BACKGROUND:and Purpose: The endothelial glycocalyx (EG) is a protective carbohydrate-rich layer lining the luminal surface of endothelial cells and a key component of the neurovascular unit, where it contributes to blood-brain barrier (BBB) integrity, vascular permeability control, and regulation of inflammatory and hemostatic responses. Disruption of the EG is increasingly recognized as an early marker of endothelial injury in acute vascular diseases. Syndecan-1, released during glycocalyx degradation, is a potential biomarker of endothelial dysfunction and may reflect vascular injury in acute ischemic stroke, although its temporal dynamics and clinical implications remain poorly understood. METHODS:In this prospective observational cohort study, adults with first-ever AIS presenting within 12 hours of symptom onset were enrolled at a tertiary stroke center. Serum syndecan-1 concentrations were measured at admission, 24 hours, and 48 hours after stroke onset and compared with controls. Associations between syndecan-1 concentrations, clinical and imaging characteristics, recanalization therapy, and 90-day functional outcomes were analyzed. RESULTS:Fifty-six patients with AIS and 73 controls were included. Compared with controls, syndecan-1 concentrations did not differ significantly at baseline (p=0.658) but were significantly higher at 24 and 48 hours (both p<0.001). In the linear mixed-effects model, there was an overall effect of time (p=0.032), with a significant increase at 24 hours relative to baseline (p=0.008), but not at 48 hours (p=0.135). Lower 48-hour syndecan-1 concentrations were associated with unfavorable 90-day functional outcome in the unadjusted analysis (p=0.005), although this association was not independently maintained in the overall multivariable model (p=0.064). Exploratory descriptive analyses showed different numerical patterns according to recanalization therapy, but no formal between-group longitudinal difference was established. Among patients receiving recanalization therapy, syndecan-1 concentration at 48 hours was inversely associated with unfavorable 90-day outcome in an exploratory multivariable analysis (OR 0.94, 95% CI 0.90-0.99; p=0.03). CONCLUSIONS:Circulating syndecan-1 concentrations vary during the acute phase of AIS. Concentrations were significantly higher than those of controls at 24 and 48 hours, whereas the within-patient increase relative to baseline was statistically significant only at 24 hours. The data do not establish different temporal trajectories according to recanalization therapy, and the subgroup prognostic finding should be considered hypothesis-generating. These findings do not directly demonstrate cerebral glycocalyx degradation or blood-brain barrier injury but support further investigation of syndecan-1 as a time-dependent circulating marker in AIS.
OBJECTIVE:To evaluate the hemorrhagic and mortality risks associated with early intravenous tirofiban in patients with acute ischemic stroke. METHODS:We searched PubMed, Embase, Cochrane, from inception to December 23, 2025 evaluating the safety outcomes of tirofiban in acute ischemic stroke patients. The primary outcome was symptomatic intracranial hemorrhage. RESULTS:Eleven studies (3635 patients) were included, with data availability varying by specific safety outcomes. Tirofiban was associated with a significant increase in the risk of any intracranial hemorrhage (RR, 1.19; 95% CI, 1.02-1.38). However, there was no significant difference in the risk of the primary outcome, symptomatic intracranial hemorrhage (RR, 1.12; 95% CI, 0.56-2.22) , systemic bleeding (RR, 1.20; 95% CI, 0.79-1.83) , or mortality (RR, 0.93; 95% CI, 0.67-1.27). Subgroup analysis for symptomatic intracranial hemorrhage stratified by initial treatment strategy revealed no significant interaction (P= 0.29). CONCLUSION:Early intravenous tirofiban is associated with a significantly increased risk of any intracranial hemorrhage. Although no statistically significant increases in symptomatic intracranial hemorrhage or mortality were detected, the wide confidence intervals preclude the definitive exclusion of clinically meaningful harm.
BACKGROUND:Stroke is a major risk factor for dementia, and fatigue is common among stroke survivors. Whether self-reported fatigue is associated with dementia risk among individuals with prevalent stroke remains unclear. METHODS:We conducted a prospective cohort study of 484,749 UK Biobank participants without dementia at baseline. Participants were classified into four groups according to prevalent stroke and self-reported fatigue: neither exposure, fatigue only, prevalent stroke only, and prevalent stroke with fatigue. The primary outcome was incident all-cause dementia. Secondary outcomes were Alzheimer disease and vascular dementia. Cox proportional hazards models used age as the time scale and adjusted for demographic, socioeconomic, lifestyle, and cardiometabolic factors. Sensitivity analyses included landmark, competing-risk, extended-adjustment, stroke-subtype, and time-updated stroke analyses. RESULTS:Of 484,749 participants, 60,379 had fatigue only, 5,706 had prevalent stroke only, and 1,697 had both prevalent stroke and fatigue. Compared with participants with neither exposure, adjusted hazard ratios for all-cause dementia were 1.51 (95% CI, 1.42-1.60) for fatigue only, 1.94 (95% CI, 1.74-2.17) for prevalent stroke only, and 2.79 (95% CI, 2.32-3.35) for prevalent stroke with fatigue. For participants with both prevalent stroke and fatigue, hazard ratios were 1.86 (95% CI, 1.32-2.62) for Alzheimer disease and 4.33 (95% CI, 3.24-5.80) for vascular dementia. Among participants with prevalent stroke, fatigue was associated with all-cause dementia after adjustment for time from recorded stroke occurrence to baseline assessment (HR, 1.36; 95% CI, 1.10-1.70), whereas the associations with Alzheimer disease and vascular dementia were not statistically significant. CONCLUSIONS:Prevalent stroke with self-reported fatigue was associated with the highest risk of incident dementia compared with neither exposure. Among participants with prevalent stroke, fatigue was associated with all-cause dementia but not clearly with Alzheimer disease or vascular dementia.
BACKGROUND:Symptomatic intracranial hemorrhage (sICH) remains a devastating complication undermining reperfusion therapy in acute ischemic stroke (AIS). Current prediction models rely on static baseline parameters, neglecting dynamic post-treatment physiological changes. We aimed to develop and validate a dynamic, explainable risk prediction framework integrating high-resolution temporal data. METHODS:In this prospective multicenter study, 2,341 AIS patients with anterior circulation large vessel occlusion receiving reperfusion therapy were consecutively enrolled (January 2023-June 2024). High-frequency vital signs and serial laboratory tests were collected over 72 hours post-treatment. Time-series features (trend, volatility, stability) were engineered, and XGBoost-based dynamic models were constructed at five timepoints (6, 12, 24, 48, 72 hours). Performance was evaluated in a held-out validation cohort (n=576) against a static baseline model. SHAP was applied for interpretability. RESULTS:Of 2,158 analyzed patients, 218 (10.1%) developed sICH. The dynamic model consistently outperformed the static model across all timepoints (AUC 0.83-0.90 vs. 0.71-0.75; all P<0.001). SHAP identified three core risk drivers: hemodynamic volatility (24-hour SBP standard deviation ranked highest), metabolic-inflammatory trajectories, and early tissue injury markers. Unsupervised clustering revealed three risk phenotypes: persistent low-risk (71.5%, sICH 0.8%), early rapid-riser (18.2%, 52.3%), and delayed-riser (10.3%, 38.1%). CONCLUSION:This dynamic, explainable framework shifts sICH risk prediction from static snapshots to continuous, interpretable monitoring. Hemodynamic volatility emerged as the strongest modifiable predictor, offering clinically actionable insights for personalized post-procedural care in AIS.
BACKGROUND:Admission hyperglycemia (glucose > 140 mg/dL) after ischemic stroke is associated with poor clinical outcomes, including cognitive impairment. Although hyperglycemia is commonly observed following intracerebral hemorrhage (ICH), it remains unclear whether its presence is also associated with reduced cognitive performance. METHODS:In this post hoc analysis of the ICH Deferoxamine Trial, admission hyperglycemia and other baseline characteristics were compared between patients with and without cognitive impairment (90-day Montreal Cognitive Assessment score < 26) using univariable and multivariable models. RESULTS:Among 293 patients with spontaneous, supratentorial ICH (aged 60±12 years, 38% female), 132 had hyperglycemia and 134 met criteria for cognitive impairment. Patients with cognitive impairment were older (61±12 vs. 57±11 years, p = 0.02), more likely to be female (46% vs. 28%, p = 0.02), had less coronary artery disease (6% vs. 16%, p = 0.06), higher hemorrhage volumes (19.5 mL [IQR 9.3-32.7] vs. 12.2 mL [IQR 6.1-18.3], p < 0.01), and more lobar hemorrhages (25% vs. 13%, p = 0.05). When these variables were entered into a multivariable logistic regression model, age (aOR 1.04, 95% CI [1.01-1.07]), coronary artery disease (aOR 0.33, 95% CI [0.11-0.97]), hyperglycemia (aOR 2.03, 95% CI [1.03-3.97]), and ICH volume (aOR 1.03, 95% CI [1.01-1.06]) were independently associated with impaired cognition. CONCLUSION:The association between admission hyperglycemia and cognition indicates that acute hyperglycemia may identify patients at heightened risk of cognitive decline, underscoring the need for further studies to determine whether aggressive glycemic control mitigates post-ICH cognitive impairment.
BACKGROUND:Hemodynamic management after endovascular thrombectomy (EVT) for patients with acute ischemic stroke from large-vessel occlusions is a critical and unsolved challenge: four major randomized controlled trials that applied fixed systolic blood pressure targets yielded neutral or harmful results, and the 2026 American Heart Association guideline cautions against aggressive systolic blood pressure reduction below 140 mmHg in the early post-EVT period. Independent physiological data demonstrate that cerebral autoregulation is profoundly and heterogeneously impaired after LVO stroke, suggesting that population-level fixed thresholds may be intrinsically mismatched to the biological diversity of autoregulatory states across individual patients. SUMMARY:Continuous, personalized monitoring of cerebral autoregulation offers a precise alternative to uniform blood pressure targets. Current post-EVT hemodynamic management is reactive: blood pressure is measured intermittently, population-level thresholds are applied regardless of individual physiology, and clinical deterioration is often recognized only after secondary injury has occurred. Near-infrared spectroscopy-based computation of the cerebral oximetry index enables real-time derivation of each patient's optimal mean arterial pressure and autoregulatory limits, but current monitoring platforms remain confined to specialized research settings. This review examines how recent advances in wearable ultrasound engineering, including conformal transcranial patches, wireless integrated systems, and low-cost disposable devices, create the technical foundation for portable, scalable cerebral hemodynamic monitoring with the potential to extend personalized autoregulation-guided care from specialized academic centers to community hospitals and broader stroke networks.
BACKGROUND:Although obesity is associated with cerebral small vessel disease (CSVD), the extent to which hypertension (HTN) and diabetes mellitus (DM) statistically account for this association in Asian populations remains unclear. METHODS:We analyzed asymptomatic Japanese adults enrolled in a Japanese Brain Dock registry between 2018 and 2024. The primary outcome was high CSVD burden, defined as a composite score ≥2 on a 0-4 scale based on the STandards for ReportIng Vascular changes on nEuroimaging criteria and incorporating moderate-to-severe white matter hyperintensities, lacunes, cerebral microbleeds, and pathologic basal ganglia perivascular spaces. Obesity was defined as a body mass index ≥25 kg/m² according to Asian-specific criteria. We performed multivariable logistic regression, parametric mediation-decomposition analyses with bootstrap-derived 95% confidence intervals (CIs), and Karlson-Holm-Breen (KHB) decomposition. RESULTS:Among 84,204 participants (45.7% women; median age, 50 years), obesity was associated with high CSVD burden (adjusted odds ratio [OR] 1.51 [95% CI 1.32-1.71]); this association attenuated to 1.24 (1.09-1.41) after adjustment for HTN and 1.21 (1.07-1.38) after additional adjustment for DM. In KHB decomposition, HTN and DM jointly accounted for 49.4% of the association (HTN, 91.9%; DM, 8.1%). The natural indirect effect was significant for HTN (1.27 [1.20-1.36]) but not for DM (1.00 [0.99-1.01]). A significant obesity × DM interaction was observed (p <0.05). CONCLUSION:In this large Japanese brain-screening cohort, approximately half of the association between obesity and high subclinical CSVD burden was statistically apportioned to HTN and DM, predominantly through HTN. These cross-sectional decomposition findings should be interpreted as statistical, not mechanistic, mediation and support prioritizing blood-pressure assessment in obese adults undergoing brain screening.
INTRODUCTION:While endovascular thrombectomy (EVT) is the standard treatment for large vessel occlusion, its role in distal medium vessel occlusion (DMVO) remains uncertain. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of EVT in patients with acute ischemic stroke (AIS) due to DMVO. METHODS:We systematically searched PubMed, MEDLINE, Embase, Web of Science, and Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from inception up to February 2025 reporting the efficacy and safety of EVT for DMVO, compared with best medical management (BMM). Study risk of bias was assessed using the Newcastle Ottawa Scale (NOS) for observational studies and the Cochrane Risk of Bias tool 2 (RoB 2) for randomized controlled studies. Random-effects meta-analyses were performed to pool data. Outcomes of interest included the proportion of excellent functional outcomes (mRS 0-1 at 90 days), the proportion of favorable functional outcome (mRS 0-2 at 90 days), 90-day mortality, and symptomatic intracranial hemorrhage (sICH). We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to evaluate the certainty of the evidence. The study protocol was registered on PROSPERO (CRD420250656493). RESULTS:A total of 37 studies with 12,742 patients were included in our meta-analysis. Overall, no significant differences were observed between the EVT and BMM group regarding excellent functional outcome (OR: 1.02, 95% CI: 0.86-1.21) and favorable functional outcome (OR: 1.02, 95% CI: 0.87-1.19). However, the EVT group demonstrated significantly higher odds of mortality (OR: 1.28, 95% CI: 1.07-1.54) and sICH (OR: 1.44, 95% CI: 1.04-1.98) compared with the BMM group. Subgroup analyses indicated EVT was associated with a higher proportion of favorable functional outcome (OR: 1.52, 95% CI: 1.07-2.16) in patients with M2 occlusion (GRADE = very low). In addition, EVT was associated with lower proportion of favorable functional outcome (OR: 0.61, 95% CI: 0.37-0.98) in patients with ACA occlusion (GRADE = low). EVT achieved higher proportion of excellent functional outcome (OR: 1.20, 95% CI: 1.02-1.40) (GRADE = low) but higher risk of mortality (OR: 1.65, 95% CI: 1.17-2.31) and sICH (OR: 2.53, 95% CI: 1.48-4.33) in patients with PCA occlusion (GRADE = low, GRADE = moderate, respectively). CONCLUSIONS:Our meta-analysis revealed that, for the broad population of DMVO-AIS, EVT is not associated with improved 90-day functional outcomes and may increase mortality and sICH risks. However, subgroup analyses suggest that effects are not uniform and may be favorable for selected patients, particularly those with M2 occlusions. Notably, these aggregate findings are limited by observational studies with inherent selection bias, so the generalizability may be affected.
OBJECTIVES:To develop an evidence-based, contextually relevant clinical practice guideline (CPG) for motor rehabilitation across the stroke continuum in India, identify priority recommendations for implementation, and evaluate the feasibility of its implementation. DESIGN:A three-phase mixed-methods study integrating a scoping review, focus group discussions, and systematic guideline synthesis. SETTING:India, across tertiary, secondary, and community-based rehabilitation settings. PARTICIPANTS:Rehabilitation professionals (neurologists, physiatrists, physiotherapists, occupational therapists, nurses, social workers) with ≥10 years' experience, persons with lived experience of stroke, and stakeholders including policymakers, researchers, and administrators. MAIN OUTCOME MEASURES:Development of contextually relevant CPG recommendations and their classification based on the strength of evidence and implementation feasibility. RESULTS:Rehabilitation pathways were fragmented, with limited access post-discharge and no standardized referral systems. Sixty clinical questions were refined into nine PICO questions and two practice points. A total of 84 recommendations were synthesized from high-quality international guidelines (AGREE-II/REX ≥60%). Using a modified Alper tool, 50 recommendations supported interventions, 13 advised against routine use, and others had limited or unclear evidence. Feasibility assessment using the Adopt-Contextualize-Adapt (ACA) framework showed 39 recommendations suitable for adoption, 32 requiring contextualization, and 13 requiring adaptation. Key domains included motor recovery, activities of daily living, quality of life, complication prevention, therapy dosage, and caregiver involvement. CONCLUSIONS:This study developed a stakeholder-informed, contextually adapted stroke rehabilitation CPG for India. The guideline provides a scalable framework to improve rehabilitation quality and access, with potential applicability to other low- and middle-income countries.
INTRODUCTION:Timely identification and transfer of patients with large vessel occlusion (LVO) to thrombectomy-capable stroke centers (TSCs) for endovascular thrombectomy (EVT) remains a major challenge in prehospital stroke care. This study evaluated the clinimetric performance of the Cincinnati Prehospital Stroke Scale (CPSS), the Maria Prehospital Stroke Scale (MPSS) and novel LVO screening scales created by integrating four LVO-related items into these established prehospital assessments. METHODS:Using prehospital electronic records linked with hospital data across Kawasaki City from April 2023 to March 2024, we retrospectively analyzed whether the addition of aphasia, unilateral spatial neglect, conjugate eye deviation, and atrial fibrillation (via ambulance ECG) improved prehospital LVO detection. These items were incorporated into the MPSS (MPSS+4 scale) and CPSS (CPSS+4 scale), and the predictive performance of four tools: CPSS, CPSS+4 scale, MPSS, and MPSS+4 scale was compared. RESULTS:Among 1,653 transported patients, 207 (12.5%) had LVO. MPSS+4 scale demonstrated the highest predictive performance for LVO (AUROC 0.768). The addition of the four LVO-related items significantly improved LVO prediction for both MPSS and CPSS (p < 0.001 for each). Higher MPSS+4 scale scores were strongly and progressively associated with the likelihood of receiving EVT after hospital arrival. Adjusted odds ratios increased from 2.97 to 100.59 for scores 2-9 compared with a score of 1. CONCLUSION:Incorporating LVO-related items into prehospital stroke assessment substantially improved diagnostic precision for LVO, with MPSS+4 scale outperforming all other tools. The strong association between MPSS+4 scale scores and subsequent EVT implementation suggests that MPSS+4 scale may serve as a practical, clinically meaningful instrument for emergency medical technicians in prehospital triage of suspected acute stroke and identification of EVT candidates.
INTRODUCTION:The simplified Edinburgh criteria utilize computed tomography (CT) to identify cerebral amyloid angiopathy (CAA)-related intracerebral hemorrhage (ICH), showing good performance in the original autopsy cohort. However, diagnostic performance varies in external validation, particularly among survivors with smaller hematoma volumes. We hypothesized that applying a minimum volume threshold could improve diagnostic accuracy. METHODS:We externally validated the simplified Edinburgh criteria in a Chinese cohort. All patients underwent CT imaging as the index test. The reference standard was a diagnosis of probable CAA, with or without pathological confirmation, based on the Boston 2.0 criteria. Diagnostic indices, including the area under the curve (AUC), were assessed. Additionally, likelihood ratio differences were analyzed to explore a potential hematoma volume threshold associated with improved diagnostic performance. RESULTS:A total of 171 patients were included: 52 lobar ICH cases with histological confirmation and 119 with magnetic resonance imaging (MRI) data. Patients undergoing hematoma evacuation had larger ICH volumes and were younger than those assessed by MRI.Overall, the simplified Edinburgh criteria showed limited sensitivity and specificity for both rule-in criteria (65% and 54%) and rule-out criteria (56% and 58%). The pathology-confirmed subgroup showed higher rule-in specificity than the MRI-based subgroup (87% vs. 43%). In patients with hematoma volume >30 mL, rule-in specificity increased to 71.4% and rule-out sensitivity increased to 89.3%, although overall diagnostic performance remained moderate. CONCLUSION:The simplified Edinburgh CT criteria may yield more accurate diagnoses in patients with larger hematomas, and a 30 mL threshold may serve as a potential exploratory cutoff.
INTRODUCTION:Cardiovascular and cerebrovascular diseases represent major causes of morbidity, mortality, and economic burden in the United States. Growing evidence demonstrates high rates of financial distress, defined as the negative impact of medical costs on a person's financial wellbeing, among individuals with cardiovascular and cerebrovascular disease. This study aimed to examine the association between cardiovascular/cerebrovascular disease history and financial distress among U.S. adults and to identify factors associated with financial distress in this high-risk population. METHODS:We conducted a cross-sectional analysis of pooled 2021-2023 National Health Interview Survey data. Financial distress was defined using self-reported measures of medical affordability and cost-related medication nonadherence. Propensity score matching was used to balance cardiovascular/cerebrovascular disease and non-disease cohorts. Multivariable logistic regression models assessed the association between disease history and financial distress and identified factors associated with financial distress among the disease cohort. RESULTS:After matching, 20,246 respondents were included in each cohort. Financial distress was more prevalent among the disease cohort than the non-disease cohort (47.1% vs. 45.9%, p=0.042), with higher odds of any financial distress (OR=1.05, 95% CI: 1.01-1.09, p=0.014). The disease cohort had greater odds of problems paying medical bills (OR=1.32, 95% CI: 1.24-1.41, p<0.001) and inability to afford prescription medications (OR=1.20, 95% CI: 1.11-1.31, p<0.001). Among the disease cohort, female sex, Hispanic ethnicity, lower educational attainment, and lack of insurance were associated with higher odds of financial distress, whereas older age and Medicaid coverage were associated with lower odds. CONCLUSIONS:Cardiovascular/cerebrovascular disease is associated with greater financial distress across multiple domains. Targeted strategies to reduce cost-related healthcare barriers in this population are urgently needed.
INTRODUCTION:Large vessel occlusion (LVO) stroke requires rapid endovascular thrombectomy (EVT). Prehospital LVO screening combined with smartphone-based real-time pre-notification may accelerate in-hospital activation, but supporting evidence remains limited. We evaluated a regional prehospital triage system integrating the Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale with the JoinTriage application. METHODS:We conducted a single-center observational study comparing patients transported with suspected stroke before (2020-2021) and after (2022-2024) system implementation. During the after period, emergency medical service personnel used JoinTriage to share FAST-ED scores and clinical data in real time. We compared clinical characteristics and workflow metrics, including door-to-puncture (DTP) time, across the two periods. RESULTS:The cohort included 721 patients (before, n = 262; after, n = 459). The LVO rate was significantly higher in the after period (25.5% vs. 18.7%, p = 0.043), with a numerically higher but non-significant EVT rate (19.4% vs. 14.1%, p = 0.083). Among FAST-ED/JoinTriage-triaged patients (193/459, 42.0%), LVO and EVT rates were further enriched, reaching 35.8% and 24.4%, respectively. Among EVT-treated patients, median DTP decreased from 88 to 62 min (p < 0.001), and DTP < 60 min increased from 10.8% to 46.8%. Multivariate analysis identified the after period as an independent predictor of DTP < 60 min (adjusted odds ratio, 4.76; p = 0.019). The trend toward prolonged DTP during off-hours observed in the before period (p = 0.054) was resolved in the after period. CONCLUSION:The smartphone-based FAST-ED triage system was associated with a higher concentration of suspected LVO patients at the receiving hospital, as well as streamlined in-hospital workflow and reduced off-hour treatment delays.
OBJECTIVE:To evaluate the safety and efficacy of endovascular thrombectomy (EVT) in adults with posterior circulation acute ischemic stroke (PCAIS) in Latin America and the Caribbean (LATAC). BACKGROUND:While recent studies have shown improved outcomes with EVT in PCAIS, data from LATAC remain limited. This region presents unique sociodemographic and healthcare challenges, with patients often experiencing worse stroke outcomes. METHODS:Studies assessing EVT in LATAC adults with PCAIS were included. Primary outcomes were favorable functional outcome (90-day mRS 0-3), successful recanalization rate (mTICI 2b-3), symptomatic intracerebral hemorrhage (sICH), and all-cause mortality at 90 days. Study quality was assessed using the Newcastle-Ottawa Scale for observational studies. A single-arm meta-analysis using a random-effects model was performed, and heterogeneity was evaluated using I² statistics. RESULTS:Eight observational studies comprising 210 patients were included. Approximately one third of patients in cohort studies received bridging IVT prior to EVT. The pooled proportion of favorable functional outcome was 33% (95% CI: 26-42), successful recanalization was achieved in 85% of cases (95% CI: 77-90), mortality was 31% (95% CI: 17-50), and sICH was 7% (95% CI: 4-14). Only two studies identified independent outcome predictors via multivariate analysis. Most studies had low to moderate risk of bias. CONCLUSIONS:EVT for PCAIS in LATAC shows comparable mortality and sICH rates to larger RCTs; however, functional outcomes may be less favorable. This may reflect regional disparities in stroke systems of care.
BACKGROUND:Whether severe early motor deficit after deep intracerebral hemorrhage represents a fixed recovery ceiling or a recoverable mixture of structural and reversible mechanisms is unclear. We synthesized time-dependent motor outcomes and corticospinal tract-related predictors after basal ganglia or thalamic hemorrhage. METHODS:Following PRISMA 2020 and Synthesis Without Meta-analysis guidance, with the protocol registered on OSF Registries (DOI 10.17605/OSF.IO/JH86X), we searched PubMed/MEDLINE, Embase, Web of Science, Scopus, and the Cochrane Library from inception to April 26, 2026. Adults with spontaneous deep supratentorial intracerebral hemorrhage and any motor outcome measure were eligible. Studies were classified into severe-deficit, broader, and predictor cohorts. The primary synthesis was structured, with a limited aggregate proportion for rehabilitation discharge walking independence. Risk of bias was assessed with the Quality in Prognosis Studies tool. RESULTS:Of 1,463 records identified, 25 studies were included. Six severe-deficit/recovery cohorts, including a strict severe-baseline core and supportive cohorts, suggested meaningful 6-month motor recovery; gains in severe putaminal hemorrhage appeared concentrated within the first four months. In two broader rehabilitation cohorts, approximately 53% achieved Functional Ambulation Category ≥4 at discharge - a contextual estimate, not a severe-baseline recovery rate. Across fourteen imaging predictor studies, corticospinal tract integrity, fractional anisotropy, CT-based corticospinal tract lesion load, and posterior limb internal capsule involvement were directionally consistent predictors of motor outcome, with supportive CT-based evidence from a secondary analysis of the multicenter MISTIE III trial. CONCLUSION:Severe early motor deficit should not be treated as a fixed recovery ceiling on clinical grounds alone after basal ganglia or thalamic hemorrhage, but recovery is anatomically constrained by corticospinal tract and posterior limb internal capsule involvement. Prognostic counseling should integrate acute imaging-based assessment with the 4-month recovery window suggested in severe putaminal hemorrhage.
INTRODUCTION:Patients with atrial fibrillation (AF) exhibit a notable prevalence of both (covert) brain infarcts and white matter hyperintensities (WMHs). They face an elevated risk of cognitive decline and dementia, yet the pathogenesis remains largely unknown. Here, we aimed to investigate a potential relationship between lesion location of embolic brain infarcts or WMHs and (i) remote cortical volume using a tract-based analysis, as well as (ii) global cognitive function using voxel-based lesion-symptom mapping. METHODS:This is a cross-sectional analysis from a prospective, multicenter cohort study of unselected patients with AF (Swiss-AF) enrolling 1,716 patients with eligible MRI data (mean age 73 ± 8 years, 27% women, 90% anticoagulated). We assessed the association of brain lesions including embolic brain infarcts and WMHs in specific white matter tracts with remote cortical volume by using LASSO regression. In addition, voxel-based lesion-symptom mapping was deployed to assess the effect of WMH location in relationship to embolic brain infarcts on cognitive function. RESULTS:We observed WMH in 1,699 of 1,716 (99%) and embolic brain infarcts in 395 of 1,716 (23%) patients. The presence of embolic infarcts within most fiber tracts (mean, IQR: 55, 8-66 cm3) accounted for more variability in remote cortical volumes than WMH regional volume (mean, IQR: 366, 63-657 cm3) despite their lower volume. In addition, while the presence of WMH was initially associated with cognitive function across most brain regions (61.8% of voxels with significant association), when adjusting models for the presence of embolic infarcts, only a minor fraction of WMH remained significantly associated with cognitive function (23.6% of voxels). CONCLUSIONS:Among patients with AF, (covert) embolic brain infarcts and WMHs are associated with remote cortical atrophy and with lower cognitive performance. The disruption of brain networks through embolic infarcts seems to contribute to cognitive impairment in patients with AF.
INTRODUCTION:Stroke often substantially impacts a person's physical, psychological, and social wellbeing. The impact on carers and family can also be considerable, but is less often quantified. We aimed to measure changes in physical, psychological, and social health status (assessed using frailty, depression, and loneliness) before and following a stroke among survivors and their spouses compared to age- and sex-matched controls who had not experienced a stroke themselves or within their household. METHODS:We used data from three population longitudinal ageing surveys (Health and Retirement Survey [HRS], USA; Survey of Health, Ageing and Retirement in Europe [SHARE]; and the English Longitudinal Study of Ageing [ELSA]). Participants aged ≥50 were surveyed at 2-yearly intervals along with their household. We identified people who had survived a stroke occurring after their initial visit (and so had data collected both pre- and post-stroke) as well as their spouses. Stroke participants were included regardless of whether they had a spouse or not. We also identified age-, sex-, and survey wave-matched controls and their spouses. We assessed frailty using a cumulative deficit frailty index, depression using the Centre for Epidemiological Studies Depression (CES-D) Scale or the Euro-Depression Scale, and loneliness using a single question ("do you feel lonely?") - each measured at both time points. We assessed change in frailty and depression scores using (generalised) linear mixed regression models (with a logistic link function for loneliness) adjusted for age and sex. RESULTS:There were 5,399 participants experiencing stroke and 3,013 spouses, 16,197 matched controls, and 8,249 control spouses. People with stroke had higher baseline (pre-stroke) levels of frailty, depression, and loneliness than matched controls. The average change in frailty index values following a stroke was greater than controls (3.17 deficits, 95% confidence interval [95% CI]: 3.03-3.31). Spouses of stroke survivors did not show significant changes in frailty. Both stroke survivors and their spouses, on average, showed increases in depression scores which were greater than controls (0.18 standard deviations increase [95% CI: 0.14-0.21] for stroke survivors versus controls and 0.12 [95% CI: 0.07-0.17] for spouses versus control spouses). The odds of becoming lonely were greatest for spouses of stroke survivors compared to control spouses (odds ratio 5.07 [95% CI: 2.74-9.41]); however, the changes in loneliness among stroke survivors were not significantly different from controls (1.35 [95% CI: 0.95-1.91]). CONCLUSION:Stroke does not just affect the individual, but it also affects families. The psychosocial sequalae of stroke should be proactively managed, with family actively involved in post-stroke support strategies.
INTRODUCTION:Local hemodynamic conditions influence atherosclerotic plaque biology; however, their relationship with plaque characteristics in carotid artery disease remains incompletely understood. METHODS:In this single-center observational study using retrospectively collected data, we analyzed 49 patients who underwent carotid endarterectomy with preoperative computed tomography angiography. Computational fluid dynamics was used to quantify local minimum and maximum wall shear stress (WSS_min and WSS_max) within each plaque. Associations between regional WSS patterns and clinical and radiological features were evaluated. Histopathological evaluation using hematoxylin and eosin staining was performed in a subset of 17 lesions, with exploratory assessment of neutrophil extracellular traps (NETs) using citrullinated histone H3 immunostaining. RESULTS:WSS_min was preferentially observed in ulcerated plaque regions and was associated with symptomatic presentation, particularly in analyses restricted to ulcerated lesions. In contrast, WSS_max correlated with stenosis severity and was predominantly observed in asymptomatic lesions. Histopathological analysis demonstrated multilayered lesion architecture and inflammatory changes in WSS_min regions, whereas WSS_max regions more frequently exhibited plaque rupture. However, the luminal surface was often covered by endothelium, and thick fibrous caps were also observed. In paired analyses, NET accumulation was higher in WSS_min regions than in WSS_max regions. CONCLUSIONS:Local wall shear stress is associated with plaque features and distinct histopathological characteristics in carotid artery disease. These findings suggest that regional hemodynamic conditions contribute to plaque biology and provide complementary insights beyond conventional morphological evaluation, while remaining hypothesis-generating and requiring validation in larger studies.
INTRODUCTION:Neurosurgical decision support systems, which integrate evidence with patient-specific factors into transparent and reproducible decision pathways, represent a promising approach to standardize the delivery of evidence-based care and improve outcomes in spontaneous intracerebral hemorrhage (ICH). Here, we developed JR-ZQSI-NICHE (Jose Reyes-Zeenat Qureshi Stroke Institute-Neurology and Neurosurgery Intracerebral Hemorrhage Evaluation), a web-based algorithm-driven application designed to support the identification of ICH patients who may benefit from neurosurgical intervention. We aimed to evaluate the clinical effectiveness of JR-ZQSI-NICHE by comparing mortality and functional outcomes before and after implementation. METHODS:This retrospective before-after cohort study included consecutive adult patients admitted with spontaneous ICH at the Philippine National Specialty Center for Brain and Spine Care between January 2019 and December 2024. Data were extracted from a prospectively maintained institutional stroke registry. JR-ZQSI-NICHE was implemented on January 1, 2022, defining the pre- and post-implementation study periods. The primary outcome was all-cause in-hospital mortality. Secondary outcomes were 90- and 180-day functional status, assessed using the modified Rankin Scale (mRS). RESULTS:A total of 1,551 patients were included (767 pre-implementation; 784 post-implementation). JR-ZQSI-NICHE implementation was independently associated with lower odds of all-cause in-hospital mortality (adjusted OR 0.16, 95% confidence interval [CI]: 0.09-0.30). Functional outcomes were improved at Day 90 (adjusted ordinal OR 0.39, 95% CI: 0.32-0.47); however, this association did not persist in sensitivity analyses. At Day 180, implementation was independently associated with better functional outcomes (adjusted ordinal OR 0.42, 95% CI: 0.35-0.52). CONCLUSION:JR-ZQSI-NICHE implementation was associated with lower in-hospital mortality and improved functional outcomes at 180 days in patients with spontaneous ICH. These findings provide preliminary, hypothesis-generating evidence supporting the potential clinical benefit of algorithm-based clinical decision support systems for neurosurgical decision-making in ICH. Prospective randomized trials are warranted to confirm these findings.
