Impact of smoking on stroke outcome after endovascular treatment

Predictors of Good Functional Outcome in Patients with Tandem Occlusion After Revascularization Treatment: Single-Center Experience with 12-Month Follow-Up

OBJECTIVE

The optimal management and procedural strategy for tandem occlusion (TO) in acute ischemic stroke are still unclear, as is the long-term outcome of these patients. The aim of this study was to evaluate predictors of good functional outcome in patients with TO through the analysis of demographics, clinical, and radiological data with a 1-year follow-up.

METHODS

We collected data on 100 patients with TO who underwent revascularization treatments in our comprehensive stroke center. We divided patients into 2 groups: those with good functional outcome, defined as a modified Rankin Scale 0-2, and those with poor functional outcome, defined as a modified Rankin Scale 3-6 at 3, 6, and 12-month follow-up. Moreover, we investigated which variables were able to influence mortality.

RESULTS

At multivariate analysis, endovascular treatment with mechanical thrombectomy combined with emergent cervical carotid artery stenting was an independent predictor of good functional outcome at 6 and 12 months (adjusted odds ratio [aOR] 4.3, confidence interval [CI] 1.49-12.31, P = 0.007) (aOR 3.5, CI 1.25-9.61, P = 0.017) and was associated with a lower rate of mortality at 3 and 6 months follow-up (aOR 0.14, CI 0.04-0.57, P = 0.006 and aOR 0.296, CI 0.97-0.902, P = 0.032, respectively). Furthermore, smoking habit was associated with a better outcome at 3-month follow-up (aOR 10.7, CI 2.2-51.6, P = 0.003) but not at 6- and 12-month.

CONCLUSIONS

Our research, conducted in a small sample size of patients with acute ischemic stroke due to TO of anterior circulation, found that acute stent placement seems to be safe, improving clinical outcome, and it is associated with low rate of mortality at long-term follow-up.

Effect of smoking status on clinical outcomes after reperfusion therapy for acute ischemic stroke

Smoking has detrimental effects on the cardiovascular system; however, some studies have reported better clinical outcomes after thrombolysis for ischemic stroke in smokers than in nonsmokers, a phenomenon known as the smoking paradox. Therefore, this study aimed to examine the smoking paradox in patients with ischemic stroke receiving reperfusion therapy. Data were collected from a multicenter hospital-based acute stroke registry in Fukuoka, Japan. The 1148 study patients were categorized into current and noncurrent smokers. The association between smoking and clinical outcomes, including neurological improvement (≥ 4-point decrease in the National Institutes of Health Stroke Scale during hospitalization or 0 points at discharge) and good functional outcomes (modified Rankin Scale score of 0-2) at 3 months, was evaluated using logistic regression analysis and propensity score-matched analysis. Among the participants, 231 (20.1%) were current smokers. The odds ratios (ORs) of favorable outcomes after adjusting for potential confounders were not significantly increased in current smokers (OR 0.85, 95% confidence interval [CI] 0.60-1.22 for neurological improvement; OR 0.95, 95% CI 0.65-1.38 for good functional outcome). No significant association was found in the propensity score-matched cohorts. Smoking cessation is strongly recommended since current smoking was not associated with better outcomes after reperfusion therapy.

Clinical predictors of prognosis in stroke patients after endovascular therapy

Endovascular therapy (EVT) is effective in the treatment of large vascular occlusive stroke. However, many factors are associated with the outcomes of acute ischemic stroke (AIS) after EVT. This study aimed to identify the main factors related to the prognosis of AIS patients after EVT. We analyzed the clinical data of AIS patients in the neurology department of our medical center from June 2017 to August 2021 following treatment with EVT. The data included the patients' blood pressure upon admission, blood glucose concentration, National Institutes of Health Stroke Scale (NIHSS) score, 90-day modified Rankin scale (mRs) score follow-up data, and time from LKN to the successful groin puncture (GP). A good outcome was defined as a 90-day mRs score of 0-2, and a poor outcome was defined as a 90-day mRs score of 3-6. A total of 144 patients were included in the study. Admission, smoking, and LKN-to-GP time, NIHSS score of 6-12 was found to be relevant to the prognosis. The results of multivariate analysis showed that prognosis was significantly influenced by baseline NIHSS (odds ratio = 3.02; 95% confidence interval, 2.878-4.252; P = 0.001), LKN-to-GP time (odds ratio = 2.17; 95% confidence interval, 1.341-2.625; P = 0.003), and time stratification (6-12 h) (odds ratio = 4.22; 95% confidence interval, 2.519-5.561; P = 0.001). Our study indicated that smoking, baseline NIHSS score, and LKN-to-GP time were the risk factors for a poor outcome in stroke patients following an EVT. Quitting smoking and shortening LKN time to GP should improve the outcome of AIS after EVT.

Smoke Signals: Unraveling the Paradoxical Impact of Smoking on Stroke Prognosis and Treatment Efficacy

Smoking is a well-established risk factor for stroke, yet its impact on stroke prognosis remains complex and multifaceted. This systematic review aims to elucidate the relationship between smoking and various stroke outcomes, including response to treatment and long-term recovery. We conducted a comprehensive analysis of four fundamental studies that examined the prognosis of stroke in smokers, focusing on clinical outcomes post-endovascular treatment, response to antiplatelet therapy, incidence of post-stroke delirium, and the effectiveness of thrombolysis treatment. The studies varied in design, including observational, retrospective, and post hoc trial analyses. The review reveals that smoking may paradoxically predict better clinical outcomes in specific treatment scenarios, such as post-endovascular treatment and when using clopidogrel. However, smokers also demonstrated higher rates of ischemic stroke and post-stroke delirium. Notably, the smoker's paradox in thrombolysis treatment was not supported. These findings highlight the need for personalized treatment approaches based on smoking status. Smoking has a complex and significant impact on stroke prognosis. While some benefits in specific treatment contexts were observed, the overall evidence strongly advises against smoking due to its adverse health consequences. This review underscores the importance of personalized stroke management in smokers and the integration of smoking cessation programs in post-stroke care. Future research should focus on larger, longitudinal studies to explore these associations further.

Impact of smoking on one year functional outcomes after thrombectomy for young stroke patients

BACKGROUND

The incidence of stroke in young patients (20-50 years old) has increased in recent decades. Unlike the use of good functional outcomes to evaluate prognosis, excellent functional outcomes are a better indicator of return to work among younger patients. The rate of return to work increases with time after stroke. This study investigated the short term (3 months) and long term (1 year) predictors of excellent functional outcomes in young patients after endovascular thrombectomy (EVT).

METHODS

We included young patients who underwent EVT for acute ischemic stroke (AIS) due to large vessel occlusion within 6 hours after stroke onset between 2015 and 2021. Patients with intracerebral hemorrhage on pretreatment CT were excluded. The associations between clinical, imaging, and procedure variables, and excellent functional outcomes were analyzed using univariate and multivariable logistic regression analyses. An excellent functional outcome was defined as a modified Rankin Scale score of ≤1.

RESULTS

Of the 361 patients with AIS eligible for EVT, 55 young patients (aged 24-50 years) were included. Of these, 36.4% and 41.8% achieved excellent functional outcomes at 3 and 12 months, respectively. Multivariate analysis revealed that smoking was the independent negative predictor of both 3 month (adjusted OR (aOR) 0.232, 95% CI 0.058 to 0.928; p=0.039) and 12 month (aOR 0.180, 95% CI 0.044 to 0.741; p=0.018) excellent functional outcomes.

CONCLUSIONS

Current or former smoking habit was an independent negative predictor of both short term and long term excellent functional outcomes in young adults with AIS.

Impact of smoking on outcomes following endovascular therapy for acute ischemic stroke: A systematic review and meta-analysis

BACKGROUND

Smoking represents a leading risk factor for acute ischemic stroke (AIS). Previous literature has described a "smoking paradox", wherein smokers experience better outcomes following intravenous thrombolysis for AIS. It is unclear whether such a phenomenon exists in smokers undergoing endovascular therapy (EVT) for AIS. To assess outcomes in smokers following EVT for AIS, we conducted a systematic review and meta-analysis.

METHODS

Following the PRISMA guidelines, a systematic literature review of the English language literature was conducted using PubMed, Embase Web of Science, and Scopus. Outcomes of interest included 90-day modified Rankin Scale (mRS) 0-2, thrombolysis in cerebral infarction (TICI) score 2b-3, symptomatic intracranial hemorrhage (sICH), and mortality. We calculated mean difference (MD), pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CI).

RESULTS

Eight studies with 2633 patients comprised our analysis. On average, smokers were 10.14 years (MD  =  10.14, [95% CI  =  -14.49 to -5.79], P-value < 0.001) younger than non-smokers. Smokers achieved mRS 0-2 (OR =  1.82, [95% CI, 1.34-2.48], P-value < 0.001) and TICI 2b-3 (OR =  1.61, [95% CI, 1.19-2.19], P-value  =  0.002) at a higher rate than non-smokers. sICH rates were comparable between smokers and non-smokers (OR =  1.07, [95% CI, 0.62-1.85], P-value  =  0.81). Smokers had a lower rate of 90-day mortality than non-smokers (OR =  0.54, [95% CI, 0.41-0.71], P-value < 0.001).

CONCLUSIONS

In this meta-analysis of eight studies, we found that smokers with AIS undergoing EVT experienced better 90-day outcomes and higher rates of TICI 2b-3. This may be due to baseline differences between smokers and non-smokers, but future studies should explore alternative reasons that could explain this relationship between smoking and AIS treated with EVT.

Resolving the Smoking Paradox: No Evidence for Smoking-Induced Preconditioning in Large Vessel Occlusion Stroke

INTRODUCTION

Smoking is an established risk factor for stroke. However, several studies have reported a better outcome after stroke for patients who smoke. According to this "smoking paradox" hypothesis, smoking might promote less severe strokes, higher collateral scores, and smaller infarct cores.

METHODS

In this retrospective study, we screened data of 2,980 acute ischemic stroke patients with MCA-M1 occlusion treated with mechanical thrombectomy. Patients were categorized according to smoking status (current, former, or never). We assessed univariate associations between clinical characteristics and smoking status. Subsequently, we used adjusted regression analysis to evaluate associations of smoking with stroke severity on admission (National Institutes of Health Stroke Scale [NIHSS]; primary endpoint), infarct core volume, and collateral status (secondary endpoints).

RESULTS

Out of 320 patients, 19.7% (n = 63) were current smokers and 18.8% (n = 60) were former smokers. Admission NIHSS, reperfusion success, and modified Rankin Scale (mRS) after 3-6 months were similar in all groups. Current smokers were younger, more often male and less likely to have atrial fibrillation compared to former and never smokers. In regression analyses, smoking status was neither associated with admission NIHSS (estimate 0.54, 95% confidence interval [CI]: -1.27-2.35, p = 0.557) nor with collateral status (estimate 0.79, 95% CI: 0.44-1.44, p = 0.447) or infarct core volume (estimate -0.69, 95% CI: -15.15-13.77, p = 0.925 for current vs. never smokers).

CONCLUSION

We could not confirm the smoking paradox. Our results support the fact that smoking causes stroke at a younger age, highlighting the role of smoking as a modifiable vascular risk factor.

Machine learning to predict futile recanalization of large vessel occlusion before and after endovascular thrombectomy

Background and purpose

Futile recanalization occurs when the endovascular thrombectomy (EVT) is a technical success but fails to achieve a favorable outcome. This study aimed to use machine learning (ML) algorithms to develop a pre-EVT model and a post-EVT model to predict the risk of futile recanalization and to provide meaningful insights to assess the prognostic factors associated with futile recanalization.

Methods

Consecutive acute ischemic stroke patients with large vessel occlusion (LVO) undergoing EVT at the National Advanced Stroke Center of Nanjing First Hospital (China) between April 2017 and May 2021 were analyzed. The baseline characteristics and peri-interventional characteristics were assessed using four ML algorithms. The predictive performance was evaluated by the area under curve (AUC) of receiver operating characteristic and calibration curve. In addition, the SHapley Additive exPlanations (SHAP) approach and partial dependence plot were introduced to understand the relative importance and the influence of a single feature.

Results

A total of 312 patients were included in this study. Of the four ML models that include baseline characteristics, the “Early” XGBoost had a better performance {AUC, 0.790 [95% confidence intervals (CI), 0.677–0.903]; Brier, 0.191}. Subsequent inclusion of peri-interventional characteristics into the “Early” XGBoost showed that the “Late” XGBoost performed better [AUC, 0.910 (95% CI, 0.837–0.984); Brier, 0.123]. NIHSS after 24 h, age, groin to recanalization, and the number of passages were the critical prognostic factors associated with futile recanalization, and the SHAP approach shows that NIHSS after 24 h ranks first in relative importance.

Conclusions

The “Early” XGBoost and the “Late” XGBoost allowed us to predict futile recanalization before and after EVT accurately. Our study suggests that including peri-interventional characteristics may lead to superior predictive performance compared to a model based on baseline characteristics only. In addition, NIHSS after 24 h was the most important prognostic factor for futile recanalization.

Impact of Stroke Severity on the Smoking Paradox in Patients Treated with Intravenous Thrombolysis

OBJECTIVE

To our knowledge, no previous studies have investigated the impact of stroke severity on the smoking paradox after intravenous thrombolysis (IVT). We aimed to explore the contribution of stroke severity to the association between smoking and stroke prognosis after IVT.

METHODS

We enrolled consecutive patients who received IVT within 4.5 hours from stroke onset. A logistic regression model was used to estimate the unadjusted and adjusted odds ratios (ORs) with their 95% confidence intervals (CIs) for poor functional outcome and mortality at 3 months.

RESULTS

Among patients with moderate stroke, smokers experienced a lower risk of 3-month poor outcomes than non-smokers (33.0% vs. 44.4%, unadjusted OR: 0.616; 95% CI: 0.402-0.945). However, among those with severe stroke, smokers had a higher risk of 3-month poor outcomes than non-smokers (81.6% vs. 55.9%, unadjusted OR: 3.496; 95% CI: 1.207-10.127). After adjustment, the negative correlation between smoking and 3-month poor outcome following IVT lost statistical significance in patients with moderate stroke (OR: 0.677 [95% CI: 0.418-1.097]). However, smoking remained a risk factor for 3-month poor outcomes in patients with severe stroke (OR: 4.216 [95% CI: 1.236-14.385]). We also observed a significant interaction between smoking and stroke severity with regard to the risk of poor functional outcomes (p=0.023). However, no such interaction influenced mortality (p=0.901).

CONCLUSION

Stroke severity affects the association between smoking and 3-month clinical functional outcomes following IVT.

Clinical outcomes of rescue stenting for failed endovascular thrombectomy: a multicenter prospective registry

BACKGROUND

Mechanical thrombectomy (MT) is a primary endovascular modality for acute intracranial large vessel occlusion. However, further treatment, such as rescue stenting, is occasionally necessary for refractory cases. We aimed to investigate the efficacy and safety of rescue stenting in first-line MT failure and to identify the clinical factors affecting its clinical outcome.

METHODS

A multicenter prospective registry was designed for this study. We enrolled consecutive patients who underwent rescue stenting for first-line MT failure. Endovascular details and outcomes, follow-up patency of the stented artery, and clinical outcomes were summarized and compared between the favorable and unfavorable outcome groups.

RESULTS

A total of 78 patients were included. Intracranial atherosclerotic stenosis was the most common etiology for rescue stenting (97.4%). Seventy-seven patients (98.7%) were successfully recanalized by rescue stenting. A favorable outcome was observed in 66.7% of patients. Symptomatic intracranial hemorrhage and mortality were observed in 5.1% and 4.0% of patients, respectively. The stented artery was patent in 82.1% of patients on follow-up angiography. In a multivariable analysis, a patent stent on follow-up angiography was an independent factor for a favorable outcome (OR 87.6; 95% CI 4.77 to 1608.9; p=0.003). Postprocedural intravenous maintenance of glycoprotein IIb/IIIa inhibitor was significantly associated with the follow-up patency of the stented artery (OR 5.72; 95% CI 1.45 to 22.6; p=0.013).

CONCLUSIONS

In this multicenter prospective registry, rescue stenting for first-line MT failure was effective and safe. For a favorable outcome, follow-up patency of the stented artery was important, which was significantly associated with postprocedural maintenance of glycoprotein IIb/IIIa inhibitors.

Smoking-Induced Sex Differences in Clinical Outcomes in Patients Undergoing Mechanical Thrombectomy for Stroke

OBJECTIVE

Ischemic stroke is the fifth leading cause of death in the United States. Smoking accelerates the onset of stroke by 10 years. The effects of smoking status on percent change in National Institutes of Health Stroke Scale (NIHSS) score, infarct volume, and edema volume were examined following mechanical thrombectomy for large vessel occlusion in patients with acute ischemic stroke.

METHODS

Subjects (N = 90; >18 years old) were divided into 3 groups based on smoking status: current smokers, previous smokers (defined as having quit >6 months before the ischemic event), and nonsmokers. Percent change in NIHSS score was defined as score at admission minus score at discharge divided by score at admission and was used as a predictor of functional outcome. Linear regression analysis was performed based on infarct or edema volume versus percent change in NIHSS score and separated by sex.

RESULTS

Consistent with previous findings, smokers experienced a stroke 10 years earlier than nonsmokers (P = 0.004). Statistically significant linear regressions existed between infarct volume or edema volume in relation to worsening change in NIHSS score with female smokers only. Stroke-induced tissue damage, as measured by magnetic resonance imaging or computed tomography, was predictive of functional recovery only in female smokers.

CONCLUSIONS

These findings are valuable for patient counseling, particularly for women, for smoking cessation.

The smoking paradox in ischemic stroke patients treated with intra-arterial thrombolysis in combination with mechanical thrombectomy-VISTA-Endovascular

BACKGROUND

The smoking-paradox of a better outcome in ischemic stroke patients who smoke may be due to increased efficacy of thrombolysis. We investigated the effect of smoking on outcome following endovascular therapy (EVT) with mechanical thrombectomy alone versus in combination with intra-arterial (IA-) thrombolysis.

METHODS

The primary endpoint was defined by three-month modified Rankin Scale (mRS). We performed a generalized linear model and reported relative risks (RR) for smoking (adjustment for age, sex, hypertension, atrial fibrillation, stroke severity, time to EVT) in patient data stemming from the Virtual International Stroke Trials Archive-Endovascular database.

RESULTS

Among 1,497 patients, 740(49.4%) were randomized to EVT; among EVT patients, 524(35.0%) received mechanical thrombectomy alone and 216(14.4%) received it in combination with IA-thrombolysis. Smokers (N = 396) had lower mRS scores (mean 2.9 vs. 3.2; p = 0.02) and mortality rates (10% vs. 17.3%; p<0.001) in univariate analysis. In all patients and in patients treated with mechanical thrombectomy alone, smoking had no effect on outcome in regression analyses. In patients who received IA-thrombolysis (N = 216;14%), smoking had an adjusted RR of 1.65 for an mRS≤1 (95%CI 0.77-3.55). Treatment with IA-thrombolysis itself led to reduced RR for favorable outcome (adjusted RR 0.30); interaction analysis of IA-thrombolysis and smoking revealed that non-smokers with IA-thrombolysis had mRS≤2 in 47 cases (30%, adjusted RR 0.53 [0.41-0.69]) while smokers with IA-thrombolysis had mRS≤2 in 23 cases (38%, adjusted RR 0.61 [0.42-0.87]).

CONCLUSIONS

Smokers had no clear clinical benefit from EVT that incorporates IA-thrombolysis.

Smoking Does Not Alter Treatment Effect of Intravenous Thrombolysis in Mild to Moderate Acute Ischemic Stroke-A Dutch String-of-Pearls Institute (PSI) Stroke Study

Background: The smoking-thrombolysis paradox refers to a better outcome in smokers who suffer from acute ischemic stroke (AIS) following treatment with thrombolysis. However, studies on this subject have yielded contradictory results and an interaction analysis of exposure to smoking and thrombolysis in a large, multicenter database is lacking.

Methods: Consecutive AIS patients admitted within 12 h of symptom onset between 2009 and 2014 from the prospective, multicenter stroke registry (Dutch String-of-Pearls Stroke Study) were included for this analysis. We performed a generalized linear model for functional outcome 3 months post-stroke depending on risk of the exposure variables (smoking yes/no, thrombolysis yes/no). The following confounders were adjusted for: age, smoking, hypertension, atrial fibrillation, diabetes mellitus, stroke severity, and stroke etiology.

Results: Out of 468 patients, 30.6% (N = 143) were smokers and median baseline NIHSS was 3 (interquartile range 1–6). Smoking alone had a crude and adjusted relative risk (RR) of 0.99 (95% CI 0.89–1.10) and 0.96 (95% CI 0.86–1.01) for good outcome (modified Rankin Score ≤ 2), respectively. A combination of exposure variables (smoking and thrombolysis) did not change the results significantly [crude RR 0.87 (95% CI 0.74–1.03], adjusted RR 1.1 (95%CI 0.90–1.30)]. Smoking alone had an adjusted RR of 1.2 (95% CI 0.6–2.7) for recanalization following thrombolysis (N = 88).

Conclusions: In patients with mild to moderate AIS admitted within 12 h of symptom onset, smoking did not modify treatment effect of thrombolysis.

Serum immunoglobulin G antibody titer to Fusobacterium nucleatum is associated with unfavorable outcome after stroke

Stroke can be a cause of death, while in non-fatal cases it is a common cause of various disabilities resulting from associated brain damage. However, whether a specific periodontal pathogen is associated with increased risk of unfavorable outcome after stroke remains unknown. We examined risk factors for unfavorable outcome following stroke occurrence, including serum antibody titers to periodontal pathogens. The enrolled cohort included 534 patients who had experienced an acute stroke, who were divided into favorable (n = 337) and unfavorable (n = 197) outcome groups according to modified ranking scale (mRS) score determined at 3 months after onset (favorable = score 0 or 1; unfavorable = score 2-6). The associations of risk factors with unfavorable outcome, including serum titers of IgG antibodies to 16 periodontal pathogens, were examined. Logistic regression analysis showed that the initial National Institutes of Health stroke scale score [odds ratio (OR) = 1·24, 95% confidence interval (CI) = 1·18-1·31, P < 0·001] and C-reactive protein (OR = 1·29, 95% CI = 1·10-1·51, P = 0·002) were independently associated with unfavorable outcome after stroke. Following adjustment with those, detection of the antibody for Fusobacterium nucleatum ATCC 10953 in serum remained an independent predictor of unfavorable outcome (OR = 3·12, 95% CI = 1·55-6·29, P = 0·002). Determination of the antibody titer to F. nucleatum ATCC 10953 in serum may be useful as a predictor of unfavorable outcome after stroke.

Smoking Status and Functional Outcomes After Acute Ischemic Stroke

Background and Purpose—

Smoking is an established risk factor for stroke; however, it is uncertain whether prestroke smoking status affects clinical outcomes of acute ischemic stroke. This study aimed to elucidate the association between smoking status and functional outcomes after acute ischemic stroke.

Methods—

Using a multicenter hospital-based stroke registry in Japan, we investigated 10 825 patients with acute ischemic stroke hospitalized between July 2007 and December 2017 who had been independent before stroke onset. Smoking status was categorized into those who had never smoked (nonsmokers), former smokers, and current smokers. Clinical outcomes included poor functional outcome (modified Rankin Scale score ≥2) and functional dependence (modified Rankin Scale score 2–5) at 3 months. We adjusted for potential confounding factors using a logistic regression analysis.

Results—

The mean age of patients was 70.2±12.2 years, and 37.0% were women. There were 4396 (42.7%) nonsmokers, 3328 (32.4%) former smokers, and 2561 (24.9%) current smokers. The odds ratio (95% CI) for poor functional outcome after adjusting for confounders increased in current smokers (1.29 [1.11–1.49] versus nonsmokers) but not in former smokers (1.05 [0.92–1.21] versus nonsmokers). However, among the former smokers, the odds ratio of poor functional outcome was higher in those who quit smoking within 2 years of stroke onset (1.75 [1.15–2.66] versus nonsmokers). The risk of poor functional outcome tended to increase as the number of daily cigarettes increased in current smokers ( P for trend=0.002). All these associations were maintained for functional dependence.

Conclusions—

Current and recent smoking is associated with an increased risk of unfavorable functional outcomes at 3 months after acute ischemic stroke.

Registration—

URL: http://www.fukuoka-stroke.net/english/index.html . Unique identifier: 000000800.

Current Smoking Does Not Modify the Treatment Effect of Intravenous Thrombolysis in Acute Ischemic Stroke Patients-A Post-hoc Analysis of the WAKE-UP Trial

Background: The “smoking paradox” indicates that patients with acute ischemic stroke (AIS) who smoke at the time of their stroke may have a better prognosis after intravenous thrombolysis than non-smokers. However, findings are inconsistent and data analyzing the effect of smoking on treatment efficacy of intravenous thrombolysis are scarce.

Methods: We performed a pre-specified post-hoc subgroup analysis of the Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke (WAKE-UP) trial that randomized AIS patients with unknown time of symptom onset who had diffusion-weighted imaging-fluid attenuation inversion recovery (DWI-FLAIR) mismatch to either alteplase or placebo. Patients were categorized as current smokers or non-smokers (including former smokers and never-smokers). Baseline demographic and clinical characteristics, as well as clinical and imaging follow-up data were analyzed according to smoking status.

Results: Four hundred and eighty six patients were included in the analysis. Current smokers (133, 27.4%) were younger (60.1 ± 13.0 vs. 67.2 ± 10.3 years; p < 0.001) and less often had arterial hypertension (45.0% vs. 56.8%; p = 0.02) or atrial fibrillation (3.8% vs. 15.3%; p < 0.001). The acute stroke presentation was more often due to large vessel occlusion among current smokers (27.1 vs. 16.2%; p = 0.01), and smokers had a trend towards more severe strokes (National Institutes of Health Stroke Scale score>10 in 27.1% vs. 19.5%; p = 0.08). The treatment effect of alteplase, quantified as odds ratio for a favorable outcome (modified Rankin Scale [mRS] score at 90 days of 0 or 1), did not differ between current smokers and non-smokers (p-value for interaction: 0.59). After adjustment for age and stroke severity, neither the proportion of patients with favorable outcome, nor the median mRS score at 90 days differed between current smokers and non-smokers. When additional potential confounders were included in the model, the median mRS score was higher in current smokers than in non-smokers (cOR of better outcome for current smokers vs. non-smokers: 0.664 [0.451–0.978], p = 0.04).

Conclusions: In patients with mild to moderate MRI-proven AIS and unknown time of symptom onset with DWI-FLAIR mismatch, current smokers had worse functional outcome as compared to non-smokers. Current smoking did not modify the treatment effect of alteplase.

Clinical Trial registration: Main trial (WAKE-UP): ClinicalTrials.gov, NCT01525290; and EudraCT, 2011-005906-32. Registered 02 February 2012.

"Smoking paradox" is not true in patients with ischemic stroke: a systematic review and meta-analysis

Background

Ischemic stroke (IS) is a common cause of death from vascular diseases. Studies have found that smoking increases the risk of ischemic stroke, but the association of smoking with the outcome of IS remains unclear. This meta-analysis aims to investigate the effect of smoking on the prognosis of IS.

Methods

We searched four electronic databases including PubMed, EMBASE, Cochrane library and Web of science for papers, published before January 2019. In this meta-analysis, Review Manager 5.3 software was used to calculate for the pooled estimate effect, as well as the inverse-variance method for pooled mean difference (MD) and odds ratio (OR) of incidence in two groups of population.

Results

A total of 14,789 citations were identified during the literature search, 21 studies were included in the meta-analyses after screening. The full-adjusted OR of poor prognostic outcome in smoking and nonsmoking patients with stroke was pooled as 0.96 (95% CI 0.77–1.21), suggested that smoking or not has no impact on prognosis of IS. The pooled MD of onset age between smoking and nonsmoking IS patients was − 10.05 (− 12.91, − 7.19), indicated that smoking causes first onset of IS to occur 10 years earlier.

Conclusions

This meta-analysis showed that smoking was not a protective factor for poor prognosis of IS. Smoking patients with IS are 10 years younger than nonsmoking patients at time of the first onset of stroke.

Predictors of Parenchymal Hematoma After Mechanical Thrombectomy: A Multicenter Study

Background and Purpose

Parenchymal hematoma (PH) is a rare but dreadful complication of acute ischemic stroke with unclear underlying mechanisms. We aimed to study the incidence and predictors of PH after mechanical thrombectomy.

Methods

Data from a prospective observational multicenter registry was screened to identify acute ischemic stroke patients with an anterior circulation large vessel occlusion who underwent mechanical thrombectomy. Clinical, imaging, and procedural characteristics were used for the analysis, including brain imaging systematically performed at 24 hours. PH occurrence was assessed according to ECASS (European Collaborative Acute Stroke Study) criteria. Univariate and multivariable analyses were performed to identify predictors of PH.

Results

A total of 1316 patients were included in the study. PH occurred in 153 out of 1316 patients (11.6%) and was associated with a lower rate of favorable outcome and increased mortality. On multivariable analysis, age (per 1 year increase, odds ratio [OR], 1.01; 95% CI, 1.00–1.03; P=0.05), current smoking (OR, 2.02; 95% CI, 1.32–3.09; P<0.01), admission Alberta Stroke Program Early CT Score (per a decrease of 1 point, OR, 1.70; 95% CI, 1.18–2.44; P<0.01), general anesthesia (OR, 1.98; 95% CI, 1.36–2.90; P<0.001), angiographic poor collaterals (OR, 2.13; 95% CI, 1.36–3.33; P<0.001) and embolization in new territory (OR, 2.94; 95% CI, 1.70–5.10; P<0.001) were identified as independent predictors of PH.

Conclusions

PH occurred at a rate of 11.6% after mechanical thrombectomy, with high morbidity and mortality. Our study identified clinical, radiological, and procedural predictors of PH occurrence that can serve as the focus of future periprocedural management studies with the aim of reducing its occurrence.

Cerebrovascular accidents differ between patients with atrial flutter and patients with atrial fibrillation

INTRODUCTION

Few studies have explored the potential impact of atrial flutter (AFl) on ischaemic stroke (IS) outcome. The aim of the present study was to compare the clinical course of IS in patients with AFl and patients with atrial fibrillation (AF).

MATERIAL AND METHODS

A retrospective analysis of patients consecutively admitted to a tertiary care centre between 2013 and 2015 due to IS or transient ischaemic attack with permanent AFl or permanent or persistent AF was performed.

RESULTS

The study groups consisted of 528 patients, including 490 (92.8%) patients with AF and 38 (7.2%) patients with AFl. The mean age and prestroke CHA2DS2-VASc scores were similar between the patients with AFl and those with AF. Most IS cases in the AF group were classified as cardioembolic strokes (74.9% vs. 39.5% in AFl, p < 0.01), and lacunar strokes were the most common in the AFl group (47.4% vs. 14.3% in AF, p < 0.01). The multivariable analysis revealed that the presence of AF (OR = 8.6, 95% CI: 1.2-57, p = 0.02), lacunar stroke (OR = 0.1, 95% CI: 0.03-0.31, p < 0.001), baseline Rankin scale score (OR = 16.6, 95% CI: 9.8-28), lack of prestroke therapeutic anticoagulation (OR = 6.1, 95% CI: 1.1-33), diabetes (OR = 2.9, 95% CI: 1.3-6.5, p < 0.01), chronic heart failure (OR = 14.2, 95% CI: 5.8-34, p < 0.001), and current smoking (OR = 0.92, 95% CI: 0.39-0.99, p < 0.01) were significantly associated with the stroke outcome.

CONCLUSIONS

Disabling or fatal IS was observed less often in patients with AFl than in patients with AF. This finding can possibly be explained by the more frequent occurrence of lacunar strokes in the AFl group compared with that in the AF group.