BACKGROUND: Sleep-disordered breathing (SDB) is common after ischemic stroke and has been associated with adverse outcomes, yet evidence from large stroke cohorts remains limited. We evaluated the association of SDB severity with all-cause mortality, major adverse cardio- and cerebrovascular events (MACCE), and 3-month functional outcome. METHODS: This retrospective cohort study included consecutive patients with ischemic stroke or transient ischemic attack admitted to Inselspital Bern between 2017 and 2021 who underwent in-hospital respiratory polygraphy. SDB severity was classified according to the apnea-hypopnea index as mild (5–<15 events/h), moderate (15–<30 events/h), or severe (≥30 events/h). Outcomes included all-cause mortality, first postindex MACCE, and modified Rankin Scale scores at 3 months. Multivariable Cox and logistic regression models adjusted for age, sex, body mass index, vascular risk factors, admission National Institutes of Health Stroke Scale, intravenous thrombolysis, and mechanical thrombectomy. RESULTS: Among 1083 patients (mean age, 66.0±14.5 years; 62.6% male), SDB (apnea-hypopnea index ≥5 events/h) was present in 819 patients (75.6%), including mild (29.8%), moderate (22.9%), and severe (22.9%). Median follow-up was 51.1 months (interquartile range, 39.1–67.8) for mortality and 47.7 months (interquartile range, 36.9–65.5) for first postindex MACCE; 178 deaths and 153 of 880 patients experienced a first postindex MACCE. Severe SDB was independently associated with increased all-cause mortality (adjusted hazard ratio, 1.73 [95% CI, 1.04–2.89]). Mild, moderate, and severe SDB were associated with first postindex MACCE (adjusted hazard ratio, 1.78 [95% CI, 1.03–3.06]; 2.20 [95% CI, 1.26–3.84]; and 2.16 [95% CI, 1.23–3.78], respectively; P for trend=0.009). Moderate and severe SDB were associated with unfavorable 3-month functional outcome (adjusted odds ratio, 1.74 [95% CI, 1.01–3.04] and 2.48 [95% CI, 1.45–4.31], respectively; P for trend <0.001). CONCLUSIONS: Severe SDB was independently associated with all-cause mortality, whereas SDB severity was associated with first postindex MACCE and unfavorable 3-month functional outcome. Acute-phase SDB assessment may improve prognostic risk stratification.
BACKGROUND: Obesity increases the risk of stroke and cognitive decline, but its association with intracranial arterial hemodynamics remains unclear. We examined whether obesity score is associated with intracranial signal-intensity gradient, a time-of-flight magnetic resonance angiography–derived surrogate of arterial wall shear conditions, and whether this association differs by vascular territory. METHODS: This cross-sectional study included 5618 adults who underwent comprehensive health screening, including intracranial time-of-flight magnetic resonance angiography, in the Republic of Korea between 2012 and 2020. Body mass index was calculated from measured height and weight, and waist circumference was measured by health-screening staff on the same day as brain magnetic resonance angiography. An obesity score was calculated by assigning 1 point each for general and abdominal obesity, yielding scores of 0 (neither), 1 (either), or 2 (both). Arterial SIG and arterial radius were calculated using semiautomated 3-dimensional vessel segmentation. Lower SIG values were interpreted as reflecting reduced arterial wall shear conditions. Multivariable linear regression models assessed the association between obesity score and SIG across 11 intracranial arteries, adjusting for demographics, arterial radius, and cardiometabolic factors. RESULTS: Among 5618 participants (mean [SD] age, 55.9 [8.6] years; 45.2% women), higher obesity score was associated with lower SIG across all intracranial arteries ( P value for trend <0.001). In adjusted models, each 1-point increase in obesity score was associated with reduced SIG, including in the basilar artery (B=−0.26 [95% CI, −0.31 to −0.21]). The obesity-related reduction in SIG was greater in the posterior than anterior circulation and persisted after adjustment for arterial radius and cardiometabolic factors. CONCLUSIONS: A higher obesity score was associated with reduced intracranial arterial SIG, consistent with adverse time-of-flight magnetic resonance angiography–derived flow-related hemodynamic alterations. Greater reductions in the posterior circulation suggest territory-specific vulnerability, which may be associated with early cerebrovascular compromise in the context of obesity.
BACKGROUND: This prespecified post hoc analysis of the ATAMIS trial (Antiplatelet Therapy in Acute Mild to Moderate Ischemic Stroke) aimed to investigate whether the benefit of dual antiplatelet therapy versus aspirin alone differs in patients with mild versus moderate stroke. METHODS: Using data from the modified intention‑to‑treat population of the ATAMIS trial, eligible patients were divided into mild (National Institutes of Health Stroke Scale [NIHSS] score 4–5) and moderate (NIHSS score 6–10) groups. The primary outcome was early neurological deterioration at 7 days, defined as an increase in the NIHSS score of ≥2 points from baseline. Safety outcomes included bleeding events and intracranial hemorrhage within 90 days. Binary logistic regression, Cox regression, and generalized linear models were used as appropriate. Adjusted models included age, sex, diabetes, hypertension, onset-to-treatment time, stroke cause, and other imbalanced baseline variables. Treatment-by-baseline stroke severity interaction was assessed. RESULTS: A total of 2915 patients were included, including 1992 (68.4%) with mild stroke and 923 (31.6%) with moderate stroke. Median age was 66 years (interquartile range, 59–73); 35.0% were women. Clopidogrel plus aspirin was associated with a significantly lower risk of early neurological deterioration compared with aspirin alone in the moderate stroke group (adjusted odds ratio, 0.31 [95% CI, 0.17–0.59]; P <0.001), whereas no significant difference was observed in the mild stroke group (adjusted odds ratio, 0.96 [95% CI, 0.66–1.41]; P =0.841). A significant interaction was identified between treatment effect and NIHSS score subgroup ( P interaction =0.003). The occurrence of bleeding events and intracranial hemorrhage was similar between treatment groups in both severity subgroups. CONCLUSIONS: In patients with acute mild-to-moderate ischemic stroke, the benefit of clopidogrel plus aspirin versus aspirin alone in preventing early neurological deterioration at 7 days may be greater among patients with moderate stroke (NIHSS score 6–10) than among those with mild stroke (NIHSS score 4–5), without an increased risk of bleeding. These findings suggest that baseline stroke severity may inform antiplatelet therapy selection, and warrant confirmation in future prospective studies. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02869009.
BACKGROUND: Cerebral venous thrombosis is an uncommon cause of stroke that primarily affects young adults. Several clinical trials and observational studies have compared vitamin K antagonists (VKAs) with direct oral anticoagulants (DOACs) for treating cerebral venous thrombosis, but the small sample sizes limit the ability to draw firm conclusions. METHODS: We performed a systematic review and meta-analysis of randomized controlled trials and observational studies comparing DOACs with VKAs for the treatment of cerebral venous thrombosis. Studies published between January 2007 and July 2025 were included. Prespecified subgroup analyses were conducted by study design, DOAC class (anti–factor Xa inhibitors versus direct thrombin inhibitors), and VKA. Risk of bias was assessed using the Cochrane Risk-of-Bias Tool 2 for randomized trials and the Risk of Bias in Nonrandomized Studies of Interventions for observational studies. Pooled risk ratios (RRs) with 95% CIs were calculated using random-effects models. RESULTS: Fourteen studies (8 randomized clinical trials [RCTs] and 6 observational studies) were included. Among 3698 patients, 1669 (45.1%) received DOACs and 2029 (54.9%) received VKAs. Rates of recurrent venous thromboembolism (10.24% versus 10.99%), major bleeding (4.26% versus 6.18%), clinically relevant nonmajor bleeding (2.63% versus 1.66%), good functional outcomes (95.09% versus 89.25%), and mortality (3.37% versus 3.30%) were similar in DOACs and VKAs. Recurrent venous thromboembolism was similar between DOACs and VKAs in RCTs (RR, 1.06 [95% CI, 0.35–3.24]) and in the overall pooled analysis of all studies (RR, 0.92 [95% CI, 0.55–1.53]). Major bleeding did not differ between DOACs and VKAs in RCTs (RR, 0.73 [95% CI, 0.24–2.22]) or in the overall analysis (RR, 0.74 [95% CI, 0.44–1.25]; P =0.26). Clinically relevant nonmajor bleeding was also comparable in RCTs (RR, 1.06 [95% CI, 0.25–4.48]) and overall (RR, 1.22 [95% CI, 0.38–3.86]). Good functional outcomes (modified Rankin Scale score of 0–2) were similar between DOACs and VKAs in RCTs (RR, 1.00 [95% CI, 0.84–1.19]) and in the combined analysis of all studies (RR, 1.02 [95% CI, 0.93–1.11]). Mortality was similar between DOACs and VKAs in RCTs (RR, 1.15 [95% CI, 0.28–4.68]) and in the pooled analysis. When direct thrombin inhibitors were compared with factor Xa inhibitors, there were no significant differences in outcomes. CONCLUSIONS: DOACs demonstrated comparable efficacy and safety to VKAs in the treatment of cerebral venous thrombosis. These findings support the use of DOACs as a reasonable alternative.
BACKGROUND: The carotid Plaque Reporting and Data System (Plaque-RADS) provides a standardized framework for evaluating plaque morphology, but prospective validation remains limited. We investigated the association between computed tomography angiography-based Plaque-RADS categories and subsequent ischemic events in patients with noncardioembolic stroke/transient ischemic attack, from a completed clinical trial of colchicine. Second, we assessed whether the effect of colchicine differed by Plaque-RADS risk classification. METHODS: We conducted a posthoc observational cohort analysis of 517 participants in the CONVINCE trial (Colchicine for Prevention of Vascular Inflammation in Non-CardioEmbolic Stroke) from 13 European sites. Associations between Plaque-RADS and recurrent ipsilateral stroke, any stroke/transient ischemic attack, and major adverse cardiovascular events were assessed using multivariable Cox proportional hazards models. Plaque-RADS was analyzed as both dichotomized (<3 versus ≥3) and ordinal (per 1-point increase) variables. Treatment effects were assessed by Plaque-RADS classification using interaction and stratified analyses. RESULTS: A total of 510 patients (median age, 67.0 years; 72.2% male) with 966 internal carotid arteries were included. Among 321 internal carotid arteries ipsilateral to the index ischemic stroke, 12 recurrent ipsilateral strokes, 32 any strokes/transient ischemic attacks, and 37 major adverse cardiovascular events occurred over a median 35.7-month follow-up. Plaque-RADS ≥3 (n=140) was independently associated with recurrent ipsilateral stroke (adjusted hazard ratio, 7.80 [95% CI, 1.55–39.30]; P =0.01), any stroke/transient ischemic attack (adjusted hazard ratio, 3.94 [95% CI, 1.68–9.24]; P <0.01), and major adverse cardiovascular events (adjusted hazard ratio, 2.52 [95% CI, 1.19–5.34]; P =0.02) after adjustment for age, sex and cardiovascular risk factors. A significant interaction with colchicine treatment was observed for major adverse cardiovascular events ( P =0.047), with greater benefit among patients with Plaque-RADS scores ≥3 (hazard ratio, 0.35 [95% CI, 0.15–0.82]). CONCLUSIONS: In internal carotid arteries ipsilateral to the index ischemic stroke, computed tomography angiography-based carotid Plaque-RADS was associated with recurrent ischemic stroke and cardiovascular events. Importantly, treatment effects of colchicine varied across Plaque-RADS classification (<3 versus ≥3), suggesting that plaque vulnerability assessment may help refine patient selection for anti-inflammatory therapy beyond stenosis-based classification. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02898610.
