Do Clinicians Overestimate the Severity of Intracerebral Hemorrhage?

Clinical value and role of long non-coding RNA PSMB8-AS1 in the progress of ischemic stroke in patients with hypertension

Hypertension is a common risk factors for ischemic stroke (IS), with the widely involvement of long non-coding RNAs (lncRNAs). The expression pattern and clinical significance of lncRNA PSMB8-AS1 was examined in essential hypertension (EH) patients with or without IS, as well as its role and mechanism in IS-induced neuron cell injury. Serum PSMB8-AS1 levels in 260 EH cases without IS and 280 participants with IS were detected via reverse transcription - quantitative polymerase chain reaction (RT-qPCR). The outcome during 12-month follow-up period was recorded. Receiver operating characteristic (ROC) curve and Kaplan - Meier (K-M) plot were drawn to evaluate diagnostic and prognostic values. HT22 cells were exposed to oxygen-glucose deprivation/reoxygenation (OGD/R) condition for cell function experiments. The cell viability, apoptosis, and inflammatory response were detected. Elevated expression of PSMB8-AS1 can differentiate IS from EH patients, and was independently related to the poor functional prognosis. Patients with high PSMB8-AS1 expression were likely to relapse during the 12-month follow-up period. In vitro, PSMB8-AS1 knockdown attenuated OGD/R-induced neuron cell apoptosis and inflammatory response, which was returned by microRNA-22-3p downregulation. PI3K-Akt signaling was of significance during the progress based on the Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis. PSMB8-AS1 acts as a novel biomarker for the diagnosis of IS in EH patients. Elevated PSMB8-AS1 is associated with worse neurological outcomes and higher recurrence rates of IS patients. LncRNA PSMB8-AS1 knockdown might have a promising role in attenuating OGD/R-induced neuron cell injury, that might be related to miR-22-3p.

Early vs later non-vitamin K antagonist oral anticoagulants in patients with acute ischemic stroke and atrial fibrillation: A meta-analysis and systematic review of randomized trials

BACKGROUND

There are conflicting published data on the optimal timing of non-vitamin K antagonist oral anticoagulants (NOACs) in atrial fibrillation (AF) patients with acute ischemic stroke.

OBJECTIVE

To compare the efficacy and safety of early initiation of NOACs with later initiation of NOACs in those patients, we conducted a meta-analysis of phase 3 or phase 4 randomized controlled trials.

METHODS

We systematically searched the Cochrane Library, PubMed, and Embase databases. A random effects model was selected to pool the effect measurement estimates (risk ratios [RRs] and 95% confidence intervals [CIs]).

RESULTS

Three randomized controlled trials with 6442 enrolled patients with AF and acute ischemic stroke were included. Compared with later NOAC therapy, early NOAC therapy was associated with nonsignificant reductions in the risk of primary outcomes (RR, 0.82; 95% CI, 0.65-1.05). Subgroup analysis found that in reducing risk of primary outcomes, early anticoagulation may benefit female patients more than male patients (0.54 [0.35-0.83] vs 0.97 [0.63-1.50]; P for interaction, .06). Numerically lower rates of recurrent ischemic stroke (RR, 0.80; 95% CI, 0.56-1.15), death (RR, 0.96; 95% CI, 0.81-1.15), and systemic embolism (RR, 0.43; 95% CI, 0.16-1.11) were observed in early initiation of NOACs in comparison with later initiation of NOACs. There was no difference in major bleeding (RR, 0.98; 95% CI, 0.55-1.74), symptomatic intracranial hemorrhage (RR, 0.93; 95% CI, 0.43-1.96), or major extracranial bleeding (RR, 0.73; 95% CI, 0.28-1.95) between groups.

CONCLUSION

In AF patients with acute ischemic stroke, early initiation of NOACs is not inferior to later initiation of NOACs in reducing composite events, without increased hazard of bleeding, especially in female patients.

Prehospital stroke detection scales: A head-to-head comparison of 7 scales in patients with suspected stroke

BACKGROUND

Several prehospital scales have been designed to aid paramedics in identifying stroke patients in the ambulance setting. However, external validation and comparison of these scales are largely lacking.

AIMS

To compare all published prehospital stroke detection scales in a large cohort of unselected stroke code patients.

METHODS

We conducted a systematic literature search to identify all stroke detection scales. Scales were reconstructed with prehospital acquired data from two observational cohort studies: the Leiden Prehospital Stroke Study (LPSS) and PREhospital triage of patients with suspected STrOke (PRESTO) study. These included stroke code patients from four ambulance regions in the Netherlands, including 15 hospitals and serving 4 million people. For each scale, we calculated the accuracy, sensitivity, and specificity for a diagnosis of stroke (ischemic, hemorrhagic, or transient ischemic attack (TIA)). Moreover, we assessed the proportion of stroke patients who received reperfusion treatment with intravenous thrombolysis or endovascular thrombectomy that would have been missed by each scale.

RESULTS

We identified 14 scales, of which 7 (CPSS, FAST, LAPSS, MASS, MedPACS, OPSS, and sNIHSS-EMS) could be reconstructed. Of 3317 included stroke code patients, 2240 (67.5%) had a stroke (1528 ischemic, 242 hemorrhagic, 470 TIA) and 1077 (32.5%) a stroke mimic. Of ischemic stroke patients, 715 (46.8%) received reperfusion treatment. Accuracies ranged from 0.60 (LAPSS) to 0.66 (MedPACS, OPSS, and sNIHSS-EMS), sensitivities from 66% (LAPSS) to 84% (MedPACS and sNIHSS-EMS), and specificities from 28% (sNIHSS-EMS) to 49% (LAPSS). MedPACS, OPSS, and sNIHSS-EMS missed the fewest reperfusion-treated patients (10.3-11.2%), whereas LAPSS missed the most (25.5%).

CONCLUSIONS

Prehospital stroke detection scales generally exhibited high sensitivity but low specificity. While LAPSS performed the poorest, MedPACS, sNIHSS-EMS, and OPSS demonstrated the highest accuracy and missed the fewest reperfusion-treated stroke patients. Use of the most accurate scale could reduce unnecessary stroke code activations for patients with a stroke mimic by almost a third, but at the cost of missing 16% of strokes and 10% of patients who received reperfusion treatment.

Acute Stroke With Hyperdense Middle Cerebral Artery (MCA) Sign in an Adolescent Female With Tyrosine Kinase Inhibitor Treatment-What You Need to Know

BACKGROUND

Acute stroke in an adolescent patient is a rare phenomenon. Tyrosine kinase inhibitors (TKIs) are newer targeted anticancer medications without widespread side effects typically associated with traditional chemotherapy. However, recent literature reveals several potential life-threatening side effects.

CASE REPORT

We present an unusual case of acute stroke with hyperdense middle cerebral artery (MCA) sign, in a 16-year-old female with a history of rhabdomyosarcoma and recent treatment with pazopanib, a tyrosine kinase inhibitor (TKI). The patient developed sudden right-sided weakness at school. She was brought to the emergency department (ED) by her parents. Prompt diagnosis with noncontrast computed tomography (CT)-brain and CT angiogram of head and neck followed by immediate administration of thrombolytic treatment with alteplase and referral for mechanical thrombectomy resulted in a successful restoration of blood flow and a favorable clinical outcome. This paper highlights the importance of recognizing stroke symptoms in young patients with a history of malignancy, discusses the risks associated with TKI treatment, and the efficacy of the treatment modalities employed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be mindful of the many new targeted anticancer therapies and their potential deleterious side effects. Due to the lack of pediatric stroke guidelines, adult stroke guidelines may be applied in the management of adolescent patients with acute stroke. Emergency physicians should also be able to recognize a hyperdense MCA sign on a noncontrast CT scan of the brain in a patient presenting with anterior circulation stroke symptoms.

Advancing stroke safety and efficacy through early tirofiban administration after intravenous thrombolysis: The multicenter, randomized, placebo-controlled, double-blind ASSET IT trial protocol

BACKGROUND

Intravenous thrombolysis (IVT) is the cornerstone treatment for the acute ischemic stroke (AIS) within 4.5 h after onset. Current guidelines recommend administering antiplatelet medications 24 h after IVT. However, vascular reocclusion is a common occurrence after IVT. Tirofiban, a platelet glycoprotein IIb/IIIa antagonist, can help deter macrovascular reocclusion, prevent microvascular thrombosis, and enhance cerebral blood flow.

OBJECTIVE

This trial aims to assess whether early administration of tirofiban can improve clinical outcomes in patients with AIS who received IVT.

METHODS AND DESIGN

The Advancing Stroke Safety and Efficacy through Early Tirofiban Administration after Intravenous Thrombolysis (ASSET IT) Trial is an investigator-initiated, randomized, placebo-controlled, double-blind, multicenter study. Up to 832 eligible patients will be consecutively randomized in a 1:1 ratio to receive either intravenous tirofiban or placebo over a period of 2 years across 38 stroke centers in China.

OUTCOMES

The primary endpoint is excellent functional status at day 90, defined as a modified Rankin Score of 0-1. Primary safety endpoints include symptomatic intracerebral hemorrhage at 24 h and mortality at 90 days.

TRIAL REGISTRY NUMBER

NCT06134622 (clinicaltrials.gov).

Electroacupuncture improves cerebral blood flow in pMCAO rats during acute phase via promoting leptomeningeal collaterals

Perfusion through leptomeningeal collateral vessels is a likely pivotal factor in the outcome of ischemic stroke patients. Acupuncture has been reported to restore cerebral blood flow (CBF) after acute ischemic stroke, but the underlying mechanisms are poorly understood. This study aimed to examine whether electroacupuncture (EA) could improve CBF following an acute ischemic injury by regulating leptomeningeal collaterals. The clinical outcomes suggest that EA resulted in an increase in the average CBF within the whole brain and gray matter of healthy subjects compared to pre-intervention. The experiments conducted on animals revealed that EA was able to improve neurological function, reduce infarct volume, and salvage tissue damage in the peri-infarct areas of permanent middle cerebral artery occlusion rats. Additionally, EA was found to increase cerebral perfusion and the diameter of developed leptomeningeal anastomoses, accompanied by activation of cholinergic neurons of the nucleus basalis of Meynert (NBM). However, these effects of EA were reversed by chemogenetic inhibition of cholinergic neurons in the NBM or by intraperitoneal injection of acetylcholine receptors antagonist atropine. These findings suggest that EA improved CBF after acute ischemic stroke, partially via activating cholinergic projections from the NBM to the cortex, thereby promoting leptomeningeal collateral circulation. ClinicalTrials.gov identifier: NCT03444896.

Incidence of dysphagia-related safety incidents in older adults across feeding methods: A systematic review and meta-analysis

OBJECTIVE

Dysphagia-related safety incidents encompass near-miss events, no-harm occurrences, or harmful incidents associated with oral or enteral feeding methods. This systematic review and meta-analysis aimed to assess the incidence rates of dysphagia-related safety incidents in older adults across various feeding methods.

METHODS

A comprehensive literature search was conducted using PubMed, Embase, Web of Science, Cochrane Library, and CINAHL databases to identify studies reporting dysphagia-related safety incidents in older adults. The feeding methods analyzed included oral feeding, nasogastric (NG) tube feeding, and percutaneous endoscopic gastrostomy (PEG) tube feeding. Randomized controlled trials (RCTs), non-randomized studies, and cohort studies were included. The analysis adhered to the PRISMA guidelines, and meta-analytic outcomes were presented with 95% confidence intervals (CIs).

RESULTS

A total of 30 studies satisfied the inclusion criteria. The overall incidence rates of safety incidents were 13.8% for oral feeding, 23.9% for NG tube feeding, and 26.5% for PEG tube feeding. Aspiration pneumonia emerged as the most prevalent safety incident across all feeding methods, with incidence rates of 12.0% for oral feeding, 20.6% for NG tube feeding, and 12.4% for PEG tube feeding. Tube feeding methods were associated with diarrhea and wound infection. Additionally, specialized safety incidents were observed for each feeding method: suffocation in oral feeding; gastroesophageal reflux in NG tube feeding; and tube blockage, tube dislodgment, tube leakage, vomiting, nausea, site pain, gastrointestinal hemorrhage, and peritonitis in PEG tube feeding.

CONCLUSIONS

Dysphagia-related safety incidents in older adults demonstrated considerable variability in type and frequency across different feeding methods. Understanding these differences could provide healthcare professionals with valuable insights for targeted risk prediction and proactive management strategies to mitigate such incidents.

Lepalvir: Biomaterial efficacy and safety for patients with acute ischemic stroke

Lepalvir, derived from inflamed rabbit skin inoculated with vaccinia virus, has potential neuroprotective and anti-inflammatory effects. We conducted a phase II, multicenter, randomized, blind, placebo-controlled trial investigating the efficacy and safety of Lepalvir for acute ischemic stroke (AIS). Participants aged 18-80 years with AIS in the anterior circulation and a National Institutes of Health Stroke Scale (NIHSS) score of 4-24 within 48 h post-onset were randomized to receive high-dose (192U), low-dose (96U) Lepalvir, or saline placebo for 14 days. The primary outcome was the proportion of patients achieving a modified Rankin Scale (mRS) score ≤ 1 at day 90 (D90) post-randomization. Among 238 patients, no significant difference in mRS score at D90 was observed across groups, yet a higher percentage in the high-dose group achieved a mRS score ≤ 1 at D90, compared to the control and low-dose group. No significant safety concerns were noted. While functional improvement was not significantly different at D90, Lepalvir showed a favorable safety profile and potential at the higher dosage, warranting further phase III investigation.

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.

Normobaric hyperoxia combined with endovascular treatment for acute ischaemic stroke in China (OPENS-2 trial): a multicentre, randomised, single-blind, sham-controlled trial

BACKGROUND

Endovascular treatment improves the recanalisation rate for patients with acute ischaemic stroke; however, even with endovascular treatment, approximately half of patients do not have a favourable functional outcome. We aimed to evaluate the effect of normobaric hyperoxia combined with endovascular treatment on functional outcomes up to 90 days after treatment in patients who had an acute ischaemic stroke with large-vessel occlusion.

METHODS

In this multicentre, randomised, single-blind, sham-controlled trial, patients aged 18-80 years presenting within 6 h of acute ischaemic stroke attributed to large-vessel occlusion in anterior circulation, who were candidates for endovascular treatment, were recruited from 26 comprehensive stroke centres in China. Eligible patients were randomly assigned (1:1), with an Interactive Web Response System on the basis of a minimisation process to balance assignment at each participating site both overall and according to age, sex, occlusion location, and use of intravenous thrombolytics, to receive either normobaric hyperoxia combined with endovascular treatment or sham normobaric hyperoxia combined with endovascular treatment. Participants and assessors were blinded to treatment assignment. Normobaric hyperoxia treatment involved inhaling 100% oxygen at a flow rate of 10 L/min through a non-rebreather mask for 4 h, or an inspiratory oxygen fraction (FiO2) of 1·0 in participants for whom intubation was necessary. Sham treatment was 100% oxygen delivered at a flow rate of 1 L/min or an FiO2 of 0·3. The primary outcome was the comparison of the ordinal scores on the modified Rankin Scale (mRS) at 90 days assessed in the intention-to-treat population (including all patients randomly assigned to treatment). Safety was assessed in all patients who received any oxygen therapy. This trial is registered with ClinicalTrials.gov, NCT04681651, and is now complete.

FINDINGS

Between April 22, 2021, and Feb 5, 2023, 473 patients were screened, of whom 282 were randomly assigned to either normobaric hyperoxia plus endovascular treatment (n=140) or sham normobaric hyperoxia plus endovascular treatment (n=142; intention-to-treat population). The median age was 65 years (IQR 57-71), 75 (27%) of 282 participants were female, 207 (73%) were male, and 282 (100%) of participants were of Chinese Han ethnicity. At 90 days, the median score on the mRS for the normobaric hyperoxia group was 2 (IQR 1-4) and it was 3 (1-4) in the sham normobaric hyperoxia group (adjusted common odds ratio 1·65 [95% CI 1·09-2·50]; p=0·018). At 90 days, 14 (10%) of 140 patients in the normobaric hyperoxia group and 17 (12%) of 142 in the sham normobaric hyperoxia group died (adjusted risk difference -0·02 [95% CI -0·09 to 0·06]) and 28 (20%) and 33 (23%) had serious adverse events (adjusted risk difference -0·03 [-0·12 to 0·07]).

INTERPRETATION

In patients with acute ischaemic stroke caused by large-vessel occlusion in the anterior circulation who were candidates for endovascular treatment, normobaric hyperoxia yielded superior functional outcomes at 90 days compared with the sham normobaric hyperoxia, without raising safety concerns.

FUNDING

Beijing Municipal Education Commission, Beijing Municipal Finance Bureau, and National Natural Science Foundation of China.

Efficacy and Safety of Mechanical Thrombectomy in Acute Ischemic Stroke Secondary to Infective Endocarditis

OBJECTIVES

Acute ischemic strokes (stroke) are frequent and severe extracardiac complications in infective endocarditis (IE). Since intravenous thrombolysis (IV-thrombolysis) is contraindicated, mechanical thrombectomy (thrombectomy) offers potential benefit. We aimed to compare thrombectomy efficacy and safety between IE-related and general stroke cases.

METHODS

Multicenter study of consecutive IE cases treated with thrombectomy at nine stroke centers in Spain from 2011 to 2022. Using propensity score matching, 50 IE cases were 1:4 matched with non-IE stroke patients (n=200). Efficacy was defined by successful recanalization rates [modified treatment in cerebral ischemia scale (mTICI) ≥2b], neurological improvement at 24 hours [decrease of National Institutes of Health Stroke Scale (NIHSS) compared to baseline], and good neurological outcome rates at 3 months [modified Rankin scale (mRS) ≤ 2]. Safety was assessed by intracranial hemorrhage (IC-hemorrhage), symptomatic IC-hemorrhage, crude mortality, and stroke-related mortality.

RESULTS

Among 54 IE cases, 50 were matched with 200 controls. Successful recanalization was similarly achieved in both groups (76% vs 83%). Median NIHSS at 24h was comparable, with analogous rates of neurological improvement (78% vs 78%), and early dramatic response (48% vs 46.5%). No differences were seen regarding IC-hemorrhage rates, except for when prior IV-thrombolysis was given. Although crude mortality was higher in the IE cohort, no differences were seen in stroke-related mortality (12% vs 15%). At three months, mRS scores of the two groups were superimposable.

CONCLUSIONS

Thrombectomy in IE is as effective and safe as in non-IE patients, and prior IV-thrombolysis could decrease the procedural safety. Clinical practice guidelines may consider including the recommendation to perform thrombectomy alone in IE-related stroke.

Genetic determinants of insufficiency of the collateral circulation

It has been estimated that approximately two million neurons, sixteen billion synapses and twelve kilometers of axons are lost each minute following anterior large-vessel stroke. The level of collateral blood flow has become recognized as a primary determinant of the pace of this loss and an important factor in clinical decision-making. Many of the topics in this review cover recent developments that have not been reviewed elsewhere. These include that: the number and diameter of collaterals and collateral blood flow vary greatly in the brain and other tissues of healthy individuals; a large percentage of individuals are deficient in collaterals; the underlying mechanism arises primarily from naturally occurring polymorphisms in genes/genetic loci within the pathway that drives collateral formation during development; evidence indicates collateral abundance does not exhibit sexual dimorphism; and that collaterals-besides their function as endogenous bypass vessels-may have a physiological role in optimizing oxygen delivery. Animal and human studies in brain and other tissues, where available, are reviewed. Details of many of the studies are provided so that the strength of the findings and conclusions can be assessed without consulting the original literature. Key questions that remain unanswered and strategies to address them are also discussed.

Nonlinear Relationship Between Blood Urea Nitrogen to Albumin Ratio and 3-Month Outcomes in Patients With Acute Ischemic Stroke: A Second Analysis Based on a Prospective Cohort Study

OBJECTIVE

Patients with acute ischemic stroke (AIS) have limited evidence regarding the relationship between blood urea nitrogen and albumin. Aiming to investigate the relationship between the blood urea nitrogen to albumin ratio (BUN/ALB ratio) and poor outcomes in AIS patients at 3 months was the purpose of this study.

METHODS

AIS participants at a Korean hospital from January 2010 to December 2016 were included in a secondary analysis of a prospective cohort study. Logistic regression and restricted cubic splines were used to examine the relationship between BUN/ALB ratio and poor outcomes after 3 months.

RESULTS

There is a skewed distribution of BUN/ALB ratios, ranging from 0.114 to 1.250. Model II of the binary logistic regression showed that the BUN/ALB ratio was not statistically significant in predicting poor outcomes for AIS patients after 3 months. However, there was a notable nonlinear relationship between them, with the inflection point of the BUN/ALB ratio identified as 0.326. The BUN/ALB ratio on the left side of the inflection point was associated with a 42% reduction in 3-month poor outcomes (odds ratio = 0.58, 95% confidence interval: 0.40 to 0.83). Conversely, the relationship was not statistically significant on the right side of the inflection point.

CONCLUSIONS

The BUN/ALB ratio and poor outcomes in AIS patients show a nonlinear correlation. For AIS patients, a BUN/ALB ratio of approximately 0.326 is associated with the lowest risk of adverse outcomes at 3 months. Specifically, for nonsmoking AIS patients, a BUN/ALB ratio of approximately 0.295 is associated with the lowest risk of adverse outcomes at 3 months.

The Association Between FLAIR Vascular Hyperintensities and Outcomes in Patients with Border Zone Infarcts Treated with Medical Therapy May Vary with the Infarct Subtype

RATIONALE AND OBJECTIVES

Fluid-attenuated inversion recovery vessel hyperintensities (FVHs) reflect the haemodynamic state and may aid in predicting the prognosis of border zone (BZ) infarct patients. This study was to explore the relationship between FVHs and functional outcomes for different BZ infarct subtypes following medical therapy administration.

MATERIALS AND METHODS

Consecutive patients with ischemic stroke were retrospectively enrolled and classified into internal BZ (IBZ) infarct, cortical BZ (CBZ) infarct and mixed-type infarct patients. FVHs were quantified using the FVH-Alberta Stroke Program Early CT Score (ASPECTS) system, and the scores were used to divide the patients into low-FVH (0-3) and high-FVH (4-7) groups. The FVH location and the cerebrovascular stenotic degree were recorded. Logistic regression was performed to identify risk factors for poor outcomes (modified Rankin scale score ≥3).

RESULTS

A total of 207 BZ infarct patients (IBZ, n = 130; CBZ, n = 52; mixed-type, n = 25) were included. The FVH score was positively correlated with cerebrovascular stenosis (r = 0.332, P < 0.001) in all patients. A high FVH score was associated with poor outcomes in all (OR 2.568, 95% CI (1.147 to 5.753), P = 0.022) and in CBZ infarct patients (OR 9.258, 95% CI 1.113 to 77.035), P = 0.040). FVH-diffusion-weighted imaging (DWI) mismatch was not significantly associated with outcomes in the entire patient group or in any subgroup.

CONCLUSIONS

A high FVH score is associated with poor long-term outcomes in patients with CBZ infarcts but not in those with IBZ or mixed-type infarcts.

Impact of cerebral collateral recycle status on clinical outcomes in elderly patients with endovascular stroke treatment

BACKGROUND

Elderly patients are at high risk of acute ischemic stroke caused by large vessel occlusion (AIS-LVO) and usually suffer disability and fatality from stroke even after receiving endovascular treatment (EVT). Previous studies lacked the knowledge of comprehensive cerebral collateral for elderly patients. Hence, we explore the role of cerebral collateral recycle (CCR) status in clinical outcomes in a real-world setting among elderly AIS-LVO patients undergoing EVT.

METHODS

This was a multicenter retrospective cohort study. Computed tomographic angiography (CTA) at admission was applied to evaluate cerebral venous outflow profiles by the Cortical Vein Opacification Score (COVES) and pial arterial collaterals by the Tan scale. According to the status of cerebral collaterals, enrolled patients were divided into the poor, moderate, and favorable CCR groups. The primary outcome was functional independence (90-day modified Rankin Scale score 0-2).

RESULTS

Among 860 AIS-LVO patients receiving EVT, a total of 338 elderly patients were included in the present study after strict screening. Compared with the poor CCR group, the moderate CCR group (31.1 % vs. 10.2 %; adjusted odds ratio[aOR] 3.80; 95 % confidence interval[CI] 1.71-8.44; P = 0.001) and the favorable CCR group (63.3 % vs. 10.2 %; aOR 8.49; 95 % CI 4.02-17.92; P < 0.001) both had a significantly higher rate of functional independence. In subgroup analysis, similar results were found in AIS-LVO patients with older age, large core infarction, or late time window.

CONCLUSION

The cerebral collateral status in elderly patients with AIS-LVO treated by EVT is a strong predictor of functional outcomes and more robust CCR means better outcomes.

Global Trends of Mechanical Thrombectomy in Acute Ischemic Stroke Over the Past Decade: A Scientometric Analysis Based on WOSCC and GBD Database

OBJECTIVE

To present a global overview of the current research landscape and emerging trends in mechanical thrombectomy for acute ischemic stroke (AIS) over the past decade.

METHODS

A thorough search was conducted on the Web of Science on May 20, 2024, focusing on original articles and reviews in English. Bibliometric tools were employed to make a network analysis and visual representation. Additionally, data on disability-adjusted life years, prevalence, and incidence of ischemic strokes were extracted from the Global Burden of Disease database.

RESULTS

A total of 7776 papers were included, indicating a steady increase from 169 to 1311 between 2014 and 2023. The United States led in core publications with 2887 papers. The incidence and disability-adjusted life years of ischemic stroke have continued to rise in Asia but have recently declined in North America and European countries. The University of Calgary emerged as the leading institution and Mayank Goyal was the most prolific author. Neurointerventional Surgery was the top contributing journal with 790 articles. The analysis identified 6332 keywords forming 5 clusters, with "mechanical thrombectomy" serving as the largest cluster, focusing mainly on interventional thrombectomy techniques for AIS. The term "tissue plasminogen activator" exhibited strong burst strength of 46.58. Keywords such as "injury", "diagnosis", "posterior circulation", and "severity" burst in 2020 and lasted until 2024.

CONCLUSIONS

Interest in mechanical thrombectomy for AIS was progressively increasing. Future research directions may include minimizing intraoperative injuries, refining diagnostic techniques, investigating interventions for posterior circulation, and tailoring thrombectomy strategies based on stroke severity and large vessel occlusion etiology.

Ferritinophagy promotes microglia ferroptosis to aggravate neuroinflammation induced by cerebral ischemia-reperfusion injury via activation of the cGAS-STING signaling pathway

Cerebral ischemia-reperfusion injury (CIRI) is a common and serious complication of reperfusion therapy in patients with ischemic stroke (IS). The regulation of microglia-mediated neuroinflammation to control CIRI has garnered considerable attention. The balance of iron metabolism is key to maintaining the physiological functions of microglia. Nuclear Receptor Coactivator 4 (NCOA4)-mediated ferritinophagy, an important pathway in regulating iron metabolism, is a promising intervention target. However, studies on the impacts of ferritinophagy on microglia-mediated neuroinflammation are lacking. This study aimed to identify potential treatments for CIRI-induced neuroinflammation by focusing on ferritinophagy and the specific mechanisms whereby iron metabolism regulates microglia-mediated neuroinflammation. CIRI induced the activation of ferritinophagy in microglia, characterized by the upregulation of NCOA4, downregulation of Ferritin Heavy Chain 1 (FTH1), and increased intracellular iron levels. This activation contributes to increased ferroptosis, oxidative stress, and the release of inflammatory factors. Silencing NCOA4 or application of the ferroptosis-specific inhibitor Ferrostatin-1 (Fer-1) effectively suppressed the CIRI-induced damage in vivo and in vitro. While Fer-1 addition did not inhibit the CIRI-activated ferritinophagy, it did partially reverse the alleviation of NCOA4 depletion-induced neuroinflammation, suggesting that ferroptosis is an essential intermediate step in ferritinophagy-induced neuroinflammatory damage. Furthermore, using IS-related transcriptomic data, the cGAS-STING pathway was identified as a crucial mechanism connecting ferritinophagy and ferroptosis. Specific inhibition of the cGAS-STING pathway reduced ferritinophagy-induced ferroptosis and neuroinflammation. In summary, our results indicated that ferritinophagy activates the cGAS-STING signaling pathway, which promotes the inflammatory response and oxidative stress in microglia in a ferroptosis-dependent manner, thereby exacerbating CIRI-induced neuroinflammation. These findings provide theoretical support for the clinical treatment of CIRI.

Cilia-Mimic Locomotion of Magnetic Colloidal Collectives Enhanced by Low-Intensity Ultrasound for Thrombolytic Drug Penetration

Rapid thrombolysis is very important to reduce complications caused by vascular blockage. A promising approach for improving thrombolysis efficiency is utilizing the permanent magnetically actuated locomotion of nanorobots. However, the thrombolytic drug transportation efficiency is challenged by in-plane rotating locomotion and the insufficient drug penetration limits further improvement of thrombolysis. Inspired by ciliary movement for cargo transportation in human body, in this study, cilia-mimic locomotion of magnetic colloidal collectives is realized under torque-force vortex magnetic field (TFV-MF) by a designed rotating permanent magnet assembly. This cilia-mimic locomotion mode can generate more disturbances to the fluids to improve thrombolytic drug transportation and the increased height and area of colloidal collectives boosted the imaging capability. In addition, low-intensity ultrasound is applied to enhance colloids infiltration by producing the fiber breakage and inducing erythrocyte deformation. In vitro thrombolytic experiments demonstrate that the thrombolysis efficiency increased by 16.2 times compared with that of pure tissue plasminogen activator (tPA) treatments. Furthermore, in vivo rat models of femoral vein thrombosis confirmed that this approach can achieve blood flow recanalization more quickly. The proposed cilia-mimic locomotion of magnetic colloidal collectives combined with low-intensity ultrasound irradiation mode provides a new insight of therapeutic interventions for vascular thrombus by enhancing drug penetration.

Diagnostic yield and therapeutic implications of vascular imaging in acute ischemic stroke: prospective and consecutive study of small vessel versus large vessel ischemia

INTRODUCTION

To evaluate patients acute cerebral ischemia in order to assess for factors which may help to differentiate patients with small vessel involvement from those with large vessel involvement in an effort to determine diagnostic yield of vascular imaging.

MATERIAL AND METHOD

We prospectively and consecutively evaluated all acute ischemic stroke patients at our medical center from May 16, 2021 to December 10, 2021. Distinction between small vessel and large vessel involvement was based upon clinical presentation, the results of brain imaging and either computed tomographic angiography, in the vast majority, or magnetic resonance angiography. Patient demographics and risk factors for stroke as well as therapeutic intervention was assessed.

CONCLUSION AND RESULT

Of the 90 patients studied, 59 had large vessel ischemia (66%) with 26 (44%) having large vessel occlusion and one had symptomatic high-grade middle cerebral artery stenosis. Conversely, none of the 31 patients with small vessel presentation (34%) had large vessel occlusion or high-grade stenosis. In addition, 19 out of 59 (32%) large vessel patients compared to 2 of 31 (6%) of the small vessel patients had atrial fibrillation identified as a potential mechanism with a p-value of 0.01 by univariate analysis and 0.17 by multivariate analysis. The routine use of vascular imaging in acute ischemic stroke is of very low yield in small vessel presentation with the presence of potential cardiogenic emboli is also relatively low. Efforts at accelerated identification of a small vessel mechanism, to avoid unnecessary testing, should provide significant value from both a patient management and cost standpoint.

Clinically relevant findings on 24-h head CT after acute stroke therapy: The 24-h CT score

BACKGROUND

Routine head computed tomography (CT) is performed 24 h post-acute stroke thrombolysis and thrombectomy, even in patients with stable or improving clinical deficits. Predicting CT results that impact management could help prioritize patients at risk and potentially reduce unnecessary imaging.

METHODS

In this institutional review board (IRB)-approved retrospective study, data from 1461 consecutive acute ischemic stroke patients at our Comprehensive Stroke Center (n = 8943, 2012-2022) who received intravenous thrombolysis or endovascular therapy, exhibited stable or improving 24-h exams, and underwent 24-h follow-up head CT per standard acute stroke care guidelines. CT reports 24 h post-stroke were reviewed for edema, mass effect, herniation, and hemorrhage. The primary outcome was any clinically relevant 24-h CT finding that led to changes in antithrombotic treatment or blood pressure goals, extended intensive care unit (ICU) stays or hospitalizations, neurosurgical interventions, or administration of mannitol or hypertonic saline. Multivariable logistic regression identified independent predictors of clinically meaningful CT abnormalities. A 24-h CT score was developed and cross-validated.

RESULTS

The mean age was 70 years, with 47% women. The median National Institutes of Health Stroke Scale (NIHSS) score at admission was 12 (interquartile range (IQR): 6-18). Stroke-related abnormalities on 24-h CT were present in 325 patients (22.2%), with 183 (12.5%) showing clinically relevant findings. Age, admission NIHSS, and blood glucose levels were independent predictors of clinically relevant 24-h CT findings. The final model C statistic was 0.72 (95% confidence interval (CI): 0.68-0.76) in the derivation cohort and 0.72 (95% CI: 0.67-0.75) in bootstrapping validation. The 24-h CT score was developed using these predictors: NIHSS score 5-15 (+3); NIHSS score ⩾16 (+5); age < 75 years (+1); admission glucose ⩾ 140 mg/dL (+1). The prevalence of clinically relevant CT findings was 4.3% in the low-risk group (24-h CT score ⩽ 4), 11.3% in the medium-risk group (score 5), and 21.4% in the high-risk group (score ⩾ 6). The 24-h CT score demonstrated good calibration.

CONCLUSION

In patients undergoing thrombolysis or thrombectomy who undergo routine 24-h head CT despite remaining clinically stable or improving, only one in eight prove to have 24-h head CT findings that impact management. The 24-h CT score provides risk stratification that may improve resource utilization.

DATA ACCESS STATEMENT

A.S. and B.Z. have full access to the data used in the analysis in this article. Deidentified data will be shared after ethics approval if requested by other investigators for purposes of replicating the results.

Early Neurological Deterioration in Acute Ischemic Minor Stroke Patients with Large Vessel Occlusion Following Intravenous Thrombolysis

OBJECTIVE

Early identification of risk factors associated with early neurological deterioration (END) in patients with acute minor stroke and large vessel occlusion (LVO) receiving intravenous thrombolysis (IVT) could assist in formulating treatment decisions.

METHODS

Consecutive patients with acute minor stroke and LVO were extracted from a single-center prospective database spanning from January 2020 to December 2023. END was defined as an increase of ≥4 points in the National Institutes of Health Stroke Scale score from baseline or ≥2 points in any single National Institutes of Health Stroke Scale item, within 24 hours of IVT. Multivariate logistic regression analysis, adjusted for confounding variables, was employed to identify risk factors associated with END.

RESULTS

A total of 163 patients were included in this study, of which 36 (22.1%) patients encountered END. Patients in the END group had a higher proportion of isolated internal carotid artery (ICA) occlusion (30.6% vs. 6.3%), delayed antiplatelet therapy (88.9% vs. 66.1%), and a larger Tmax > 4 seconds volume (142 vs. 114 mL) (all P < 0.05). Multivariate logistic regression analysis after adjusting for confounding factors showed that isolated (ICA) occlusion (adjusted odds ratio = 2.49, 95% confidence interval = 1.97-4.41; P < 0.001) and delayed antiplatelet therapy (adjusted odds ratio = 1.46, 95% confidence interval = 1.17-1.84; P < 0.001) were significantly associated with END.

CONCLUSIONS

Isolated ICA occlusion and delayed antiplatelet therapy were significantly associated with END in minor stroke patients with LVO following IVT. Bridging thrombectomy and early administration of antiplatelet therapy may be considered reasonable strategies.

Buyang Huanwu Decoction prevents hemorrhagic transformation after delayed t-PA infusion via inhibiting NLRP3 inflammasome/pyroptosis associated with microglial PGC-1α

ETHNOPHARMACOLOGICAL RELEVANCE

Delayed tissue-type plasminogen activator (t-PA) thrombolysis, which has a restrictive therapeutic time window within 4.5 h following ischemic stroke (IS), increases the risk of hemorrhagic transformation (HT) and subsequent neurotoxicity. Studies have shown that the NLRP3 inflammasome activation reversely regulated by the PGC-1α leads to microglial polarization and pyroptosis to cause damage to nerve cells and the blood-brain barrier. The effect of Buyang Huanwu Decoction (BHD), a traditional Chinese medicine prescription widely used in the recovery of IS, on HT injury after delayed t-PA treatment had been found with clinical studies, while the underlying mechanisms are reminded to be further clarified.

AIM OF THE STUDY

This study sought to investigate the therapeutic effect and the underlying mechanisms of BHD in ischemic rat brains with delayed t-PA treatment.

MATERIALS AND METHODS

The components of BHD extracts were identified by High Performance Liquid Chromatography (HPLC) and the effective components in the rat brains from BHD were analyzed by liquid chromatography-mass spectrometry (LC-MS). In vivo experiment was carried out by 5 h of middle cerebral artery occlusion (MCAO) following by t-PA infusion for 0.5 h plus reperfusion 19 h, while the in vitro BV2 cells were stimulated by lipopolysaccharide (LPS)-adenosine triphosphate (ATP) to activate microglia pyroptosis, of which the MCC950 (NLRP3 inhibitor) and NSA (GSDMD inhibitor) were adopted as reverse validation. PGC-1α siRNA was utilized to study the mechanisms of BHD against microglial polarization and pyroptosis in BV2 cells.

RESULTS

HPLC analysis demonstrated the fingerprint of BHD with six reference standards (Hydroxysafflor yellow A, Calycosin-7-glucoside, Paeoniflorin, Formononetin, Ferulic acid and Amygdalin), the last two of which can be found in rat brains by LC-MS analysis. In the following experiments, we found the major discoveries as follow: (1) BHD improved the neurological outcomes, the structural integrity of the blood-brain barrier and the neuronal structure in HT rats with MCAO following by delayed t-PA infusion; (2) the presence of t-PA promoted the suppression of PGC-1α and the activation of microglial NLRP3 inflammasome and pyroptosis in the HT rats; (3) BHD promoted the transformation of microglia from M1 to M2 type for inhibiting inflammatory response; (4) BHD restrained NLRP3 inflammasome/pyroptosis activation in microglia, prevented the translocations of NF-κB into the nucleus, as well as enhanced microglia-specific PGC-1α in ischemic rats following t-PA delayed thrombolysis; (5) BHD suppressed NLRP3 inflammasome assembly and increased PGC-1α expression in the LPS-ATP-induced BV2 cells; (6) PGC-1α silencing withdrew the protective role of BHD against NLRP3 inflammasome/pyroptosis.

CONCLUSION

Mechanistically, BHD existed the protective effect against HT injury after delayed t-PA treatment through up-regulating microglial PGC-1α to inhibit NLRP3 inflammasome and pyroptosis, and serves as a potential adjuvant therapy for HT injury.

Very High-Power Short-Duration Ablation for Atrial Fibrillation in Adults With Congenital Heart Disease

INTRODUCTION

Data regarding safety and long-term outcome of very high-power-short duration (vHPSD) ablation in adult congenital heart disease (ACHD) patients with paroxysmal or persistent atrial fibrillation (AF) are lacking.

METHODS

Retrospective observational single-center study. The data of 66 consecutive ACHD patients (mean age 60 ± 12.8 years, 46% male) with mild (69.7%), moderate (22.7%), or complex (7.6%) congenital heart disease (CHD) who underwent ablation for paroxysmal (40.9%) or persistent AF (59.1%) were analyzed. Circumferential PVI was performed in all patients and additional substrate ablation in 79,4% of persistent AF patients using irrigated RF energy with vHPSD settings of 70 W/5-7 s or 60 W/7-10 s.

RESULTS

Mean procedure time was 123.6 ± 42 min with a mean RF time of 18.19 ± 10 min. No technique related adverse events occurred. Vascular access complications were detected in seven patients (10.6%) requiring intervention in four patients (6%). A median follow-up time of 491 days (IQR: 194-1054 days). Freedom from any atrial arrhythmia off antiarrhythmic drugs (AAD) at 1 year was present in 58% of patients (77.8% with paroxysmal AF, 43.6% with persistent AF).

CONCLUSION

vHPSD for ablation of paroxysmal or persistent AF in ACHD patients is safe and effective. Regardless of CHD complexity, no vHPSD ablation modality related complications occurred. Long-term outcome for paroxysmal AF after one ablation was excellent whereas results for persistent AF were limited.

Artificial biomarker-based feedback-regulated personalized and precise thrombolysis with lower hemorrhagic risk

The body weight-based thrombolytic medication strategy in clinical trials shows critical defects in recanalization rate and post-thrombolysis hemorrhage. Methods for perceiving thrombi heterogeneity of thrombolysis resistance is urgently needed for precise thrombolysis. Here, we revealed the relationship between the thrombin heterogeneity and the thrombolysis resistance in thrombi and created an artificial biomarker-based nano-patrol system with robotic functional logic to perceive and report the thrombolysis resistance of thrombi. The nano-patrols are contrallable and are able to accomplish thrombolysis resistance-matched personalized and precise therapy according to the feedback signal from artificial biomarkers. This nano-patrol system depicted more enhanced thrombolytic efficiency (elevated by 25%) than alteplase for mini pig model and clinical thrombi and achieved recanalization in thrombotic model where alteplase encountered failure. Moreover, the nano-patrol remarkably reduced the infarct volume and the hemorrhagic transformation risk (0.12-fold of alteplase) of cerebral thrombosis. Therefore, we developed a unique tool for diagnosing thrombolysis resistance and achieving personalized and precise thrombolysis.

Endovascular therapy for acute vertebrobasilar occlusion (VERITAS): a systematic review and individual patient data meta-analysis

BACKGROUND

Trials of endovascular therapy for basilar artery occlusion, including vertebral occlusion extending into the basilar artery, have shown inconsistent results. We aimed to pool data to estimate safety and efficacy and to explore the benefit across pre-specified subgroups through individual patient data meta-analysis.

METHODS

VERITAS was a systematic review and meta-analysis that pooled patient-level data from trials that recruited patients with vertebrobasilar ischaemic stroke who were randomly assigned to treatment with either endovascular therapy or standard medical treatment alone. We included studies done between Jan 1, 2010, and Sept 1, 2023. The primary outcome was 90-day favourable functional status (modified Rankin Scale [mRS] score 0-3, with a score of 3 indicating moderate disability). Safety outcomes were symptomatic intracranial haemorrhage and 90-day mortality.

FINDINGS

We screened 934 titles and abstracts. Of these, seven (<1%) full texts were screened. We included four trials (ATTENTION, BAOCHE, BASICS, and BEST). The pooled data included 988 patients (556 [56%] in the intervention groups and 432 [44%] in the control groups; median age 67 years [IQR 58-74]; 686 (69%) were male and 302 (31%) were female). 904 (91%) patients were randomly assigned within 12 h of estimated stroke onset. Three RCTs were done in a Chinese population and one included European and Brazilian patients. The proportion of patients achieving favourable functional status was higher in the endovascular therapy than control group (90-day mRS score 0-3 in 251 [45%] participants vs 128 [30%]; adjusted common odds ratio 2·41 [95% CI 1·78-3·26]; p<0·0001). Endovascular therapy led to an increase in functional independence (mRS score 0-2 in 194 [35%] participants vs 89 [21%]; 2·52 [1·82-3·48]; p<0·0001) as well as a reduction in both the degree of overall disability (2·09 [1·61-2·71]; p<0·0001) and mortality (198 [36%] of 556 patients vs 196 [45%] of 432; 0·60 [0·45-0·80]; p<0·0001) at 90 days, despite higher rates of symptomatic intracranial haemorrhage (30 [5%] of 548 vs two [<1%] of 413; 11·98 [2·82-50·81]; p<0·0001). Heterogeneity of treatment effect was noted for baseline stroke severity (uncertain effect in baseline National Institutes of Health Stroke Scale <10) and occlusion site (greater benefit with more proximal occlusions) but not across subgroups defined by age, sex, baseline posterior circulation Alberta Stroke Program Early CT Score, presence of atrial fibrillation or intracranial atherosclerotic disease, and time from onset to imaging.

INTERPRETATION

VERITAS supports the robust benefit of endovascular therapy in patients with vertebrobasilar artery occlusion with moderate to severe symptoms, with approximately 2·5-times increased likelihood of achieving a favourable functional outcome. Despite a significant increase in symptomatic intracranial haemorrhage risk, endovascular therapy for vertebrobasilar artery occlusion was associated with a significant reduction in both overall disability and mortality. Although the benefit of endovascular therapy remains uncertain for patients vertebrobasilar artery occlusion presenting with mild stroke severity and extensive infarcts on neuroimaging, we found a significant clinical benefit across a range of patients with vertebrobasilar artery occlusion.

FUNDING

None.

Efficacy and safety of tirofiban plus recombinant tissue plasminogen activator versus recombinant tissue plasminogen activator alone in acute ischemic stroke patients: a meta-analysis

OBJECTIVE

Tirofiban plus recombinant tissue plasminogen activator (rtPA) shows good efficacy and safety in treating acute ischemic stroke (AIS) patients, but there is a lack of comprehensive assessment. This meta-analysis aimed to compare the efficacy and safety of rtPA plus tirofiban with rtPA alone in AIS patients.

METHODS

This meta-analysis retrieved studies comparing rtPA intravenous thrombolysis followed by tirofiban (rtPA+T group) versus rtPA intravenous thrombolysis alone (rtPA group) for AIS patients in Excerpt Medica Database, Web of Science, Cochrane, PubMed, China National Knowledge Infrastructure, Wanfang, and SinoMed until March 2024.

RESULTS

Twenty studies with 2048 AIS patients were enrolled in this meta-analysis. National Institute of Health stroke scale (NIHSS) score after treatment was lower in the rtPA+T group than the rtPA group [standardized mean differences (SMD)=-1.41; 95 % confidence interval (CI)=-1.83, -0.98; P<0.001]. The proportion of AIS patients achieving a favorable functional outcome (modified Rankin Scale score ≤2) was increased in the rtPA+T group versus the rtPA group [relative risk (RR)=1.13; 95 % CI=1.05, 1.21; P=0.001]. The incidence of re-occlusion was lower in the rtPA+T group than in the rtPA group (RR=0.24; 95 % CI=0.10, 0.59; P=0.002), but the incidence of intracranial hemorrhage (ICH) (RR=0.85; 95 % CI=0.51, 1.43), symptomatic ICH (RR=1.10; 95 % CI=0.43, 2.84), and mortality (RR=1.39; 95 % CI=0.53, 3.65) was not different between the two groups (all P>0.05). The stability assessed by sensitivity analysis was good, and no publication bias was found.

CONCLUSION

rtPA plus tirofiban achieves superior efficacy with comparable safety profiles compared to rtPA alone in AIS patients.

White Matter Hyperintensity is Associated with Malignant Cerebral Edema in Ischemic Stroke Treated with Thrombectomy

BACKGROUND

White matter hyperintensity (WMH) burden may lead to poor clinical outcomes after endovascular thrombectomy (EVT). But the relationship between WMH burden and cerebral edema (CED) is unclear.

PURPOSE

To examine the association between WMH burden and CED and functional outcome in patients treated with EVT.

STUDY TYPE

Retrospective.

SUBJECT

344 patients with acute anterior circulation large-vessel occlusion stroke who received EVT at two comprehensive stroke centers. Mean age was 62.6 ± 11.6 years and 100 patients (29.1%) were female.

FIELD STRENGTH/SEQUENCE

3T, including diffusion-weighted imaging and fluid-attenuated inversion recovery (FLAIR) images.

ASSESSMENT

The severity of WMH was evaluated using the Fazekas scale on a FLAIR sequence before EVT. The severity of CED was assessed using CED score (three for malignant cerebral edema [MCE]) and net water uptake (NWU)/time on post-EVT cranial CT. The impact of WMH burden on MCE, NWU/time, and 3-month poor outcome (modified Rankin scale >2) after EVT were assessed.

STATISTICAL TESTS

Pearson's chi-squared test, Fisher exact test, 2-tailed t test, Mann-Whitney U test, multivariable logistic regression, multivariate regression analysis, Sobel test. A P value <0.05 was considered statistically significant.

RESULTS

WMH burden was not significantly associated with MCE and parenchymal hemorrhage (PH) in the whole population (P = 0.072; P = 0.714). WMH burden was significantly associated with an increased risk of MCE (OR, 1.550; 95% CI, 1.128-2.129), higher NWU/time (Coefficient, 0.132; 95% CI, 0.012-0.240), and increased risk of 3-month poor outcome (OR, 1.434; 95% CI, 1.110-1.853) in the subset of patients without PH. Moreover, the connection between WMH burden and poor outcome was partly mediated by CED in patients without PH (regression coefficient changed by 29.8%).

DATA CONCLUSION

WMH burden is associated with CED, especially MCE, and poor outcome in acute ischemic stroke patients treated with EVT. The association between WMH burden and poor outcome may partly be attributed to postoperative CED.

LEVEL OF EVIDENCE: 3

TECHNICAL EFFICACY

Stage 5.

Added value of artificial intelligence solutions for arterial stenosis detection on head and neck CT angiography: A randomized crossover multi-reader multi-case study

PURPOSE

The purpose of this study was to investigate the added value of artificial intelligence (AI) solutions for the detection of arterial stenosis (AS) on head and neck CT angiography (CTA).

MATERIALS AND METHODS

Patients who underwent head and neck CTA examinations at two hospitals were retrospectively included. CTA examinations were randomized into group 1 (without AI-washout-with AI) and group 2 (with AI-washout-without AI), and six readers (two radiology residents, two non-neuroradiologists, and two neuroradiologists) independently interpreted each CTA examination without and with AI solutions. Additionally, reading time was recorded for each patient. Digital subtraction angiography was used as the standard of reference. The diagnostic performance for AS at lesion and patient levels with four AS thresholds (30 %, 50 %, 70 %, and 100 %) was assessed by calculating sensitivity, false-positive lesions index (FPLI), specificity, and accuracy.

RESULTS

A total of 268 patients (169 men, 63.1 %) with a median age of 65 years (first quartile, 57; third quartile, 72; age range: 28-88 years) were included. At the lesion level, AI improved the sensitivity of all readers by 5.2 % for detecting AS ≥ 30 % (P < 0.001). Concurrently, AI reduced the FPLI of all readers and specifically neuroradiologists for detecting non-occlusive AS (all P < 0.05). At the patient level, AI improved the accuracy of all readers by 4.1 % (73.9 % [1189/1608] without AI vs. 78.0 % [1254/1608] with AI) (P < 0.001). Sensitivity for AS ≥ 30 % and the specificity for AS ≥ 70 % increased for all readers with AI assistance (P = 0.01). The median reading time for all readers was reduced from 268 s without AI to 241 s with AI (P< 0.001).

CONCLUSION

AI-assisted diagnosis improves the performance of radiologists in detecting head and neck AS, and shortens reading time.

Emerging ethical issues in patients with disorders of consciousness: A clinical guide

Clinicians who manage patients with disorders of consciousness (DoC) commonly encounter challenging ethical issues. Consciousness disorders include the vegetative state, the minimally conscious state, and covert consciousness resulting from cognitive-motor dissociation. The practice landscape of ethical issues encompasses making the correct diagnosis; making and communicating an accurate prognosis despite irreducible uncertainty; conducting effective shared decision-making with a lawful surrogate decision-maker to deliver goal-concordant care; providing optimal medical, rehabilitative, and palliative care across the spectrum of care sites: acute inpatient, neurorehabilitative, chronic, and palliative; respecting the human rights of and advocating for DoC patient, an historically under-served population and, when appropriate, properly participating in decisions to withhold or withdraw life-sustaining therapy. Research and translational issues in DoC patients include the challenges posed by emerging diagnostics and therapeutics and their prudential integration into clinical practice in the service of patients and their families. Our conceptual analysis of these ethical issues and our practical advice to address them comprise the subject material of this chapter.

Scp776, A Novel IGF-1 Fusion Protein for Acute Therapy to Promote Escape From Apoptosis in Tissues Affected by Ischemic Injury: 2 Randomized Placebo-Controlled Phase 1 Studies in Healthy Adults

Apoptosis is a major driver of cell loss and infarct expansion in ischemic injuries such as acute ischemic stroke (AIS) and acute myocardial infarction (AMI). Insulin-like growth factor-1 (IGF-1) can mitigate cell death and potentiate recovery following acute ischemic injury, but short half-life and nonspecificity limit its therapeutic potential. Scp776 is an IGF-1 fusion protein designed to target damaged tissue and promote apoptosis escape and is in clinical development as an acute therapy for AIS and AMI. Two phase 1 placebo-controlled studies in healthy volunteers evaluated safety, tolerability, pharmacokinetic profile, and pharmacodynamics under single (1, 2, or 4 mg/kg) or multiple (6, 6.2, or 7.25 mg/kg total doses) dosing regimens. In addition, a blood glucose management plan was developed and implemented to mitigate hypoglycemia that may develop following scp776 injection. Scp776 was well tolerated in healthy volunteers (n = 51) without serious adverse events. Exposure increased in a near dose-proportional manner with a mean half-life across all doses of 8 hours. Adaptive dextrose infusions maintained normal blood glucose levels with occasional mild hypoglycemic events. These results informed scp776 dose selection and the design of blood glucose monitoring protocols for phase 2 studies.

The Efficacy of Intensive Statin Therapy in Acute Ischemic Stroke Following Intravenous Thrombolysis: The CASE II Study

AIMS

This study aimed to investigate the efficacy of early intensive statin therapy following intravenous thrombolysis (IVT) in patients with acute ischemic stroke (AIS).

METHODS

AIS patients who received IVT and statin therapy were included from multicenter registry databases. The primary endpoint was functional independence, defined by a modified Rankin Scale (mRS) score of 0-2 at 90 days. Propensity score matching (PSM) analyses were employed.

RESULTS

A total of 21,349 patients were included in this study, with a mean age of 68.5 ± 12.6 years, of whom 13,578 (63.6%) were male. The baseline NIHSS score was 4 (IQR 2-8). A total of 9532 patients (44.6%) received intensive statin therapy. In the PSM analysis, the proportion of patients with mRS scores of 0-2 was significantly higher in the intensive statin therapy group (OR = 1.095, 95% CI 1.022-1.173, p = 0.010). Statin type modified the effect of intensive statin therapy on functional independence (p-value for interaction = 0.030). Treatment effects favoring the intensive approach were observed in patients receiving atorvastatin (OR = 1.134, 95% CI 1.051-1.224, p = 0.001).

CONCLUSION

Early intensive statin therapy following IVT leads to a significant but modest improvement in neurological outcomes, particularly in patients treated with atorvastatin as part of the intensive regimen.

Safety and efficacy of intravenous recombinant human prourokinase for acute ischaemic stroke within 4·5 h after stroke onset (PROST-2): a phase 3, open-label, non-inferiority, randomised controlled trial

BACKGROUND

Intra-arterial prourokinase has been shown to be a promising thrombolytic agent in patients with acute ischaemic stroke. Given the global shortage of thrombolytics, we aimed to assess the non-inferiority of intravenous recombinant human prourokinase compared with alteplase in patients with acute ischaemic stroke who were ineligible for or who refused endovascular thrombectomy.

METHODS

PROST-2 was a phase 3, open-label, non-inferiority, randomised controlled trial conducted at 61 hospitals in China. Patients older than 18 years with acute ischaemic stroke, who were ineligible for or who refused endovascular thrombectomy, were randomly assigned in a 1:1 ratio within 4·5 h of stroke onset to receive intravenous recombinant human prourokinase (15 mg bolus followed by 20 mg infusion within 30 min) or intravenous alteplase (0·9 mg per kg, maximum dose 90 mg; 10% bolus followed by remainder as infusion over 60 min). The primary efficacy outcome was the proportion of patients with a modified Rankin Scale score of 0 or 1 at 90 days, assessed via masked review in the intention-to-treat population, with a non-inferiority margin for the risk ratio of 0·93. The primary safety outcome was the incidence of symptomatic intracranial haemorrhage within 36 h. This trial is registered with ClinicalTrials.gov (NCT05700591) and is now completed.

FINDINGS

Between Jan 29, 2023, and March 14, 2024, 1552 patients were randomly assigned: 775 received recombinant human prourokinase and 777 received alteplase. The primary outcome of a modified Rankin Scale score of 0 or 1 at 90 days was reached by 558 (72·0%) of 775 patients in the recombinant human prourokinase group versus 534 (68·7%) of 777 in the alteplase group (risk ratio 1·04 [95% CI 0·98 to 1·10]; p<0·0001 for non-inferiority). The frequency of symptomatic intracranial haemorrhage within 36 h was lower in the recombinant human prourokinase group than in the alteplase group (two [0·3%] of 770 patients vs ten [1·3%] of 775, risk difference -1·0 percentage points [95% CI -2·1 to -0·1]; p=0·021), as was the incidence of major bleeding at 7 days (four [0·5%] vs 16 [2·1%]; -1·5 percentage points (-2·8 to -0·4); p=0·0072). All-cause mortality within 7 days did not differ between groups (five [0·6%] deaths in the recombinant human prourokinase group vs 13 [1·7%] in the alteplase group; risk difference -1·0 percentage points; 95% CI -2·3 to 0·1]; p=0·060).

INTERPRETATION

In our trial, recombinant human prourokinase was shown to be non-inferior to alteplase for achieving excellent functional outcome, with no difference between groups in safety endpoints. These findings support the use of recombinant human prourokinase as a viable alternative to alteplase for patients with ischaemic stroke who are eligible for intravenous thrombolysis therapy but ineligible for or who have refused endovascular thrombectomy.

FUNDING

Tasly Biopharmaceuticals, National Key R&D Program of China, National Natural Science Foundation of China, Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences, and Beijing Municipal Science & Technology Commission.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.

Endovascular Thrombectomy for Large Core Volume Acute Ischemic Stroke. Updated Systematic Review and Meta-Analysis: Thrombectomy for large core acute ischemic strokes

BACKGROUND

Several recent studies assessed the efficacy and safety of endovascular thrombectomy (EVT) for patients with acute ischemic stroke caused by an anterior circulation large vessel occlusion (LVO) with large core infarct volumes.

METHODS

We performed a systematic review and meta-analysis from inception until July 2024 of all randomized clinical trials (RCTs) and observational studies to date comparing the efficacy and safety of EVT plus best medical management (MM) for acute ischemic stroke due to anterior circulation LVO with large core, versus MM alone. Primary efficacy outcome was optimal functional outcome defined by a 90-day modified Rankin scale score (mRS) of 0-2. Safety outcomes were risk of symptomatic intracranial hemorrhage (sICH) and 90-day mortality. Subgroup analyses were done by study design. Relative risk (RR) and 95 % CIs were calculated using random-effects models and heterogeneity was assessed by I2 statistics.

RESULTS

A total of 16 studies with 3,717 participants met inclusion criteria (6 RCTs and 10 observational studies). The quality of the evidence was moderate to high. Compared with MM alone, EVT increased the outcome of mRS 0-2 (RR = 2.91, 95 % CI [2.12, 4.01], I2 = 63 %), decreased mortality (RR = 0.75 [0.63, 0.88], I2 = 60 %), but did not influence the risk of sICH (I2 = 14 %). When the analysis was restricted to data from RCTs (n = 1,887), EVT increased the outcome of mRS 0-2 (RR = 2.50 [1.89, 3.29], I2 = 8 %) and sICH (RR = 1.71 [1.09, 2.66], I2 = 0 %) but did not affect mortality (I2 = 45 %). In observational studies (n = 1,830), patients receiving EVT had a higher likelihood of achieving an mRS 0-2 (RR = 3.39 [1.98-5.79], I2 = 74 %), lower mortality (RR = 0.63 [1.49-0.82], I2 = 50 %), but equal risk of sICH (I2 = 29) than those receiving MM alone.

CONCLUSION

Among patients with LVO with large core infarct, EVT was associated with improved functional outcome at 90 days. When the analysis was restricted to RCTs, EVT increased the risk of sICH, but did not affect 90-day mortality. However, in real-world (observational) studies, EVT did not modify the risk of sICH but reduced 90-day mortality.

To bridge or not to bridge: The role of intravenous thrombolysis in mechanical thrombectomy for large cerebral infarctions through a two-center cohort study and meta-analysis

BACKGROUND

The effectiveness and safety of intravenous thrombolysis before mechanical thrombectomy (MT) in large cerebral infarctions remains uncertain. This study compares bridging MT, which includes intravenous thrombolysis, to direct MT without it.

METHODS

Data from 298 patients with anterior circulation large cerebral infarctions, assessed via non-enhanced CT (ASPECTS 0-5), who underwent MT in two-center cohort studies, were analyzed. Primary outcomes focused on independent ambulation (modified Rankin Scale scores 0-3) at 90 days post-stroke. Safety outcomes included parenchymal hemorrhage (PH) rates and mortality. We conducted a sensitivity analysis considering the timing from symptom onset to imaging within 4.5 hours. Additionally, a meta-analysis of 17 studies involving 3527 patients assessed the interventions' effectiveness and safety, with further scrutiny of high-quality studies (Newcastle-Ottawa Scale ratings 7-9) to increase robustness of results.

RESULTS

No significant differences were found in 90-day independent ambulation between the bridging MT and the direct MT group (adjusted odds ratio [aOR] 1.15, 95% CI 0.68-1.94). Rates of PH and mortality were also similar across groups. These outcomes were consistent in the subgroup imaged within 4.5 hours of symptom onset. The meta-analysis supported these outcomes, showing no improvement in ambulation (aOR 1.16, 95% CI 0.82-1.64) or reduction in PH with bridging MT. Further analysis of high-quality studies supported these results.

CONCLUSIONS

The cohort study and meta-analysis provide Class II evidence indicating no significant differences in functional outcomes or hemorrhagic risks between bridging and direct MT for large cerebral infarctions. This suggests that direct MT might be a viable alternative to bridging MT.

Neutrophil-to-Lymphocyte Ratio is Associated with Clinical Outcomes in Patients Treated with Mechanical Thrombectomy for Posterior Circulation Large Vessel Occlusion

OBJECTIVE

To investigate the potential of composite inflammatory markers, including the neutrophil-to-lymphocyte ratio (NLR), in predicting outcomes in patients with posterior circulation large vessel occlusion who underwent mechanical thrombectomy (MT).

METHODS

We included patients who underwent MT for posterior circulation large vessel occlusion between February 2016 and December 2021. We then assessed composite inflammatory markers on day 1 post-MT. The primary outcome was the modified Rankin Scale score at 3 months (favorable score: 0-3). The primary safety measure was 3-month mortality. Receiver operating characteristic (ROC) curve analysis determined each marker's predictive values and optimal cutoff values. Multivariable regression analysis assessed the relationship between markers and outcomes.

RESULTS

We included a total of 137 patients (median age: 71 years, 26% female, median National Institutes of Health Stroke Scale score: 23). NLR demonstrated the best predictive value for the prognosis of patients with posterior circulation large vessel occlusion who underwent MT. ROC analysis identified an optimal NLR cutoff of 12.5 (area under curve [AUC]: 0.741, 95% CI: 0.652-0.830) for favorable outcomes and 14.1 (AUC: 0.764, 95% CI: 0.662-0.865) for predicting death. Multivariate analysis determined an NLR <12.5 as an independent predictor of favorable post-MT outcomes (odds ratio [OR]: 10.43, 95% CI: 3.85-28.29, P < 0.001), and NLR <14.1 as an independent predictor of post-MT survival (OR: 0.09, 95% CI: 0.03-0.25, P < 0.001).

CONCLUSIONS

Among the assessed markers, NLR emerged as the strongest predictor of clinical outcomes following MT for posterior circulation large vessel occlusion.

Joint effects of atrial fibrillation and prothrombotic genotypes on the risk of ischemic stroke

BACKGROUND

Atrial fibrillation (AF) is a major risk factor for ischemic stroke. Whether prothrombotic single nucleotide polymorphisms (SNPs) impact stroke risk in AF is not well known.

OBJECTIVES

To investigate the joint effects of 5 prothrombotic SNPs and AF on ischemic stroke risk.

METHODS

A subcohort (n = 14 583) was randomly sampled from the Tromsø (1994-2012) and the Trøndelag Health (1995-2008) studies. DNA was genotyped for rs8176719 (ABO blood type), rs6025 (factor [F]V Leiden), rs1799963 (prothrombin G20210A), rs2066865 (fibrinogen-γ), and rs2036914 (F11). Hazard ratios (HRs) with 95% CIs for incident ischemic stroke were estimated by AF status for individual SNPs and by categories of a genetic risk score.

RESULTS

A total of 1091 participants developed AF during follow-up, of whom 169 (15.5%) subsequently had a stroke. Having ≥1 risk allele in prothrombin, FV Leiden, F11, or fibrinogen-γ was not associated with excess stroke risk in AF. In the absence of AF, ≥1 risk allele(s) in ABO was not associated with stroke (HR, 1.03; 95% CI, 0.85-1.25), whereas those with AF and ≥1 risk allele(s) in ABO had a 1.4-fold increased stroke risk compared with those with AF and no risk allele (HR, 1.42; 95% CI, 0.99-2.04). There was no linear increase in stroke risk across categories of the genetic risk score in participants either with or without AF.

CONCLUSION

Most prothrombotic SNPs were not associated with ischemic stroke risk, regardless of AF status. The ABO SNP was associated with ischemic stroke risk in those with AF only.

Optimal Cerebral Blood Flow Thresholds for Ischemic Core Estimation Using Computed Tomography Perfusion and Diffusion-Weighted Imaging

OBJECTIVE

Computed tomography perfusion (CTP) imaging is crucial in quantifying cerebral blood flow (CBF) and thereby making an endovascular treatment (EVT) after large vessel occlusion. However, CTP is prone to overestimating the ischemic core. We sought to delineate the optimal regional CBF (rCBF) thresholds of pre-EVT CTP.

METHODS

We collected acute ischemic stroke patients due to large vessel occlusion who achieved successful recanalization with baseline CTP, immediate post-EVT diffusion-weighted image (DWI) within 3 hours, and delayed post-EVT DWI between 24 and 196 hours. Core volumes estimated by CTP at various rCBF thresholds were validated against immediate and delayed DWI lesion volumes.

RESULTS

A total of 175 acute large vessel occlusion patients were included. Baseline CTP was taken in a median of 24 minutes (interquartile range [IQR] 21-31 minutes) after arrival; after the CTP, groin puncture in a median of 37 minutes (IQR 28-52 minutes), immediate post-EVT DWI scans in a median of 1.6 hours (IQR 0.8-2.1 hours), and delayed DWI scans in a median of 89 hours (IQR 69-106 hours). The correlations between the rCBF thresholds were the best at rCBF <22% for immediate DWI (0.64; 95% CI 0.55-0.73) and at rCBF <30% for delayed DWI (0.69; 95% CI 0.61-0.76). The interval between CTP and recanalization was inversely correlated with the overestimation of ischemic core volume compared with the subsequent DWI.

INTERPRETATION

Optimal rCBF thresholds for estimating ischemic core using CTP depend significantly on the timing of DWI post-EVT and CTP to recanalization delay. The optimal rCBF thresholds for ischemic core estimation may vary depending on the clinical setting. ANN NEUROL 2024.

Association of the Systemic Inflammation Response Index with Functional Outcome in Acute Large Vessel Occlusion Stroke Patients Receiving Mechanical Thrombectomy

Purpose

The systemic inflammation response index (SIRI) has recently emerged as a novel inflammatory and prognostic marker across various diseases. However, there is limited research examining the relationship between SIRI and 90-day functional outcome in patients with acute large vessel occlusion stroke (ALVOS) undergoing mechanical thrombectomy (MT). This study aimed to investigate the potential of SIRI as an innovative, inflammation-based predictor of 90-day functional outcome.

Methods

This retrospective cohort study consecutively recruited 604 Chinese patients with diagnosed ALVOS who underwent MT at the First College of Clinical Medical Science of China Three Gorges University between July 2017 and April 2023. Comprehensive data, including baseline demographic and clinical characteristics, were systematically extracted from electronic medical records. Poor functional outcome at 90 days was defined as modified Rankin Scale (mRS) score ≥3. We employed logistic regression models, curve fitting, sensitivity analyses, subgroup analyses, and receiver operating characteristic (ROC) curves to validate the association between SIRI and poor outcome, as well as to assess the predictive efficacy.

Results

Final analysis included 604 ALVOS subjects of whom 54.3% experienced poor functional outcome at 90 days. In the multivariate analysis, after adjusting for potential confounders, SIRI remained significantly associated with an elevated risk of poor outcomes (OR 1.18, 95% CI 1.08-1.28, P < 0.001). Nonlinear curve fitting revealed a reverse J-shaped association between SIRI and poor outcomes, with inflection points at 4.5. Subgroup analyses showed no significant interactions (all P for interaction > 0.05), However, atrial fibrillation demonstrated a significant interaction (all P for interaction = 0.001).

Conclusion

SIRI shows promise as a novel prognostic marker for 90-day functional outcome in patients with ALVOS undergoing MT. The identified nonlinear relationship and inflection point may provide valuable insights for risk stratification and clinical decision-making in this specific patient population.

Association of Vascular Risk With Severe vs Non-Severe Stroke: An Analysis of the INTERSTROKE Study

BACKGROUND AND OBJECTIVES

Acute stroke is associated with a spectrum of functional deficits. The objective of this analysis was to explore whether the importance of individual risk factors differ by stroke severity, which may be of relevance to public health strategies to reduce disability.

METHODS

INTERSTROKE is an international case-control study of risk factors of first acute stroke (recruitment 2007-August 2015) in 32 countries. Stroke severity was measured using the modified Rankin Scale (mRS) score within 72 hours of admission to hospital. Severe stroke is defined as mRS scores of 4-6 (and non-severe stroke, score of 0-3). We used multinomial logistic regression to estimate comparative odds ratios (ORs; 95% CIs) for severe and non-severe stroke and tested for heterogeneity (pheterogeneity). We also conducted a matched case-case analysis (matched for age, sex, country, and primary stroke subtype) to determine whether the prevalence of risk factors differed significantly between severe and non-severe stroke. A significant difference in the association of a risk factor of severe stroke compared with non-severe stroke was defined as p < 0.05 for both pheterogeneity and pcase-case.

RESULTS

Of patients with acute stroke (n = 13,460), 64.0% (n = 8,612) were reported to have mRS scores of 0-3 and 36.0% (n = 4,848) scores of 4-6. The mean age was 61.7 years for patients with non-severe stroke and 62.9 years for patients with severe stroke (p = 0.72). 38.1% (n = 3,278) of patients with non-severe stroke and 44.6% (n = 2,162) of patients with severe stroke were female. Hypertension (OR 3.21; 95% CI 2.97-3.47 for severe stroke, OR 2.87; 95% CI 2.69-3.05 for non-severe stroke; pheterogeneity = 0.03; pcase-case < 0.001), atrial fibrillation (OR 4.70; 95% CI 4.05-5.45 for severe stroke, OR 3.61; 95% CI 3.16-4.13 for non-severe stroke; pheterogeneity = 0.009; pcase-case < 0.001), and smoking (OR 1.87; 95% CI 1.72-2.03 for severe stroke, OR 1.65; 95% CI 1.54-1.77 for non-severe stroke; pheterogeneity = 0.02; pcase-case < 0.001) had a stronger association with severe stroke, compared with non-severe stroke. The waist-to-hip ratio had a stronger association with non-severe stroke compared with severe stroke (pheterogeneity < 0.001; pcase-case < 0.001).

DISCUSSION

Hypertension, atrial fibrillation, and smoking had a stronger magnitude of association with severe stroke (compared with non-severe stroke) while the increased waist-to-hip ratio had a stronger magnitude of association with non-severe stroke.

Predicting Futile Recanalization by Cerebral Collateral Recycle Status in Patients with Endovascular Stroke Treatment: The CHANOA Score

RATIONALE AND OBJECTIVES

The correlation between collateral circulation and futile recanalization (FR) is still controversial, and few studies have explored the influence of comprehensive cerebral collateral circulation on FR after endovascular stroke treatment. Therefore, based on cerebral collateral recycle (CCR) status, we aimed to establish an effective scoring system to identify the probability of FR.

METHODS

This was a multicenter retrospective cohort study. FR was defined as a 90-day modified Rankin Scale (mRS) score of 3-6, despite having successful recanalization (modified Thrombolysis in Cerebral Infarction score of 2b-3). The discrimination and calibration of this score were assessed using the area under the receiver operator characteristic curve, calibration curve, and decision curve analysis.

RESULTS

Out of 860 patients receiving endovascular stroke treatment, 478 were enrolled in this study after strict screening. In multivariate regression analysis, the CCR status (poor CCR, adjusted OR[aOR] 9.99, 95%CI 5.11 to 17.06, P < 0.001; moderate CCR, aOR 2.94, 95%CI 1.71 -5.06, P < 0.001), age ≥ 80 years (aOR 3.77, P < 0.001), baseline NIHSS ≥ 15 (aOR 1.81, P = 0.018), baseline ASPECTS ≤ 6 (aOR 1.95, P = 0.006), the time from stroke onset to revascularization (OTR) ≥ 600 min (aOR 2.02, P = 0.007) and any intracranial hemorrhage within 48 h (aOR 3.54, P < 0.001) were significantly associated with FR. These factors make up the CCR-hemorrhage-age-NIHSS-OTR-ASPECTS (CHANOA) score. The CHANOA score demonstrated good discrimination and calibration in this cohort, as well as the fivefold cross validation.

CONCLUSION

The CHANOA score reliably predicted FR in patients with endovascular stroke treatment, based on comprehensive cerebral collateral and clinical features.

Treadmill exercise improves cerebral ischemia injury by regulating microglia polarization via downregulation of MMP12

BACKGROUD

Exercise training is the main strategy for stroke rehabilitation, and it has shown that shifting microglia toward M2 phenotype is beneficial for the recovery of neurological function after stroke. The mechanisms governing exercise training and inflammatory response after cerebral ischemia remain largely unexplored. Herein, the aim of this study was to investigate the role of exercise training in immune response after cerebral ischemia.

METHODS

The transient middle cerebral artery occlusion (MCAO) rat model and primary microglia under oxygen-glucose deprivation/reoxygenation (OGD/R) conditions were used to mimic the ischemic stroke in vivo and in vitro respectively. Treadmill exercise with gradually increased intensity was initiated the second day after MCAO for a maximum of 14 days. The beam balance test, forelimb placement test, cornering test, modified adhesive removal test were used to assess the behavioral recovery. The right peri-infarct cortex was taken from 3 rats per group for RNA sequencing (RNA-seq) analysis. Real-time PCR, western blot, immunofluorescence, and phagocytosis assay was performed after MCAO and/or OGD/R.

RESULTS

Treadmill exercise could significantly improve behavioral outcomes and reduce the infarct volumes. In addition, treadmill exercise switched microglia polarization toward M2 phenotype (Iba+/CD206+) in the peri-infarct cortex, and significantly increased the levels of anti-inflammatory factors (TGF-β, IL10, Arg-1, CD206) and decreased a pool of pro-inflammatory factors (IL-1β, IL-6, TNF-α, iNOS, CD68) in the peri-infarct areas. RNA-seq analysis and further studies demonstrated that exercise training could significantly reduce the expression of MMP12. Through further immunofluorescence co-labeling analysis, we found that treadmill exercise predominantly reduced the expression of MMP-12 in microglia but not in neuron after MCAO. In primary microglia after OGD/R, MMP12 inhibition switched microglia polarization toward to M2 phenotype, increased the expression of M2 markers, and enhanced its phagocytic capacities.

CONCLUSIONS

Our data demonstrate that treadmill exercise could improve the inflammatory microenvironment in the brain after ischemic stroke, which may be caused by inhibition of MMP12 expression. MMP12 suppression in primary microglia could remodel microglia immune functions. In summary, this study may provide novel insights into the immune mechanism of exercise training for stroke and suggests potential targets for therapeutic approaches.

Autologous mitochondrial transplant for acute cerebral ischemia: Phase 1 trial results and review

The results of a Phase 1 trial of autologous mitochondrial transplantation for the treatment of acute ischemic stroke during mechanical thrombectomy are presented. Standardized methods were used to isolate viable autologous mitochondria in the acute clinical setting, allowing for timely transplantation within the ischemic window. No significant adverse events were observed with the endovascular approach during reperfusion therapy. Safety outcomes in study participants were comparable to those of matched controls who did not undergo transplantation. This study represents the first use of mitochondrial transplantation in the human brain, highlighting specific logistical challenges related to the acute clinical setting, such as limited tissue samples and constrained time for isolation and transplantation. We also review the opportunities and challenges associated with further clinical translation of mitochondrial transplantation in the context of acute cerebral ischemia and beyond.

How to diagnose and manage emergency medical conditions in patients on left ventricular assist device support: A clinician's field guide

Left ventricular assist devices (LVADs) have revolutionized the treatment of advanced heart failure, providing mechanical circulatory support for patients awaiting heart transplantation or as destination therapy. However, patients on LVAD support are susceptible to a range of emergency medical conditions that require prompt recognition, intervention, and multidisciplinary management. This review paper aims to provide an algorithmic approach and a field guide on the diagnosis and management of emergency medical conditions in LVAD patients, including LVAD alarms, gastrointestinal bleeding, cerebrovascular accidents, pump thrombosis and obstruction, unresponsiveness, and electrical shock by the defibrillator. By understanding the mechanisms, clinical presentation, diagnostic evaluation, and therapeutic strategies associated with these conditions, healthcare providers can improve patient outcomes and optimize LVAD care.

Transition from alteplase to tenecteplase for treatment of acute ischemic stroke in a rural stroke network of the Midwest: Planning, execution, safety, and outcomes

PURPOSE

This study aims to document the transition from alteplase to tenecteplase within a rural stroke network in the Midwest. It emphasizes the planning and execution of the transition, and evaluates safety and outcomes of tenecteplase compared to alteplase one year after the adoption of the new thrombolytic.

METHODS

This is a retrospective observational study of patients who were treated with thrombolytic therapy for suspected acute ischemic stroke at Southern Illinois Healthcare rural stroke network between July 2017 and July 2024. For each patient, demographics, past medical history, clinical presentation, National Institutes of Health Stroke Scale (NIHSS), and laboratory values were reviewed. Type of thrombolytic was noted. Door-to-needle time (DTN) and complications of thrombolytic therapy including symptomatic ICH (sICH) were reviewed. The primary outcome was the rate of sICH after administration of thrombolytic therapy. Secondary outcomes included target DTN ≤ 60 minutes and modified Rankin Scale (mRS) 0-2 at 30 days.

RESULTS

Out of 279 patients treated with thrombolytics, 215 (77 %) received alteplase, and 64 (23 %) received tenecteplase. The two groups were severity matched, and did not differ in terms of demographics or baseline comorbidities. Median DTN (IQR) was comparable between alteplase and tenecteplase, in minutes ((50 (40-69) vs. 53 (37-65)). In three distinct regression models for each of the predetermined outcomes, accounting for markers of stroke severity, the type of thrombolytic was not associated with development of sICH (OR 1.59, SE 1.445, p = 0.61), target DTN ≤ 60 min (OR 0.996, SE 0.304, p = 0.988), nor mRS 0-2 at 30 days (OR 1.086, SE 0.446, p = 0.842).

CONCLUSIONS

In our population, safety and outcome of thrombolytic therapy for acute ischemic stroke did not differ based on the type of thrombolytic used. Our study highlights the planning and execution of the transition from alteplase to tenecteplase, with challenges faced and lessons learned, and supports the use of tenecteplase in real-world rural practice.

Profile of antiplatelet regimens for emergent carotid stenting in tandem occlusion. Systematic review and meta-analysis

AIM

To investigate the optimum antiplatelet therapy regimen (APTR) for emergent carotid artery stenting following mechanical thrombectomy (MT) in stroke patients with tandem occlusion.

METHODS

A literature search was performed on Pubmed/OVID/Cochran's CENTRAL database for studies from 2015 to 2022. Patient characteristics, antiplatelet regimen type, mTICI, 90 days-mRS, acute in-stent thrombosis (AIST), mortality, intracranial hemorrhage (ICH), and sample size were recorded. Exclusion criteria were non-English literature, sample size < 5 patients, other anticoagulant/antiplatelet therapy, and 100 % stent insertion in one study arm. The studies were assessed using MINORS/GRADE. Meta-analysis and meta-regression with a random effects model were performed. The outcomes were: 90 days-mRS, death, AIST and ICH RESULTS: Five-hundred-twenty-four studies were retrieved. After applying the exclusion criteria, the final population included 19/534 studies (3.6 %) for 880 patients (46.3 per article). I^2 and Q's Cochrane were 86.4 % and 132.5 for mRS, 19.9 % and 17.5 for death, 0 % and 9.4 for acute in-stent thrombosis and 62.1 % and 39.7 for intra-cranial haemorrhages, respectively. Patients in the aspirin subgroup had a significantly lower rate of functional independence (mRS≤2) than those in the DAPT subgroup (47 % [CI95 % 42.0 %-52.0 %] vs. 61.9 % [CI95 % 50.8-72.9]; p=0.0007;OR 0.75[CI95 % 0.56-1.01], p=0.06). DAPT significantly decreased the death rate compared with aspirin (8.6 % [CI95 % 5.3 %-11.9 %] vs. 16.7 % [CI95 11.1 %-22.2 %]; p=0.0012). Anti-GPIIb/IIIa demonstrated a trend of increasing the probability of mortality versus DAPT (OR 1.88[CI95 % 0.93-3.86], p=0.08. No significant differences were observed between AIST and ICH in the treatment groups.

CONCLUSION

DAPT may increases the chance of obtaining an mRS score ≤2 and reduces mortality.

Evolucollateral dynamics in stroke: Evolutionary pathophysiology, remodelling and emerging therapeutic strategies

Leptomeningeal collaterals (LMCs) are crucial in mitigating the impact of acute ischemic stroke (AIS) by providing alternate blood flow routes when primary arteries are obstructed. This article explores the evolutionary pathophysiology of LMCs, highlighting their critical function in stroke and the genetic and molecular mechanisms governing their development and remodelling. We address the translational challenges of applying animal model findings to human clinical scenarios, emphasizing the need for further research to validate emerging therapies-such as pharmacological agents, gene therapy and mechanical interventions-in clinical settings, aimed at enhancing collateral perfusion. Computational modelling emerges as a promising method for integrating experimental data, which requires precise parameterization and empirical validation. We introduce the 'Evolucollateral Dynamics' hypothesis, proposing a novel framework that incorporates evolutionary biology principles into therapeutic strategies, offering new perspectives on enhancing collateral circulation. This hypothesis emphasizes the role of genetic predispositions and environmental influences on collateral circulation, which may impact therapeutic strategies and optimize treatment outcomes. Future research must incorporate human clinical data to create robust treatment protocols, thereby maximizing the therapeutic potential of LMCs and improving outcomes for stroke patients.

Intravenous glibenclamide for cerebral oedema after large hemispheric stroke (CHARM): a phase 3, double-blind, placebo-controlled, randomised trial

BACKGROUND

No treatment is available to prevent brain oedema, which can occur after a large hemispheric infarction. Glibenclamide has previously been shown to improve functional outcome and reduce neurological or oedema-related death in patients younger than 70 years who were at risk of brain oedema after an acute ischaemic stroke. We aimed to assess whether intravenous glibenclamide could improve functional outcome at 90 days in patients with large hemispheric infarction.

METHODS

CHARM was a phase 3, double-blind, placebo-controlled, randomised trial conducted across 143 acute stroke centres in 21 countries. We included patients aged 18-85 years with a large stroke, defined either by an Alberta Stroke Program Early CT Score (ASPECTS) of 1-5 or by an ischaemic core lesion volume of 80-300 mL on CT perfusion or MRI diffusion-weighted imaging. Patients were randomly assigned in a 1:1 ratio to either intravenous glibenclamide (8·6 mg over 72 h) or placebo. The study drug was started within 10 h of stroke onset. The primary efficacy outcome was the shift in the distribution of scores on the modified Rankin Scale at day 90, as a measure of functional outcome. The primary efficacy outcome was analysed in a modified intention-to-treat population, which included all randomly assigned patients aged 18-70 years. The safety population comprised all randomly assigned patients who received a dose. This trial is registered with ClinicalTrials.gov (NCT02864953). The trial was stopped early by the sponsor for strategic and operational reasons (slow enrolment because of COVID-19), before any unblinding or knowledge of the trial results.

FINDINGS

Between Aug 29, 2018, and May 23, 2023, 535 patients were enrolled and randomly assigned, of whom 518 received a dose (safety population) and 431 were aged 18-70 years and comprised the modified intention-to-treat population (217 were assigned glibenclamide and 214 placebo). The mean age of patients was 58·7 (SD 9·0) years in the placebo group and 58·0 (9·5) years in the glibenclamide group; the median US National Institutes of Health Stroke Scale (NIHSS) score was 19 (IQR 16-23) in the placebo group and 19 (IQR 16-22) in the glibenclamide group; and the mean time from stroke onset to study drug start was 8·9 h (SD 2·1) in the placebo group and 9·2 h (2·1) in the glibenclamide group. Intravenous glibenclamide was not associated with a favourable shift in the modified Rankin scale at 90 days (common odds ratio [OR] 1·17 [95% CI 0·80-1·71], p=0·42). 90-day mortality was 29% (61 of 214) in the placebo group and 32% (70 of 217) in the glibenclamide group (hazard ratio 1·20 [0·85-1·70]; p=0·30). Serious adverse events in the prespecified safety population were consistent with the known safety profile of glibenclamide and included hypoglycaemia in 15 (6%) of 259 patients in the glibenclamide group and in four (2%) of 259 patients in the placebo group, leading to dose interruption or reduction in seven (3%) patients in the glibenclamide group and in one (<1%) in the placebo group.

INTERPRETATION

Intravenous glibenclamide did not improve functional outcome in patients aged 18-70 years after large hemispheric infarction, although the trial was underpowered to make definitive conclusions because it was stopped early. Future prospective evaluation could be warranted to identify a possible benefit of intravenous glibenclamide in specific subgroups.

FUNDING

Biogen.

Epidemiology of stroke in France

BACKGROUND

It has been nearly 10years since the first national stroke plan in France.

AIMS

To examine the epidemiology of strokes, how they are managed and patient outcomes.

METHODS

Adults hospitalized for stroke in 2022 were identified in the national database. Stroke prevalence at 1 January 2023 was defined as the number of people alive at that date with a history of hospitalization for stroke or a chronic long-term disease status due to stroke (2012-2022). Patients were monitored up for up to 1year after hospitalization for a stroke.

RESULTS

In 2022, 122,422 adults were hospitalized due to stroke, and there were an estimated 1,086,795 cases. Important geographical and socioeconomic disparities were observed. Admission to a stroke intensive care unit was found in 46.8% of patients, with significant variations by department of residence, age and gender. Only 7.2% of ischaemic strokes resulted in mechanical thrombectomy. Among survivors at 6months, admission to a rehabilitation unit was found for 34.3% for patients with ischaemic strokes and 41.7% of those with haemorrhagic strokes, while 28.8% and 18.8%, respectively, had a consultation with a neurologist, and 19.5% and 10.9% were seen by a cardiologist within 6months. Mortality rates after 1year were 20.8% and 37.9% among patients hospitalized due to ischaemic and haemorrhagic strokes, respectively.

CONCLUSION

The considerable numbers and rates of stroke - and disparities by age, sex and area - highlight the need for more effective stroke prevention, regular information campaigns on the symptoms of stroke and improved availability and accessibility of stroke units.