PURPOSE:Non-stenotic carotid plaques, despite being considered low risk for stroke, are increasingly recognized to contribute to embolic strokes of undetermined source (ESUS). Emerging evidence indicates that rather than the degree of stenosis, high-risk plaque characteristics like plaque irregularity and intraplaque haemorrhage may increase the embolic risk. We analysed the prevalence and characteristics of non-stenotic carotid plaques in ESUS and their implications for stroke recurrence risk. METHODS:We retrospectively identified 274 patients with ESUS between 2012 and 2022. The CT angiograms were analyzed for non-stenotic carotid plaques (<50% stenosis, as per NASCET criteria) by blinded neuroradiologists. The infarct patterns and plaque characteristics were evaluated. The stroke recurrence at 3 months and one year were noted. RESULTS:The mean age of the study population was 57.99 ± 12.86 years, and 65.3% were males. The non-stenotic plaques (30-50% stenosis) were more common on the symptomatic side of stroke (13.3% vs. 7.3%, p = 0.026). Plaques with irregularity were also more frequent on the symptomatic side (16.4% vs. 9.7%, p = 0.023). Patients with symptomatic non-stenotic plaques had a higher incidence of embolic (25% vs. 5%, p = 0.000) and watershed infarcts (16.7% vs. 4.6%, p = 0.005). The stroke recurrence risk and mortality at 3 months and one year did not differ between the 2 groups. CONCLUSION:In this single-centre retrospective study, non-stenotic carotid plaques with 30-50% stenosis were more prevalent on the symptomatic side, suggesting a potential role in stroke mechanism. The higher rates of embolic and watershed infarcts and the presence of plaque irregularity on the symptomatic side, support this association.
Introduction Acute ischaemic stroke and primary intracerebral haemorrhage are complicated by oropharyngeal dysphagia in more than 50% of patients. Currently, there are no definitive treatments for post-stroke dysphagia. Pharyngeal electrical stimulation (PES) can drive long-term beneficial changes in the cortical control of swallowing with functionally relevant reorganisation of the swallowing cortex correlating with reduced dysphagia. Methods The pharyngeal electrical stimulation for acute stroke dysphagia trial (PhEAST) is an international prospective randomised open-label blinded-endpoint parallel-group phase-4 superiority effectiveness trial. 638 patients with post-stroke dysphagia and dependency on nasogastric tube feeding are being recruited within 2 to 31 days of ictus. Participants are recruited from UK and Austria and randomised to six days of optimised PES (given for 10 minutes each day) versus no PES on top of standard care. The primary outcome is the dysphagia severity rating scale (DSRS), an assessment of swallowing impairment, measured locally on day 14 and centrally at day 90 by trained observers masked to treatment and analysed using repeated measures regression analysis. Secondary outcomes include: functional oral intake scale, feeding status scale, international dysphagia diet standardisation initiative scale, presence of a feeding tube, pneumonia, antibiotic use, health-related quality of life, dependency, disability, frailty, mood, cognition, global impact and health economics at days 14, 90, 180 and 365. Safety measures include death and serious adverse events. Discussion PhEAST has recruited more than 574 participants from 45 hospitals in the UK and Austria; recruitment will complete at end October 2026. The attached Supplement summarises the protocol and follows the EQUATOR SPIRIT guideline.
INTRODUCTION:Despite the established benefit of mechanical thrombectomy (MT), data on the incidence, risk factors, and longer-term outcomes of stroke-associated infections (SAIs) in this population remain limited. This retrospective, single-centre cohort study evaluated the frequency of SAI, associated variables, and longer-term mortality post-MT. METHODS:Data for acute ischaemic stroke patients undergoing MT at Manchester Centre for Clinical Neurosciences were extracted from the Sentinel Stroke National Audit Programme (April 2016-March 2024) and linked to electronic patient records. Routinely collected admission and procedural variables were analysed. Primary outcome measures were the proportion of patients developing SAI and subtypes of SAI post-MT. Multifactorial regression analysis was performed to evaluate associations between clinical variables and SAI and also between SAI and 1-year mortality. RESULTS:Of 589 patients, 179 (30%) developed SAI. Stroke-associated pneumonia (SAP) accounted for 73% of SAI (131 cases, 22% of patients); urinary tract infections comprised 9%. Admission NIHSS, dysphagia, C-reactive protein (CRP), neutrophil-lymphocyte ratio, and premorbid mRS were independently associated with SAI (p < 0.05). Similar associations were observed for SAP, though CRP association was attenuated. Crude 1-year mortality was higher in patients with SAI (34%, 60/179), including those with SAP (36%, 47/131), compared with 12% (49/410) in non-SAI patients. However, multivariable regression did not reach statistical significance. CONCLUSIONS:SAI occurred in nearly one-third of patients post-MT, predominantly as SAP. While crude mortality was increased with SAI, adjusted analyses were non-significant. Several variables were independently associated with SAI, enabling opportunities for identification of high-risk patients for enhanced monitoring or preventive strategies.
INTRODUCTION:The CHA2DS2 VASc score is widely used for stroke risk stratification in atrial fibrillation (AF). Efforts to improve prediction using demographic refinements have uncertain incremental value, particularly in multi-ethnic populations. We evaluated whether demographic modification or AF type provides additional discriminatory value. METHODS:We conducted a retrospective nested case-control study of patients with AF diagnosed prior to the fifth Auckland Regional Community Stroke Study (September 2020-August 2021). Cases with ischaemic stroke or transient ischaemic attack were identified from this population-based registry with central adjudication. Controls were randomly selected from the National Minimum Dataset, stratified by ethnicity. Predictors included CHA2DS2 VASc components, demographic refinements (alternative age transformations, ethnicity, and exclusion of sex), and AF type. The primary baseline model was a multivariable logistic regression model using standard CHA2DS2 VASc predictors as covariates. The traditional point-based CHA2DS2 VASc score was evaluated separately for comparison. Discrimination was assessed using the area under the receiver operating characteristic curve (AUC). RESULTS:The study included 1,908 patients (300 cases). A logistic regression model using standard CHA2DS2 VASc predictors demonstrated moderate discrimination {AUC 0.68 (95% confidence interval [CI]: 0.65-0.71)}. The traditional point-based CHA2DS2 VASc score showed lower discrimination (AUC 0.63 [95% CI: 0.60-0.66]; ΔAUC +0.05; p = 0.0003). Demographic refinements did not improve discrimination (ΔAUC ≤ 0.01). Addition of AF type modestly increased discrimination (AUC 0.71; ΔAUC +0.03; p = 0.015), with greater improvement in non-anticoagulated patients (ΔAUC +0.05). CONCLUSION:Demographic refinements, including ethnicity, provide limited incremental value beyond CHA2DS2 VASc, whereas AF type offers a modest discriminatory signal. This finding is hypothesis-generating and requires external validation before clinical implementation is considered.
Introduction: Identifying the cause of middle cerebral artery (MCA) occlusion before endovascular treatment in acute ischemic stroke is useful. Hypoperfusion intensity ratio (HIR) is defined as the volumetric ratio of tissue with a time-to-maximum (Tmax) >10 s to that with Tmax >6 s in perfusion magnetic resonance image (MRI). In this study, using perfusion MRI, we hypothesized that HIR could be associated with intracranial atherosclerotic disease (ICAD) in acute MCA occlusion. We also performed machine learning-based feature importance analysis to identify factors associated with the mechanism of acute MCA occlusion. Methods: We analyzed 117 patients with acute MCA occlusion treated with EVT and underwent RAPID MRI between March 2020 and December 2023. Patients were classified into the ICAD and non-ICAD groups. Clinical and imaging parameters were assessed using logistic regression. The cutoff value of HIR was calculated using Youden’s index, and its predictive value was compared using the DeLong test. Development of a machine learning algorithm for predicting ICAD using XGBoost (eXtreme Gradient Boosting) and feature importance analysis were performed. Results: A total of 34% were ICAD group with higher low-density lipoprotein cholesterol (LDL-C) levels, mild NIHSS, small DWI size, and low HIR. Late onset-to-puncture time (OTP) (>6 h) (OR: 9.67), no susceptibility vessel sign (SVS; OR: 9.05), no initial AF (OR: 63.67), low HIR (<0.31) (OR: 7.70) were associated with ICAD. Including HIR improved predictive performance (area under the curve [AUC] 0.73 vs. 0.88, p value <0.001). The XGBoost model showed high accuracy (0.92), SHAP value identified HIR, OTP, initial AF, SVS were important factors. Conclusion: HIR is a potential marker to determine the mechanism of acute MCA occlusion. Combined with established clinical and radiological features, it helps in identifying the ICAD-related MCA occlusion before EVT.
Introduction: In acute ischaemic stroke secondary to a large vessel occlusion, endovascular thrombectomy (EVT) is the standard of care. However, prediction of functional outcomes following EVT remains challenging. We sought to determine whether CT-derived morphomic data on body composition can improve outcome prediction following EVT. Methods: A retrospective analysis of anterior circulation stroke patients who underwent EVT between 2021 and 2023 at a single centre was conducted. Demographic, clinical, and morphomic data including neck muscle and fat area and density were collected. Multivariate logistic regression was used to develop pre-procedure and 24-h post-EVT models for predicting 90-day outcomes. A positive outcome was defined as a modified Rankin Scale (mRS) score of ≤2 at 90 days post-EVT. These models were subsequently tested on 2 separate validation cohorts. Results: High pre-procedure ASPECTS scores, lower baseline NIHSS scores, absence of post-procedure haemorrhage, younger age, and early neurological improvement were the strongest predictors of a positive outcome. None of the morphomic variables were significantly correlated with outcome. The 24-h model was highly accurate in predicting post-EVT outcomes in both validation cohorts. Conclusion: CT-derived morphomic variables did not significantly improve prediction of stroke outcomes post-EVT. Clinical and imaging variables (especially 24-h post-procedure data) showed high accuracy in predicting functional outcomes at 90 days.
Background In patients with acute stroke, the plasma concentrations of direct oral anticoagulants (DOACs) need to be known for further treatment decisions. The point-of-care test DOAC Dipstick contains two test pads that determine levels of direct factor Xa (FXA) inhibitors and thrombin (THR) inhibitors in urine samples; thereby determining DOAC plasma levels of > 30 ng/mL within 10 minutes. Aim This study aimed to test the feasibility of using the DOAC Dipstick to detect the presence of DOACs in patients with acute stroke and transient ischemic attack (TIA) during the early phase of intrahospital stroke management. Methods Urine samples from patients with acute stroke and TIA with or without DOAC intake were obtained within 8 hours after hospitalisation. The urine samples were tested using the DOAC Dipstick. After incubation, colour change on the DOAC Dipstick pads were analysed visually and using a semi-automated reader. Primary endpoints were the success rate of evaluable pad results and time to results after urine sampling. Results From January 2023 to April 2024, 70 patients were recruited, 66 of whom fulfilled the inclusion criteria (39% female, mean age 73 ± 11.9 years). The median (interquartile range) times from urine sample collection to visual and reader test pad results were 20 (15–26) mins and 24 (16–37) mins, respectively. The test procedure was uncomplicated in most patients (n = 60). Complications in the test procedure were delays in urine sampling (n = 3), need for repeated testing due to dry strip (n = 2), no visual evaluability of the test result (n = 1), and abnormal urine colour (n = 1). The urine samples of all patients with prior DOAC intake (n = 26) were positive for DOACs while those for all patients without prior DOAC intake (n = 39) were negative for DOACs (one patient was excluded because the urine sample was not collected in time). Conclusion The DOAC Dipstick rapidly and reliably detects DOACs in urine samples from patients with acute stroke and TIA
INTRODUCTION:Endovascular therapy (EVT) is an established treatment for large vessel occlusion in patients with acute ischaemic stroke; however, its efficacy for medium vessel occlusions, particularly isolated M2 segment occlusions, remains uncertain. As M2 occlusions are relatively proximal among medium vessel occlusions and can cause disabling neurological deficits, clarifying the role of EVT is clinically important. In this study, we aimed to evaluate the efficacy and safety of EVT compared with best medical management (BMM) in patients with acute isolated M2 occlusion using data from a multicentre registry. METHODS:We analysed the data of patients from a multicentre stroke registry who had an isolated M2 occlusion, had arrived within 24 h of onset, and were functionally independent before stroke. Data on baseline demographics, vascular risk factors, stroke characteristics, and treatment were collected. Propensity score matching generated 100 well-balanced pairs of EVT- and BMM-treated patients. The primary outcomes were favourable functional outcomes (modified Rankin Scale [mRS] score of 0-2 or 0-1) and mortality at discharge and 3 months. The secondary outcomes included neurological improvement or deterioration and haemorrhagic complications during hospitalisation. RESULTS:Among 594 eligible patients (EVT, n = 118; BMM, n = 476), data from 100 matched pairs were analysed. At 3 months, good functional outcomes (mRS score of 0-2: 49% EVT vs. 46% BMM) and mortality (7% vs. 9%) were comparable, with consistent findings at discharge. EVT was associated with higher rates of any intracranial haemorrhage (46% vs. 21%), although the symptomatic intracranial haemorrhage rates were identical (5%). In exploratory subgroup analyses, a significant interaction with onset-to-door time was observed for mRS score of 0-2 (p = 0.03), whereas no significant interaction was detected for mRS score of 0-1 or mortality. CONCLUSION:In this multicentre registry of patients with isolated M2 occlusion, EVT was not associated with superior functional outcomes or reduced mortality, compared with BMM. Although exploratory analyses suggested possible heterogeneity of treatment effect according to clinical factors, such as time from onset, these findings should be interpreted cautiously. Overall, the results highlight the heterogeneity of M2 occlusions and underscore the need for adequately powered randomised trials to inform individualised treatment decisions.
INTRODUCTION:While conventional risk factors fail to fully explain stroke incidence, psychological well-being has emerged as a potential determinant of cerebrovascular health. The aim of this study was to investigate the prospective association between baseline life satisfaction and incident stroke among middle-aged and older Chinese adults. METHODS:About 15,225 participants aged ≥45 years were included from the China Health and Retirement Longitudinal Study (CHARLS, 2011-2020). Life satisfaction was assessed at baseline using a single-item 5-point scale. Incident stroke was self-reported in follow-up waves. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), adjusting for sociodemographic factors, lifestyle behaviors, comorbidities, and depression symptoms. Subgroup analyses were performed by age, gender, comorbidities, BMI, and depression symptoms. RESULTS:Over the follow-up of 9 years, 1,296 participants (8.5%) developed stroke. Higher life satisfaction was associated with a significantly reduced risk of stroke (HR: 0.83; 95% CI: 0.72-0.95). Subgroup analyses indicated that the protective association was more pronounced among older adults, females, participants with chronic conditions (hypertension, diabetes, heart disease), overweight individuals, and those with depression symptoms. CONCLUSIONS:Higher life satisfaction was prospectively associated with a lower risk of incident stroke in middle-aged and older Chinese adults. Given the observational design and reliance on self-reported measures, these findings should be interpreted as evidence of association rather than causation. Future studies incorporating repeated assessments of well-being and clinically verified stroke outcomes are warranted.
Introduction: Poststroke complications pose significant challenges in the management of stroke patients and are associated with adverse outcomes. The potential interplay and temporal sequence of stroke-associated pneumonia (SAP) and deep vein thrombosis (DVT) following stroke remain unclear. This study aimed to investigate the association between SAP and DVT and to elucidate temporal sequence of these complications after acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH). Methods: We conducted a study using the in-hospital Medical Complications after Acute Stroke (iMCAS) registry at Beijing Tiantan Hospital from 2014 to 2016. We documented the incidence of SAP and DVT and the time from stroke onset to diagnosis of each complication. A time-dependent Cox regression model was used to evaluate the association between SAP and DVT, and the temporal sequence was compared across AIS, ICH, and SAH. Results: A total of 1,771 patients were included, comprising 1,129 with AIS, 314 with ICH, and 328 with SAH. The incidence of SAP was higher than that of DVT in AIS (7.6% vs. 1.9%), ICH (18.8% vs. 5.7%), and SAH (16.8% vs. 7.9%). SAP occurrence was significantly associated with subsequent DVT development (HR = 3.65, 95% CI: 2.08-6.40, p < 0.001). This association was also confirmed in AIS and ICH. The median time from stroke onset to SAP was 4 days (IQR: 2-6), and to DVT was 8 days (IQR: 5-12). SAP occurred significantly earlier than DVT in all stroke subtypes. Conclusion: SAP was significantly associated with an increased risk of subsequent DVT, with a consistent temporal sequence in which SAP preceded DVT.
Purpose: This study aimed to explore the relationship between serum inflammatory biomarkers and the carotid atherosclerotic plaque characteristics, given prior evidence suggesting a key role of inflammation in the development of atherosclerosis. Methods: In this prospective study, patients with carotid atherosclerotic plaque were recruited. Serum high-sensitivity CRP (Hs-CRP), homocysteine (Hcy) concentrations, and neutrophil-to-lymphocyte ratio (NLR) were obtained for all enrolled patients. Carotid atherosclerosis characteristics (such as intraplaque hemorrhage [IPH] and lipid-rich necrotic core [LRNC]) were determined by three-dimensional high-resolution vessel wall imaging. The associations between Hs-CRP, Hcy, NLR, and plaque characteristics were assessed. Results: In total, 128 patients (84.4% men; mean age, 58.0 ± 8.7 years) were included. Multivariate logistic regression indicated that increased Hs-CRP levels were associated with the presence of LRNC (OR = 1.23, 95% CI: 1.07–1.40, p = 0.003) and IPH (OR = 1.26, 95% CI: 1.10–1.45, p = 0.001). Multivariate linear regression confirmed a significant correlation between Hs-CRP level (β = 3.24, 95% CI: 0.66–5.81, p = 0.014) and the IPH volume. For plaque burden, higher Hs-CRP levels were associated with larger max normalized wall index (NWI) (β = 0.01, 95% CI: 0.00–0.02, p = 0.005) and larger Max wall thickness (β = 0.08, 95% CI: 0.02–0.14, p = 0.006). NLR and Hcy levels did not show significant associations with the carotid plaque characteristics. Conclusions: Elevated Hs-CRP levels were found to be closely associated with plaque burden and vulnerable plaque characteristics. The relationship between the elevated Hs-CRP and plaque vulnerability highlights its potential role in risk stratification and early intervention strategies. Further validation in larger, multicenter population studies is required to confirm these associations.
Introduction: Isolated intraventricular hemorrhage (IVH) is a rare phenotype of intracerebral hemorrhage (ICH), and its mechanistic basis is poorly understood. Methods: This retrospective study used a prospectively collected single-center database of patients treated between December 2010 and December 2022. Patients with ICH were classified into isolated IVH and intraparenchymal hemorrhage (IPH). The clinical profiles of patients with isolated IVH and IPH were compared. Results: Of 2,310 patients with acute ICH, 41 were excluded because of underlying vascular lesions, trauma, and tumor as possible causes. Of the remaining 2,269 patients, there were 23 patients (1%) with isolated IVH (female 44%; mean age, 73 ± 11 years) and 2,246 (99%) with IPH (43%; 71 ± 13 years). Compared with the IPH group, the isolated IVH group had a higher frequency of diabetes mellitus (35% vs. 16%) and prior anticoagulant use (44% vs. 13%). Diabetes mellitus (adjusted odds ratio: 2.50 [95% confidence interval, 1.03–6.07]) and prior anticoagulant use (3.74 [1.05–13.33]) were independently associated with isolated IVH. Compared with the IPH group, the isolated IVH group had a significantly lower NIHSS score at discharge (median 2 [interquartile range 0–12] vs. 8 [2–18], p = 0.011). Unfavorable outcome, defined as mRS 4–6, was marginally less common at 90 days (27% vs. 47%, p = 0.061) for isolated IVH than for IPH. Conclusions: Compared to IPH, isolated IVH was more frequently associated with prior anticoagulant use and diabetes mellitus and had a tendency for milder neurologic deficits and better functional outcomes.
Introduction: The benefit of intravenous thrombolysis (IVT) before endovascular therapy (EVT) in patients with acute ischemic stroke (AIS) with medium-large infarct core (MLIC) remains uncertain. Methods: We conducted a retrospective analysis of a prospective multicenter registry in Vietnam (August 2023–September 2024). We included patients with AIS large-vessel occlusion in the anterior circulation within 4.5 h of onset, an Alberta Stroke Program Early CT Score (ASPECTS) < 6, and a National Institutes of Health Stroke Scale (NIHSS) ≥ 6 at admission. The primary outcome was functional ambulation (defined as mRS 0–3) at 90 days of follow-up. Secondary outcomes were functional independence (mRS 0–2), mRS shift analysis, and rates of successful reperfusion (modified thrombolysis in cerebral infarction 2b-3). Safety outcomes were defined by symptomatic intracranial hemorrhage (sICH) according to SITS-MOST criteria and 90-day mortality. Outcomes between the bridging therapy and EVT-alone groups were compared using propensity score-matched (PSM) analysis. Results: Of 403 MLIC patients undergoing EVT, 148 presented within 4.5 h, 59 (39.9%) received bridging IVT. After PSM, we analyzed 72 patients, with 36 in each group. The median age, proportion of males, baseline ASPECTS, and NIHSS scores were similar between the two groups. The bridging group achieved higher rates of functional ambulation (75% vs. 41.7%, OR 4.2, 95% CI 1.54–11.46). Regarding safety, there was no statistically significant difference in symptomatic intracerebral hemorrhage (8.3% vs. 11.1%, p = 1.0) or mortality (8.3% vs. 19.4%, p = 0.17), though the confidence intervals were wide. Conclusion: Our study suggests that bridging therapy in patients with acute medium-large ischemic core within 4.5 h of onset results in better functional outcomes than EVT alone without increasing the sICH rate. Further studies are required to assess the safety and efficacy of bridging therapy.
INTRODUCTION:Perioperative stroke constitutes a major subset of in-hospital stroke. Evidence is lacking on whether procedure-specific risk profiles exist and how they influence functional recovery. We aimed to identify distinct clinical features and procedure-specific risk factors associated with perioperative stroke. METHODS:We retrospectively analyzed a 4-year cohort of patients with in-hospital stroke from 5 tertiary hospitals across China. Clinical data were systematically extracted through electronic medical record review. Ninety-day functional outcomes were assessed. Multivariate linear regression was performed to identify factors associated with 90-day outcomes in perioperative stroke. RESULTS:Out of 1,048,566 hospitalized patients, 166 (0.02%) patients developed in-hospital stroke. Among them, 158 patients completed the 90-day follow-up, with 100 males (63.29%) and a median age of 69 years (IQR: 61-76). Sixty-three (39.87%) had perioperative stroke, with the highest proportion (13.92%) occurring in the cardiology/cardiothoracic surgery departments. Delayed recognition (4 h [IQR: 1.58-24.00] vs. 2 h [IQR: 1.00-5.50], p = 0.020), higher NIHSS scores (12 [IQR: 5-30] vs. 9 [IQR: 4-16], p = 0.045), and lower proportion of reperfusion therapy (5.56% vs. 28.21%, p = 0.003) were observed in patients with perioperative ischemic stroke compared to those with non-perioperative stroke. In subgroup analysis, cardiovascular surgery-related ischemic stroke patients had higher NIHSS scores (20 [IQR: 8-35] vs. 8 [IQR: 5-20], p = 0.035) and 90-day modified Rankin scale scores (4 [IQR: 2-6] vs. 2 [IQR: 1-4], p = 0.039) than those non-cardiovascular surgical counterparts. Additionally, they exhibited a trend toward a higher 90-day mortality rate (33.33% vs. 10.71%; OR, 4.17 [95% CI: 1.07 to 20.83]; p = 0.052). CONCLUSION:Perioperative in-hospital stroke exhibits distinct clinical characteristics. Cardiovascular-related surgery is associated with worse functional outcomes.
Introduction: Symptomatic intracranial atherosclerotic disease (ICAD) is associated with a high risk of stroke recurrence despite aggressive medical management. However, recurrence rates and risk factors are less studied in non-Western settings. The study evaluated the clinical and imaging predictors of early and late stroke recurrence in patients with symptomatic ICAD in India. Methods: This ambispective cohort study enrolled patients with symptomatic ICAD within 1 month of symptom onset from a tertiary stroke care hospital. The intracranial arterial stenosis grade and length, infarct patterns, white matter hyperintensity (WMH), and collateral flow were documented. The primary outcome was recurrent stroke or transient ischemic attack (TIA) within 3 months and 1 year. Results: Of 876 patients with large artery atherosclerosis, 229 patients were included (mean age 59.7 ± 10.2 years; men, 72.9%). At the end of 1-year follow-up, recurrent ischemic stroke or TIA occurred in 55 (24%) patients. Of these, 47 (20.5%) patients had stroke recurrence within 3 months (early), and 14 (6.1%) patients had stroke recurrence after 3 months to 1 year (late). Six patients had both early and late stroke recurrence. A territorial and cortical infarct pattern (p = 0.038), moderate to severe WMH (p = 0.050), hypertension (p = 0.040), diabetes (p = 0.043), and coronary artery disease (p = 0.034) predicted early stroke recurrence. A territorial and cortical infarct pattern (p = 0.026), greater length of stenosis (p = 0.045), diabetes (p = 0.026), and coronary artery disease (p = 0.044) predicted late recurrence. On multivariate analysis, a territorial and cortical infarct pattern (adj. OR: 2.15; 95% CI: 1.09–4.26; p = 0.028) independently predicted early stroke recurrence. Conclusion: A territorial and cortical infarct pattern is an independent predictor of early stroke recurrence, suggesting the role of artery-to-artery embolism and plaque instability as a potential mechanism of early stroke recurrence in patients with symptomatic ICAD.
Introduction: High blood pressure (BP) is associated with a poor outcome after stroke. Trials of transdermal glyceryl trinitrate (GTN), a nitric oxide donor, have suggested that treatment between 3 and 5 h might improve functional outcome. Methods: We randomly assigned hospitalised patients with an acute ischaemic or haemorrhagic stroke to 2 days of transdermal GTN (5 mg/day) or sham, started between 3 and 5 h after onset. The primary feasibility outcome was recruitment rate; proof-of-concept (PoC) was assessed at 90 days by central observers blinded to treatment assignment using the modified Rankin Scale (mRS). Data are number (%), median [interquartile range], or mean (standard deviation). Comparisons were assessed by multiple linear regression. Results: Thirty-nine of an intended 120 participants were recruited. A total of 3,314 people were excluded, commonly related to presentation >5 h of onset or outside of researcher working hours, no eligible symptoms/signs or an unclear onset time. Mean age was 72 (SD 13) years, females were 41%, BP was 161.8 (18.4)/80.8 (14.9) mm Hg, and time from onset at baseline was 216 [186, 251] minutes. The fall in BP over 24 h did not differ between GTN versus sham. mRS at 3 months did not differ between the groups (difference in means, DIM -0.20, 95% confidence intervals -1.30, 0.90; p = 0.72). GTN was associated with improved cognition on the telephone interview of cognition scale (DIM 8.0, 95% CI 1.3, 14.8; p = 0.020). Although headache was more common, GTN was associated with fewer serious adverse events (p = 0.020). Conclusion: Recruitment limitations in this small single-centre trial prevented demonstration of feasibility for patients in the time window of 3-5 h post ictus. GTN demonstrated some evidence of PoC and was safe. A multicentre trial needs to further test this hypothesis.
Introduction: The prognosis of patients with acute ischemic stroke (AIS) following endovascular therapy (EVT) is largely influenced by the extent of reperfusion. Fluid-attenuated inversion recovery vascular hyperintensity (FVH) is a simple imaging sign which assessed based on fluid-attenuated inversion recovery (FLAIR) images. We aimed to evaluate whether FVH on posttreatment FLAIR can serve as a surrogate imaging marker of cortical hyperperfusion identified by arterial spin labeling (ASL) in patients with AIS after EVT. Methods: We retrospectively enrolled 150 patients with AIS who achieved successful recanalization after EVT. Clinical data and posttreatment magnetic resonance imaging sequences including diffusion-weighted imaging (DWI), FLAIR, and ASL were systematically collected. The 150 patients were categorized into four groups based on DWI and FVH status (A: DWI−, FVH−; B: DWI+, FVH−; C: DWI−, FVH+; D: DWI+, FVH+). Perfusion was evaluated within six predefined Alberta Stroke Program Early CT Score (ASPECTS) regions (M1–M6) per patient, yielding a total of 900 cortical regions analyzed. The perfusion status was evaluated based on visual assessment of absolute cerebral blood flow maps derived from ASL, followed by statistical analysis. Results: Among the 900 cortical territories, 250 (27.78%) were classified as group A, 361 (40.11%) as group B, 55 (6.11%) as group C, and 234 (26.00%) as group D. Inter-rater agreement for evaluating the status of posttreatment FVH was excellent (κ = 0.851). There were significant differences in perfusion characteristics across four groups (p < 0.001). In subgroup analysis, group C exhibited a higher proportion of hyperperfusion compared to group A (21.82% vs. 15.20%), although the difference did not reach significance (p = 0.442), while group D demonstrated a significantly higher percentage of hyperperfusion relative to group B (48.72% vs. 34.34%, p < 0.001). Conclusion: Positive FVH may be associated with post-EVT cortical hyperperfusion in AIS patients following successful revascularization.
Introduction: This study sought to investigate the severity of intracranial artery calcification (IAC) in relation to white matter hyperintensities (WMHs), and whether the association was mediated by cerebral autoregulation (CA). Methods: A total of 144 patients with cerebral small vessel disease were included in this study. The severity of WMH was assessed using Fazekas scores in FLAIR-magnetic resonance imaging images. On non-contrast head computed tomography images, the severity of IAC was measured by IAC scores and further classified as intimal or medial calcification. As proxy of CA, critical closing pressure (CrCP) was determined by analyzing blood pressure-flow velocity relationships in the middle cerebral artery. Mediation analyses were conducted examine the proportion of mediation of CrCP on the association between IAC and WMH. Results: IAC scores were found to be associated with WMH scores (β 0.364; 95% confidence interval [CI], 0.133–0.409; p < 0.001). After multivariable adjustment, a statistically significant association was observed between IAC scores and higher CrCP values (β, 0.329; 95% CI, 0.129–0.528; p = 0.001). Mediation analyses revealed that CrCP partially mediated (10.3%) the association between higher IAC scores and increased WMH severity. The proportion of mediation was driven by a medial calcification pattern (13.9%). Conclusion: This hospital-based study demonstrated the association between higher IAC scores and the severity of WMH in patients with cerebral small vessel disease, which can be partially mediated by CA as indicated by CrCP, especially for the patients with predominantly medial calcification.
INTRODUCTION:Spontaneous cervical artery dissection (CeAD) is an important cause of ischemic strokes in young adults. The pathophysiology as well as risk factors are largely unknown. Recurrences are considered rare and primarily to occur within the first 3 months. The frequency of asymptomatic recurrences varies in recent studies. This study seeks to determine the risk of all recurrent dissections in an unselected consecutive patient population after initial diagnosis. METHODS:Of 218 patients referred between October 2014 and December 2024, 102 were included in the final analysis. Patients' medical records were reviewed to determine demographics, including associated risk factors and antithrombotic treatments used. Reports from relevant imaging at routine follow-up and at repeat admissions were acquired to determine recurrence rates of CeAD and new cases of stroke. RESULTS:Seven (6.9%) patients had CeAD recurrences after the index event, of which 6 occurred after 6 months and 2 (28.6% of recurrences) were asymptomatic. A family history of dissections (RR: 6.9, CI: 1.7; 27.3, p = 0.006) or radiologically verified tortuous cervical arteries (RR: 9.8, CI: 2.8; 34.3, p = 0.0003) were significantly associated with recurrence. By 1-year follow-up, 56 patients had persisting vessel sequelae from the index CeAD. Stroke occurrences after the index CeAD was 2.9% (n = 3) and did not occur in patients with CeAD recurrence. All patients received antithrombotic treatment for at least a year. CONCLUSION:Recurrence of CeAD and stroke occurrence were low after the index event. CeAD were often asymptomatic and occurred later than previously reported. Long-term, regular follow-up and stroke-preventive treatments are essential to reduce morbidity from repeat CeAD and strokes, especially in patients with relevant family history or known artery tortuosity.
INTRODUCTION:We aimed to describe imaging characteristics in stroke hospitalizations with nonspecific/unspecified vascular region subcodes and to assess for systematic bias in the use of these subcodes. METHODS:We captured first ischemic stroke hospitalizations from 2018 to 2022 at a single stroke center. We reviewed imaging studies to classify a gold standard of vascular region blinded to ICD-10 subcodes in 200 randomly selected hospitalizations: 100 with nonspecific/unspecified subcodes and 100 with specific subcodes oversampled for posterior circulation strokes. We assessed for systematic bias in the use of nonspecific/unspecified subcodes using multilevel logistic regression, with primary provider included as a random intercept. Separate models were applied to the full population of strokes and to those that underwent imaging review. RESULTS:We identified 5,234 first ischemic stroke hospitalizations, of which 2,224 (43%) received a nonspecific/unspecified vascular region subcode. Out of the 100 ICD-10 nonspecific/unspecified stroke location cases that underwent imaging review, 85 had acute infarcts in specific locations: 45 anterior circulation, 40 posterior circulation, and 15 with no infarct. Factors associated with the use of nonspecific/unspecified subcodes were low NIHSS scores and non-neurological specialist but not anterior versus posterior vascular distribution. The proportion of variance explained by the models was modest (pseudo-R2 0.16). CONCLUSIONS:Most ischemic stroke hospitalizations coded with nonspecific/unspecified ICD-10 vascular region subcodes had imaging-confirmed infarcts in specific vascular regions. These strokes tended to have a lower NIHSS and were overrepresented by posterior circulation lesions. The modest variance explained in the use of nonspecific/unspecified codes indicates that much of the coding is influenced by random variation or unmeasured factors. Future studies in other healthcare systems are needed to verify these findings and evaluate for other predictors. Researchers using these subcodes should recognize the limitations and incorporate sensitivity analyses to evaluate potential bias in results.
