemic events within 1 month of the procedure (4.2% vs 10.9%; P=0.022) and proportion of patients with modified Rankin Scale score >2 at last follow-up (1.5% vs 7.8%; P=0.013) were significantly lower in the CCB group. Among patients treated with combination therapy, inclusion of a CCB was associated with a lower incidence of ischemic events (1.5% vs 13.3%; P=0.345), but the difference was not statistically significant after correction.

CONCLUSIONS

CCB use in hypertensive patients undergoing endovascular stenting for treatment of intracranial aneurysms is associated with a lower incidence of ischemic events and a lower incidence of unfavorable neurological outcomes, especially when used in combination therapy.

EEG Responses to Upper Limb Pinprick Stimulation in Acute and Early Subacute Motor and Sensorimotor Stroke: A Proof of Concept

Electroencephalogram (EEG) during pinprick stimulation has the potential to unveil neural mechanisms underlying sensorimotor impairments post-stroke. A proof-of-concept study explored event-related peak pinprick amplitude and oscillatory responses in healthy controls and in people with acute and subuacute motor and sensorimotor stroke, their relationship, and to what extent EEG somatosensory responses can predict sensorimotor impairment. In this study, 26 individuals participated, 10 people with an acute and early subacute sensorimotor stroke, 6 people with an acute and early subacute motor stroke, and 10 age-matched controls. Pinpricks were applied to the dorsa of the impaired hand to collect somatosensory evoked potentials. Time(-frequency) analyses of somatosensory evoked potential (SEP) data at electrodes C3 and C4 explored peak pinprick amplitude and oscillatory responses across the three groups. Also, in stroke, (sensori-)motor impairments were assessed with the Fugl Meyer Assessment Upper Extremity (FMA) and Erasmus modified Nottingham Sensory Assessment (EmNSA) at baseline and 7 to 14 days later. Mixed model analyses were used to address objectives. It was demonstrated that increased beta desynchronization magnitude correlated with milder motor impairments (R2adjusted = 0.213), whereas increased beta resynchronization and delta power were associated to milder somatosensory impairment (R2adjusted = 0.550). At the second session, larger peak-to-peak SEP amplitude and beta band resynchronization at baseline were related to greater improvements in EMNSA and FMA scores, respectively, in the sensorimotor stroke group. These findings highlight the potential of EEG combined with somatosensory stimuli to differentiate between sensorimotor and motor impairments in stroke, offering preliminary insights into both diagnostic and prognostic aspects of upper limb recovery.

Prehospital scale to differentiate intracerebral hemorrhage from large-vessel occlusion patients: a prospective cohort study

Evaluating scales to detect large vessel occlusion (LVO) could aid in considering early referrals to a thrombectomy-capable center in the prehospital stroke code setting. Nevertheless, they entail a significant number of false positives, corresponding to intracranial hemorrhages (ICH). Our study aims to identify easily collectible variables for the development of a scale to differentiate patients with ICH from LVO. We conducted a prospective cohort study of stroke code patients between May 2021 and January 2023. Patients were evaluated with CT/CT-Angiography at arrival. We compared clinical variables and vascular risk factors between ICH and LVO patients. Out of 989 stroke code patients, we included 190 (66.7%) LVO cases and 95 (33.3) ICH cases. In the multivariate analysis, headache (odds ratio [OR] 3.56; 1.50-8.43), GCS < 8 (OR 8.19; 3.17-21.13), SBP > 160mmHg (OR 6.43; 3.37-12.26) and male sex (OR 2.07; 1.13-3.80) were associated with ICH, while previous hypercholesterolemia (OR 0.35; 0.19-0.65) with LVO. The scale design was conducted, assigning a score to each significant variable based on its specific weight: +2 points for SBP > 160, + 1 points for headache, + 1 points for male sex, + 2 points for GCS < 8, and - 1 points for HCL. The area under the curve was 0.82 (0.77-0.87). A score ≥ 4 exhibited a sensitivity of 0.10, a specificity of 0.99, a positive predictive value of 0.21, and a negative predictive value of 0.98. We present the development of a prehospital scale to discriminate between ICH and LVO patients, utilizing easily detectable variables in the prehospital setting.

Risk of Atherosclerotic Cardiovascular Disease After Chronic Obstructive Pulmonary Disease Hospitalization among Primary and Secondary Prevention Older Adults

BACKGROUND

Meta-analyses have suggested that the risk of cardiovascular disease events is significantly higher after a chronic obstructive pulmonary disease (COPD) exacerbation, but the populations at highest risk have not been well characterized to date.

METHODS AND RESULTS

The authors analyzed the risk of atherosclerotic cardiovascular disease (ASCVD) hospitalizations after COPD hospitalization compared with before COPD hospitalization and patient factors associated with ASCVD hospitalizations after COPD hospitalization among 2 high-risk patient cohorts. The primary outcome was risk of an ASCVD hospitalization composite outcome (myocardial infarction, coronary artery bypass graft, percutaneous coronary intervention, stroke, transient ischemic accident) after COPD hospitalization relative to before COPD hospitalization. Additional analyses evaluated for risk factors associated with the composite ASCVD hospitalization outcome. In the high-risk primary prevention cohort, the hazard ratio (HR) estimate following adjustment for the composite ASCVD hospitalization outcome after COPD hospitalization versus before COPD hospitalization for 30 days was 0.74 (95% CI, 0.66-0.82; P≤0.0001); for 90 days, 0.69 (95% CI, 0.64-0.75; P≤0.0001); and for 1 year, 0.78 (95% CI, 0.73-0.82; P≤0.0001). In the secondary prevention cohort, the HR for 30-day hospitalization was 1.15 (95% CI, 1.05-1.26; P=0.0036); 90-day hospitalization, 1.08 (95% CI, 1.01-1.15; P=0.0178); and 1-year hospitalization, 1.07 (95% CI, 1.02-1.11; P=0.0026). Among the 19 characteristics evaluated, hyperlipidemia and history of acute ASCVD event were associated with the highest risk of ASCVD events 1 year after COPD hospitalization in the high-risk primary and secondary prevention cohorts.

CONCLUSIONS

The risk of ASCVD hospitalization was higher in patients with established ASCVD and lower among high-risk patients without established ASCVD after-COPD hospitalization relative to before hospitalization. We identified multiple risk factors for ASCVD hospitalization after COPD hospitalization.

Altered fibrin clot properties and elevated von Willebrand factor are associated with progression to permanent atrial fibrillation: A cohort study

BACKGROUND

The role of a prothrombotic state in atrial fibrillation (AF) progression to permanent arrythmia (PerAF) is unclear. Formation of denser and poorly lysable fibrin clots has been observed in AF patients also with sinus rhythm in association with higher stroke risk. We investigated whether altered fibrin clot properties and other prothrombotic state markers may contribute to AF transition to PerAF.

METHODS

In the cohort study, in 226 anticoagulated patients (median age 69 years, median CHA2DS2-VASc of 3) with paroxysmal (n = 83, 36.7%) or persistent (n = 143, 63.3%) AF, we assessed at baseline plasma clot permeability (Ks), clot lysis time (CLT), proteins involved in fibrinolysis and von Willebrand factor (vWF) antigen. We recorded patients with PerAF during a median follow-up of 58 months.

RESULTS

During follow-up, PerAF was documented in 62 (27.4%, 5.7%/year) subjects, who had higher prevalence of heart failure, higher body mass index and longer history of arrhythmia. AF transition to PerAF was associated with 25.7% longer CLT in relation to 21.3% higher plasminogen activator inhibitor type 1, and 29% higher vWF compared to the remainder, with no differences in Ks, plasminogen or α2-antiplasmin. By multivariable analysis, CLT (per 10 min, odds ratio [OR] 2.734, 95% confidence interval [CI] 1.788-4.180, p < .001), vWF (per 10%, OR 1.352, 95% CI 1.145-1.596, p < .001) and heart failure (OR 2.637, 95% CI 1.008-6.900, p = .048) were associated with progression to PerAF.

CONCLUSION

Suppressed fibrin clot susceptibility to lysis and elevated vWF could contribute to progression to PerAF despite anticoagulation, which suggests links between blood coagulation and AF progression.

THE DIAGNOSIS AND TREATMENT OF ASYMPTOMATIC AND SYMPTOMATIC PATIENTS WITH CAROTID ARTERY STENOSIS

Carotid artery atherosclerotic stenosis is an important annual cause of stroke in the United States. Moreover, the incidence of carotid artery stenosis is significantly increasing due to the widespread popularity of high fat and high salt diets, sedentary lifestyles, and the increasing age of the population. Of major importance to cardiovascular specialists is the fact that individuals with atherosclerotic carotid artery stenosis can have a prevalence of atherosclerotic coronary artery disease as high as 50 to 75%. Vascular screening for carotid artery stenosis with Doppler ultrasound should be considered for all symptomatic patients with possible carotid stenosis and also considered for asymptomatic patients with (1) symptomatic peripheral arterial disease, coronary artery disease, or atherosclerotic aortic aneurysm or, (2) multiple atherosclerotic risk factors. Carotid artery atherosclerotic plaques that are at high risk for rupture and thrombosis or cerebral embolization are characterized by large lipid cores, intraplaque hemorrhage, thin fibrous caps less than 165 μms that are infiltrated by macrophages and T cells or have surface ulcer(s) or fissures. Carotid artery plaque rupture with cerebral embolism can cause a stroke, TIA, or ipsilateral blindness (amaurosis fugax). Medical treatment based on the recommendations of the American and European Societies for Vascular Surgery for symptomatic patients with carotid stenosis and also asymptomatic patients with high risk carotid stenosis plaques include antiplatelet drugs, antihypertensive drugs for hypertension control and lipid lowering drugs. Management strategies and decisions about carotid revascularization in asymptomatic patients with high risk carotid stenosis should involve a multidisciplinary team and shared decision-making is recommended. The 30 day and five to 10 year outcomes in asymptomatic carotid stenosis patients who have undergone carotid endarterectomy, carotid stenting and/or optimal medical therapy are summarized from the Veterans Administration Cooperative Study, the Asymptomatic Carotid Atherosclerosis Study and the Asymptomatic Carotid Surgery Trials. The current Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) should help to resolve the debate regarding carotid artery revascularization versus primary medical treatment in asymptomatic patients with >70% carotid artery stenosis. Symptomatic patients who present within 4.5 hours of stroke onset require evaluation for acute pharmacologic intravenous thrombolysis and patients who present with large vessel occlusion within 24 hours of symptom onset should be considered for mechanical thrombectomy to reduce the neurologic deficit. Patients with carotid artery stenosis who present with a history of cerebral infarct in the preceding six months due to cerebral embolism require medical treatment and evaluation by a multidisciplinary team for carotid revascularization in order to prevent future strokes or transient ischemic attacks. The outcomes of the North American Symptomatic Carotid Endarterectomy Trial, Carotid Revascularization Endarterectomy Versus Stent Trial, Stent-Supported Percutaneous Angioplasty of the Carotid Artery vs. Endarterectomy Trial, and the Safety and Efficacy Study for Reverse Flow Used during Carotid Artery Stenting Procedure trials for symptomatic patients with carotid stenosis are reviewed. A synopsis of treatment guidelines for symptomatic and asymptomatic carotid stenosis patients from the American and European Societies of Vascular Surgery and the American Heart Association/American Stroke Association are presented. Each patient with carotid artery stenosis must be carefully evaluated to determine the best treatment based on the clinical presentation, the imaging and laboratory diagnostic information, the treatment guidelines, and the patient needs, preferences as well as the patient's social and cultural factors.

Evaluation of Advanced Artificial Intelligence Algorithms' Diagnostic Efficacy in Acute Ischemic Stroke: A Comparative Analysis of ChatGPT-4o and Claude 3.5 Sonnet Models

Background/Objectives: Acute ischemic stroke (AIS) is a leading cause of mortality and disability worldwide, with early and accurate diagnosis being critical for timely intervention and improved patient outcomes. This retrospective study aimed to assess the diagnostic performance of two advanced artificial intelligence (AI) models, Chat Generative Pre-trained Transformer (ChatGPT-4o) and Claude 3.5 Sonnet, in identifying AIS from diffusion-weighted imaging (DWI). Methods: The DWI images of a total of 110 cases (AIS group: n = 55, healthy controls: n = 55) were provided to the AI models via standardized prompts. The models' responses were compared to radiologists' gold-standard evaluations, and performance metrics such as sensitivity, specificity, and diagnostic accuracy were calculated. Results: Both models exhibited a high sensitivity for AIS detection (ChatGPT-4o: 100%, Claude 3.5 Sonnet: 94.5%). However, ChatGPT-4o demonstrated a significantly lower specificity (3.6%) compared to Claude 3.5 Sonnet (74.5%). The agreement with radiologists was poor for ChatGPT-4o (κ = 0.036; %95 CI: -0.013, 0.085) but good for Claude 3.5 Sonnet (κ = 0.691; %95 CI: 0.558, 0.824). In terms of the AIS hemispheric localization accuracy, Claude 3.5 Sonnet (67.2%) outperformed ChatGPT-4o (32.7%). Similarly, for specific AIS localization, Claude 3.5 Sonnet (30.9%) showed greater accuracy than ChatGPT-4o (7.3%), with these differences being statistically significant (p < 0.05). Conclusions: This study highlights the superior diagnostic performance of Claude 3.5 Sonnet compared to ChatGPT-4o in identifying AIS from DWI. Despite its advantages, both models demonstrated notable limitations in accuracy, emphasizing the need for further development before achieving full clinical applicability. These findings underline the potential of AI tools in radiological diagnostics while acknowledging their current limitations.

Association between postoperative thromboembolic and hemorrhagic complications and clinical outcomes after surgery for chronic subdural hematoma in patients with anticoagulation therapy for atrial fibrillation

PURPOSE

A substantial proportion of patients undergoing surgery for chronic subdural hematoma (CSDH) use anticoagulation medication due to atrial fibrillation (AF). We assessed the risk of postoperative thromboembolic and hemorrhagic complications in CSDH surgery patients with a history of anticoagulation for AF and their association with outcome.

METHODS

This posthoc analysis of a nationwide multicenter randomized controlled trial conducted during 2020-2022 included CSDH patients undergoing surgery with a history of preoperative anticoagulation use for AF. We assessed the incidence of thromboembolic and hemorrhagic complications and their associations with functional outcomes and mortality.

RESULTS

Of 589 patients, 128 patients (median age 83 years, 24% females) were on anticoagulation medication due to AF. The incidences of postoperative thromboembolic and hemorrhagic complications were 8% and 6%, respectively. A significantly higher proportion of patients with a thromboembolic complication had unfavorable functional outcome (70% vs. 21%, p < 0.001) and higher mortality (50% vs. 14%) than those without. After adjusting for risk factors, a thromboembolic complication was independently associated with a higher risk for unfavorable outcome (OR 16.8, 95% CI 3.0-94.2) and death (OR 11.1, 95% CI 2.4-52.0). Similarly, hemorrhagic complications associated independently with unfavorable outcome, although the effect size was smaller than for thromboembolic complications.

CONCLUSION

The risk for thromboembolic complications seemed to be slightly higher than the risk for postoperative hemorrhagic complications after CSDH surgery in patients with a history of preoperative anticoagulation medication use due to AF. The occurrence of a thromboembolic complication was detrimental for patient prognosis, underscoring the importance of strategies to prevent thromboembolic events. There is an urgent need for a trial assessing the optimal timing of restarting anticoagulation medication after CSDH surgery.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT04203550.