ObjectiveTo investigate the predictive value of the early postoperative ipsilateral middle cerebral artery pulsatility index (PI) for cerebral hemorrhage after endovascular treatment in patients with anterior circulation large vessel occlusion acute ischemic stroke.MethodsA total of 120 patients were divided into a cerebral hemorrhage group (n = 17) and a non-hemorrhage group (n = 103). Multivariable logistic regression and Firth penalized likelihood regression were used to identify independent predictors. Receiver operating characteristic (ROC) curves evaluated the predictive performance of individual indicators and a combined model. Bootstrap resampling (1,000 iterations) was performed for internal validation.ResultsMultivariable logistic regression showed that diabetes mellitus (OR = 4.154, 95% CI: 1.255–13.756, p = 0.020), ASPECTS >8 (OR = 0.115, 95% CI: 0.014–0.942, p = 0.044), and elevated ipsilateral PI (OR = 11.355, 95% CI: 1.267–101.761, p = 0.030) were associated with cerebral hemorrhage. Firth regression confirmed these results. The ipsilateral PI predicted cerebral hemorrhage with an AUC of 0.716 (95% CI: 0.597–0.835), an optimal cutoff of 0.735, a sensitivity of 0.882, and a specificity of 0.505. The combined model (diabetes, ASPECTS >8, PI) achieved an AUC of 0.808 (95% CI: 0.718–0.899), with a sensitivity of 0.882 and a specificity of 0.650. Bootstrap internal validation showed a bias-corrected AUC of 0.810 (95% CI: 0.717–0.896) and an optimism of −0.0022.ConclusionThe early postoperative ipsilateral middle cerebral artery PI is a potential prognostic marker for any radiographic intracranial hemorrhage after endovascular treatment in anterior circulation large vessel occlusion acute ischemic stroke, with an optimal cutoff of 0.735. In this cohort, adding PI to diabetes mellitus and ASPECTS was associated with a modest improvement in discrimination (ΔAUC = 0.088, p = 0.011) and continuous net reclassification improvement (NRI = 0.594, p = 0.020), whereas categorical NRI was not significant. These findings are exploratory and require validation in larger cohorts.
IntroductionThis study aimed to investigate the inter-center differences in recanalization therapy (RT) utilization between Estonia’s two largest comprehensive stroke centers and to assess whether variation in the management of patient subgroups is associated with differences in short-term neurological and functional outcomes.MethodsWe performed a retrospective two-center study including all acute ischemic stroke (AIS) patients admitted between January–June 2021. Mild AIS or mild stroke was defined as National Institutes of Health Stroke Scale (NIHSS) ≤ 5. Demographic, treatment, NIHSS, and modified Rankin Scale (mRS) data were analyzed using nonparametric and categorical tests. Multivariable logistic regression evaluated predictors of RT use in AIS and predictors of stroke outcome.ResultsAmong 635 AIS patients, RT was administered more frequently at Tartu University Hospital (TUH) than at North Estonia Medical Centre (NEMC) (45.2% vs. 30.7%, p < 0.001; aOR 0.49, 95% CI 0.33–0.74). A total of 301 (47.5%) patients had mild stroke. RT use in mild stroke was substantially higher at TUH (33.1% vs. 10.0%, p < 0.001). Descriptive analysis showed greater neurological improvement in RT-treated mild stroke patients than non-RT-treated patients [median NIHSS reduction 2.0 (IQR 0.8–3.0) vs. 1.0 (IQR 0.0–2.0), respectively; Wilcoxon rank-sum test, p < 0.001], whereas good functional outcome did not differ by RT exposure. After adjustment, neurological improvement was independently associated with treatment center and baseline NIHSS category but not with RT exposure (aOR 0.94, 95% CI 0.43–2.06).DiscussionRT was also not independently associated with good functional outcome. Inter-center variation in RT utilization was primarily driven by the management of mild stroke patients. Comparable stroke-care infrastructure did not ensure uniform RT utilization.
Background and objectivesFatigue is a common symptom during the first year after transient ischemic attack (TIA), but its long-term persistence remain unclear. This study aim to assessed long-term perceived fatigue after TIA and to evaluated associated comorbidities and functional consequences.Materials and methodsThis observational and cross-sectional study included 431 community-dwelling adults assessed 1–13 years after TIA in an outpatient setting, with a 25% response rate. Fatigue was measured using the Fatigue Assessment Scale in three subgroups: first-ever TIA (n = 299), recurrent TIA (n = 54), and TIA with stroke (n = 78). Depression and anxiety were evaluated using the Hospital Anxiety and Depression Scale, and. An activities of daily living and social participation using were determined using the Stroke Impact Scale. Multivariable ordinal linear regression analyses were performed in the first-ever TIA group to examine associations between fatigue, comorbidities and functional outcomes.ResultsIn the first-ever TIA group, fatigue levels were similar across time-since-TIA strata up to 13 years (mean 21.8, standard deviation [SD] 5.2); 35% exceeded the fatigue cut-off. Fatigue in the first-ever TIA group was lower than in the recurrent TIA group (mean 23.9, SD 5.7; p < 0.05) and TIA with stroke group (mean 23.8, SD 6.5; p < 0.05). Amon participants with first-ever TIA, depression (β = 6.8, 95% confidence interval [CI] 3.5–10.1; p < 0.001), severe sleep problem (category 4: β = 3.9, 95% CI 0.9–6.8; p = 0.010) and (category 5: β = 5.9, 95% CI 2.2–9.6; p = 0.002), atrial fibrillation (β = 2.1, 95% CI 0.3–3.9; p = 0.02) and heart disease (β = 1.8, 95% CI 0.2–3.4; p = 0.03) were associated with higher fatigue. Higher fatigue was also associated with reduced activities of daily living (β = 0.15, 95% CI 0.07–0.22, p < 0.001) and lower social participation (β = 0.06, 95% CI 0.02–0.10; p = 0.004).ConclusionFatigue affected more than one-third of first-ever TIA survivors and did not differ materially across cross-sectional time-since-TIA strata up to 13 years. Greater fatigue was associated with depressive symptoms, severe sleep problems, atrial fibrillation, heart disease, and reduced daily activity and social participation. Early identification and management of fatigue and related comorbidities may improve functioning. Longitudinal studies are needed to determine temporal relationships and whether targeted management improves outcomes.
ObjectiveTo investigate the relationship of serum semaphorin 4D (Sema4D) and angiopoietin-like protein 4 (ANGPTL4) levels with disease severity and prognosis in anti–acetylcholine receptor (AChR) antibody–positive myasthenia gravis (MG) patients.MethodsBetween December 2023 and April 2025, 468 anti-AChR antibody–positive MG patients hospitalized at our center were prospectively enrolled and divided into good- and poor-prognosis groups according to whether they achieved minimal manifestations (MM) or better status at the 1-year follow-up. Healthy controls were also enrolled. Serum Sema4D and ANGPTL4 levels were measured by enzyme-linked immunosorbent assay (ELISA). Correlations were evaluated by Spearman’s rank correlation. Multivariable logistic regression was used to identify independent risk factors for poor prognosis. Receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive value of the two biomarkers alone and in combination, and clinical and combined models were developed to evaluate the biomarkers’ incremental predictive value.ResultsSerum Sema4D and ANGPTL4 levels were significantly higher in MG patients than in healthy controls (both p < 0.001). Compared with the good-prognosis group, the poor-prognosis group had higher proportions of Myasthenia Gravis Foundation of America (MGFA) class IV-V, dysphagia, and thymoma, and higher Myasthenia Gravis Quality of Life 15-item revised (MG-QoL15r) and Controlling Nutritional Status (CONUT) scores (all p < 0.05), and significantly higher levels of both biomarkers (both p < 0.05). Both Sema4D and ANGPTL4 correlated positively with MG-QoL15r and CONUT scores and with each other (r = 0.431, p < 0.001). Multivariable logistic regression showed that MGFA class IV-V, dysphagia, thymoma, higher MG-QoL15r and CONUT scores, and elevated serum Sema4D and ANGPTL4 levels were all independent risk factors for poor prognosis (all p < 0.05). The combination of the two biomarkers yielded an area under the ROC curve (AUC) of 0.841, superior to either marker alone. Adding the biomarkers to the clinical model significantly improved prognostic discrimination, with the AUC increasing from 0.874 to 0.907 (p = 0.0002).ConclusionCombined measurement of serum Sema4D and ANGPTL4 is associated with disease severity and poor prognosis in anti-AChR antibody–positive MG and shows good predictive value for patient prognosis.
BackgroundAcute ischemic stroke due to large vessel occlusion (AIS-LVO) carries substantial mortality despite endovascular treatment (EVT). Whether causes of death differ between anterior (AVO) and posterior (PVO) circulation occlusions is poorly characterized. We compared cause-specific 90-day mortality between patients with AVO and PVO treated with EVT.MethodsIn this multicenter retrospective cohort, consecutive patients with AIS-LVO who underwent EVT at 111 hospitals in China (ANGEL-ACT registry [Endovascular Treatment Key Technique and Emergency Workflow Improvement of acute ischemic stroke]) were included, and adjudicated causes of death were grouped into prespecified categories. Cause-specific mortality was assessed in the complete analytic cohort using the Fine-Gray subdistribution hazard model, with survivors censored at 90 days and deaths from other causes treated as competing events. Cumulative incidence functions were estimated with the Aalen-Johansen estimator.ResultsAmong 1,671 eligible patients (1,300 AVO, 371 PVO), 228 deaths (13.6%) occurred within 90 days. All-cause mortality was higher in PVO than AVO (19.4% vs. 12.0%). Cerebral edema-related death was significantly more frequent in PVO than AVO (90-day cumulative incidence 9.16% vs. 4.15%; adjusted subdistribution hazard ratio [sHR] 0.47, 95% CI 0.30–0.73, p = 0.001; Gray’s test p < 0.001). Fatal hemorrhagic transformation was numerically more frequent in AVO but did not reach statistical significance in the complete cohort (3.77% vs. 1.89%; adjusted sHR 1.76, 95% CI 0.78–3.98, p = 0.17; Gray’s test p = 0.076), consistent across all sensitivity analyses. Pneumonia-related (adjusted sHR 0.34, 95% CI 0.17–0.68, p = 0.003) and recurrent stroke-related (adjusted sHR 0.29, 95% CI 0.10–0.86, p = 0.026) deaths were also more frequent in PVO; the pneumonia association remained significant after Bonferroni correction, whereas the recurrent stroke association did not.ConclusionFatal complications after EVT differ by occlusion territory. Posterior circulation occlusion is independently associated with a higher risk of death from cerebral edema, pneumonia, and recurrent stroke, although the recurrent stroke association did not survive Bonferroni correction. Hemorrhagic transformation accounted for a larger share of anterior circulation deaths, but this did not correspond to a statistically significant increase in risk in the complete cohort.
