Background Stroke remains a leading cause of mortality and adult disability in China, imposing a substantial disease and socioeconomic burden on society, yet nationally representative epidemiological and real-world inpatient care data remain insufficient. Methods This study integrated data from the Global Burden of Disease 2023, the Hospital Quality Monitoring System (7536 hospitals) in 2023, and the 2021 National Mortality Surveillance System to systematically assess the epidemiology, disease burden, inpatient care patterns, clinical outcomes and average costs of stroke per hospitalisation in China. Results In 2023, China reported 4.23 million incident cases, 26.68 million prevalent cases and 2.05 million deaths from stroke. Despite declining age-standardised incidence and mortality, ischaemic stroke (IS) prevalence continued to increase, while haemorrhagic stroke remains the principal contributor to disability-adjusted life years. Real-world inpatient data showed that males and older adults accounted for higher proportions of stroke admissions. Stroke admissions were predominantly concentrated in tertiary public hospitals with marked regional variation. Haemorrhagic stroke has substantially higher in-hospital mortality (intracerebral haemorrhage, ICH: 4.23%; subarachnoid haemorrhage, SAH: 4.08% vs IS: 0.49%) and adverse discharge outcomes than IS. Tertiary hospitals exhibited higher mortality (1.19% vs 0.62%) but lower 0–31-day readmission rates (1.19% vs 1.63%) than secondary hospitals, whereas private hospitals showed longer hospital stays (10.54 vs 9.86 days) and higher readmission rates (1.88% vs 1.34%) than public institutions. The mean hospitalisation cost was RMB13 927 (US$1900) per admission, with substantially higher costs for SAH and ICH than for IS. Conclusions This nationwide analysis provides comprehensive real-world evidence on the epidemiological burden, inpatient care patterns, clinical outcomes and hospitalisation costs of stroke in China, identifying substantial national, regional and hospital-level variations that may inform future research and quality improvement efforts.

OBJECTIVES:To assess how province-level healthcare resource configuration relates to in-hospital management and outcomes for acute ischemic stroke in China. METHODS:We conducted a cross-sectional study of 1 055 971 adults with acute ischemic stroke treated at 1456 secondary and tertiary hospitals in the Chinese Stroke Center Alliance, 2015 to 2019. Hospital-level management and outcome measures were linked to province-level resource indicators from the China Health Statistics Yearbook, including physician:nurse ratio, nurse:bed ratio, density of medical institutions, and total health expenditure. Associations were estimated using patient-number-weighted linear regression models adjusted for hospital level, provincial gross regional product per capita, admission timing, and year, with cluster-robust standard errors at the province level. RESULTS:Substantial interprovincial variation was observed. Most healthcare resource indicators were not significantly associated with composite adherence, although physician:nurse ratio showed a borderline positive association (β = 0.018 per 0.1 increase, 95% CI, -0.0004 to 0.036). Secondary prevention adherence was positively associated with health expenditure (β = 0.007; 95% CI, 0.0003-0.014). For thrombolysis within 4.5 hours, physician:nurse ratio was negatively associated (β = -0.062; 95% CI, -0.119 to -0.006), whereas nurse:bed ratio was positively associated (β = 1.232; 95% CI, 0.066-2.397). In contrast, healthcare resource indicators were not clearly associated with in-hospital outcomes. CONCLUSIONS:Healthcare resource configuration showed modest associations with stroke management but limited associations with in-hospital outcomes, suggesting that resource availability alone may not fully explain variation in stroke outcomes.

Chronological age is a strong predictor of poor outcomes after ischemic stroke but may not fully capture underlying biological vulnerability. This study investigated whether age-related brain atrophy and plasma YKL-40, a marker of astroglial inflammation, mediate the association between age and the one-year risk of ischemic stroke recurrence or all-cause mortality. Data were obtained from 4,305 participants enrolled in the Third China National Stroke Registry. Baseline brain atrophy was quantified from structural T1-weighted MRI using an automated deep learning–based pipeline (FastSurfer), yielding hemispheric cortical and white matter volumes that were modeled as indicators of a latent atrophy construct. Structural equation modeling was applied to estimate direct and indirect pathways linking age, brain atrophy, YKL-40, and one-year composite outcomes, adjusting for sex, atrial fibrillation or flutter, hypertension, and diabetes, with indirect effects evaluated using 5,000 bootstrap resamples. The total effect of age on one-year outcomes was not significant (β = −0.011; 95

BACKGROUND AND OBJECTIVES:Previous studies have shown a beneficial effect of clopidogrel-aspirin and intensive statin therapy in acute ischemic stroke; however, the synergistic effect of the 2 treatments is still unclear. The aim of this study was to investigate the effect of combining clopidogrel-aspirin and immediate intensive statin in patients with acute mild ischemic stroke or transient ischemic attack (TIA). METHODS:We performed a multicenter, randomized, double-blind, placebo-controlled trial with a 2-by-2 factorial design across 222 hospitals in China. Eligible participants were patients with acute mild ischemic stroke or TIA of a presumed atherosclerotic cause within 72 hours of symptom onset. Patients were randomly assigned to receive clopidogrel plus aspirin or aspirin alone and an immediate or delayed intensive statin. The primary efficacy outcome was a new stroke (ischemic or hemorrhagic) within 90 days, and the primary safety outcome was moderate-to-severe bleeding. RESULTS:Between September 17, 2018, and October 15, 2022, 6,100 patients were enrolled (median age, 65 years; 64.2% male), of whom 1,525 each were assigned to the 4 groups. New stroke within 90 days occurred in 116 patients (7.6%) in the clopidogrel-aspirin plus immediate intensive statin group (hazard ratio [HR] 0.76, 95% CI 0.60-0.97), in 106 patients (7.0%) in the clopidogrel-aspirin plus delayed statin group (HR 0.69, 95% Cl 0.54-0.89), and in 129 patients (8.5%) in the aspirin plus immediate statin group (HR 0.85, 95% Cl 0.67 to 1.07), compared with 150 patients (9.9%) in the aspirin plus delayed intensive statin group. Moderate-to-severe bleeding occurred in 17 (1.1%) in the clopidogrel-aspirin plus immediate statin group (p = 0.047), 10 (0.7%) in the clopidogrel-aspirin plus delayed statin group (p = 0.46), and 6 (0.4%) in the aspirin plus immediate statin group (p = 0.80), compared with 7 (0.5%) in the aspirin plus delayed statin group. DISCUSSION:Among patients with mild ischemic stroke or TIA of presumed atherosclerotic cause, the combination of clopidogrel-aspirin and delayed intensive statin was superior to aspirin plus delayed intensive statin in reducing the risk of new stroke, an effect that was mainly driven by clopidogrel-aspirin and not significantly different from that of clopidogrel-aspirin plus immediate statin. The combination treatment had a low but increased risk of moderate-to-severe bleeding. TRIAL REGISTRATION INFORMATION:ClinicalTrials.gov identifier: NCT03635749. CLASSIFICATION OF EVIDENCE:This study provides Class I evidence that in patients with mild ischemic stroke or TIA of presumed atherosclerotic cause, the combination of clopidogrel-aspirin plus delayed intensive statin was superior to aspirin plus delayed intensive statin in reducing the 90-day risk of new stroke.

OBJECTIVE:To assess the efficacy and safety of edaravone dexborneol, a multitarget brain cytoprotectant composed of antioxidant and anti-inflammatory ingredients, in improving functional outcomes among patients with acute ischaemic stroke undergoing endovascular thrombectomy. DESIGN:Multicentre, double blind, randomised, placebo controlled trial. SETTING:106 hospitals in China between March 2022 and May 2023. PARTICIPANTS:1362 patients with clinically diagnosed acute ischaemic stroke within 24 hours of symptom onset, aged 18-80 years, with a National Institutes of Health Stroke Scale (NIHSS) score of 6-25 and an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 6-10, confirmed large vessel occlusion in the anterior circulation, and planned endovascular thrombectomy. INTERVENTIONS:Patients were randomly allocated in a 1:1 ratio to receive edaravone dexborneol 37.5 mg (edaravone, 30 mg; (+)-dexborneol, 7.5 mg; 690 patients) or placebo (672 patients) before endovascular thrombectomy and continued the regimen twice daily for a consecutive period of 10-14 days. MAIN OUTCOME MEASURES:Functional independence at 90 days, defined as a modified Rankin Scale score (range 0 (no symptoms) to 6 (death)) of 0-2, and serious adverse events. RESULTS:One patient from each group was lost to follow-up at 90 days. Of the 1360 patients included in the intention-to-treat analysis, 379 (55.0%) of 689 patients in the edaravone dexborneol group and 333 (49.6%) of 671 patients in the placebo group achieved functional independence on day 90 (risk ratio 1.11, 95% confidence interval (CI) 1.00 to 1.23; P=0.05; risk difference 5.4%, 95% CI 0.1% to 10.7%). Patients with mismatch at admission (defined as NIHSS score ≥10 and ASPECTS ≥9 or NIHSS score ≥20 and ≥7) were more likely to achieve functional independence in the subgroup analysis (55.5% (178/321) versus 42.9% (134/312); risk ratio 1.29, 1.10 to 1.52; risk difference 13.0%, 5.6% to 20.3%; P for interaction=0.003). The rates of serious adverse events were similar in the two groups (27.2% (188/690) versus 25.7% (173/672); risk ratio 1.06, 0.89 to 1.26; risk difference 1.5%, -3.2% to 6.2%: P=0.53). CONCLUSIONS:Among patients with acute ischaemic stroke within 24 hours of symptom onset who underwent endovascular thrombectomy, those treated with edaravone dexborneol, compared with placebo, were more likely to achieve functional independence at 90 days without increased safety concerns. This effect seemed to be primarily driven by the subgroup with mismatch present at admission, suggesting that dedicated trials in this population may be warranted. TRIAL REGISTRATION:ClinicalTrials.gov NCT05249920.

Abstract Background Evidence for alteplase 4.5–24 h after acute ischemic stroke (AIS) onset remains limited in routine practice. We examined associations between late-window intravenous thrombolysis (IVT) and discharge outcomes in selected patients. Methods We analyzed China Stroke Center Alliance patients arriving 4–23.5 h after onset. Alteplase-treated patients were matched 1:1 to non-IVT patients using propensity scores. The primary outcome was modified Rankin Scale (mRS) 0–1 at discharge. Secondary and safety outcomes included mRS 0–2, registry-recorded in-hospital intracranial hemorrhage (ICH), mortality, discharge against medical advice (DAMA), and mortality or DAMA. Results Among 137,157 eligible AIS patients, 874 received IVT and were matched to 874 non-IVT patients. Median onset-to-needle time was 6.05 h (interquartile range 5.12–10.04); 48.4%, 23.7%, 6.6%, and 21.3% were treated at 4.5-<6, 6-<9, 9-<12, and 12–24 h, respectively. IVT was associated with higher rates of mRS 0–1 (30.4% vs. 17.0%, odds ratio [OR] 2.14, 95% confidence interval [CI], 1.70–2.69, p < 0.001) and mRS 0–2 (65.4% vs. 58.1%; OR, 1.36; 95% CI, 1.12–1.66, p = 0.002). In-hospital ICH was more frequent (1.7% vs. 0.6%, OR 3.04, 95% CI, 1.10–8.39, p = 0.03), whereas DAMA was less frequent (5.7% vs. 8.8%, OR 0.63, 95% CI, 0.44–0.92, p = 0.02). Length of hospital stay, mortality, and mortality or DAMA did not differ significantly. Conclusions Late-window alteplase was associated with better discharge function but more registry-recorded ICH in selected patients. Because symptomatic status, hemorrhage subtype, severity, and fatality were unavailable, hemorrhagic safety remains incompletely characterized. These observational findings require cautious interpretation.

BACKGROUND:Optimal alteplase dosing for intravenous thrombolysis in stroke patients aged >80 years remains debated due to underrepresentation in pivotal trials. This study evaluates the relative effectiveness and safety of low-dose (0.6 mg/kg) versus standard-dose (0.9 mg/kg) alteplase in elderly patients treated within 4.5 hours of onset. METHODS:Utilizing the China Stroke Center Alliance registry database (2018-2022), we conducted a propensity score-matched analysis encompassing 6,522 patients over 80 years of age, ultimately generating 2,050 matched pairs. The primary outcome was functional dependence or death at discharge (mRS 2-6). Secondary measures included major disability (mRS 3-6), in-hospital mortality, and symptomatic intracranial hemorrhage (sICH). RESULTS:The primary outcome showed no statistical difference between low-dose (81.6 %) and standard-dose (81.8 %) groups (OR 0.99; 95 % CI 0.84-1.16; P=0.871). Rates of major disability (56.0 % vs. 57.7 %; OR 1.02; P=0.730), mortality (15.6 % vs. 14.4 %; OR 1.10; P=0.294), and sICH (4.4 % vs. 5.2 %; OR 0.85; P=0.274) were broadly alike. Low-dose alteplase showed a numerical decline in bleeding events. Subgroup analysis found no modifying factors. CONCLUSIONS:In octogenarian stroke patients, low-dose alteplase offers parallel efficacy and safety to standard therapy, with a possible reduction in hemorrhagic complications. These results support low-dose regimens as a reasonable option for elderly patients, particularly when minimizing bleeding risk is a clinical priority.

OBJECTIVE:To evaluate the efficacy of a clinical decision support system (CDSS) on stroke care quality and clinical outcomes among patients with acute ischaemic stroke. DESIGN:Multicentre, cluster randomised clinical trial. SETTING:77 hospitals across China. PARTICIPANTS:77 hospitals (38 randomised to intervention group, 39 to control group) enrolled 21 603 patients with acute ischaemic stroke admitted to hospital within seven days after symptom onset. INTERVENTIONS:Hospitals in the intervention group received stroke CDSS support including artificial intelligence assisted imaging analysis, classification of stroke causes, and evidence based treatment recommendations. Hospitals in the control group provided usual care. MAIN OUTCOMES MEASURES:The primary outcome was a new vascular event (composite of ischaemic stroke, haemorrhagic stroke, myocardial infarction, and vascular death) within three months after initial symptom onset. Secondary outcomes included the composite measure and all-or-none measure of evidence based performance measures for acute ischaemic stroke care quality, a new vascular event at six and 12 months, and disability (modified Rankin Scale score 3-6) and all cause mortality at three, six, and 12 months. Safety outcomes were moderate or severe bleeding events and all bleeding events at three, six, and 12 months. RESULTS:11 054 patients in the intervention group and 10 549 patients in the control group were enrolled from January 2021 to June 2023. New vascular events at three months occurred in 2.9% (320/11 054) in the intervention group compared with 3.9% (416/10 549) in the control group (adjusted hazard ratio 0.74, 95% confidence interval (CI) 0.58 to 0.93, P=0.01). The CDSS intervention effect remained significant in the cluster level analysis (-0.01, -0.02 to -0.004, P=0.003). Patients in the intervention group were more likely to have a higher composite measure (91.4% (77 049/84 276) v 89.8% (70 794/78 834), adjusted odds ratio 1.21, 95% CI 1.17 to 1.26, P<0.001). New vascular events were significantly lower in the intervention group at 12 months (4.0% (440/11 054) v 5.5% (576/10 549), adjusted hazard ratio 0.73, 95% CI 0.56 to 0.95, P=0.02). No significant differences were found in disability and all cause mortality. Moderate or severe bleeding, and all bleeding did not differ significantly between the two groups. CONCLUSIONS:Use of the stroke CDSS in patients with acute ischaemic stroke in China led to a significant decrease in new vascular events at three months. The stroke CDSS intervention was also effective in improving stroke care quality and decreasing long term vascular events. TRIAL REGISTRATION:ClinicalTrials.gov NCT04524624.

Stroke is one of the leading causes of disability and mortality worldwide, and approximately 87% of cases are acute ischemic stroke (AIS). For patients with AIS, rapid administration of reperfusion therapy within the therapeutic time window remains the most effective treatment strategy. Over the past decade, numerous high-quality clinical trials have driven rapid advances in treatment strategies. Meanwhile, increasing attention has been directed toward cytoprotective therapies aimed at mitigating ischemic and reperfusion-related brain injury, which may act synergistically with reperfusion strategies. Although many related clinical trials have failed to demonstrate clear clinical benefit, they have provided valuable insights for the development of future cytoprotective agents. This review focuses on recent advances and remaining challenges in reperfusion therapy and cytoprotection for AIS.

Background and objectivesHealth education can help patients engage in evidence-based healthy behaviors, and the construction of smart hospitals can promote accurate video-based health education for patients. However, little is known about the clinical practice of personalized video-based health education for ischemic stroke patients in China. We investigated video-based health education viewing frequency and relevant impact factors among patients with ischemic stroke.MethodsData were collected from 1,569 ischemic stroke patients admitted to the Vascular Neurology Ward of a hospital in China between 01/08/2020 and 31/12/2022, to analyze their use of personalized video-based health education. The video-based integrated management system used in our hospital can facilitate keyword extraction, thus achieving accurate and personalized video-based health education and promotion. Data, including demographic and disease-related data, viewing frequency, total viewing amount and viewing frequency for each dimension, were extracted from the hospital's video integrated management system and medical system. Univariate analysis and multiple linear regression helped identify factors associated with whether the patients viewed personalized video-based health education materials.ResultsA total of 1569 patients were included (age = 58.72 ± 13.50 years old; 1177 (75.0%) males). Diet rehabilitation education was the most frequently viewed personalized video-based health education dimension; the average viewing frequency was 2.30 ± 1.15 times/day during an average hospitalization of 12.55 ± 4.12 days. According to the multivariable analysis, factors associated with a reduced likelihood of viewing the personalized video-based health education materials (P < 0.05) included visual and hearing impairment, longer hospital stays, and speech impairment. In contrast, compared to self-paying patients, individuals who were covered by medical insurance or received free medical service were more likely to view the personalized video-based health education materials.ConclusionA personalized video-based health education program with a keyword extraction function can help achieve accurate and personalized video-based health education and promotion and effectively improve patients' health-education participation rate.

BACKGROUND:Patients with different hypertension status could potentially respond differently to the treatment of clopidogrel-aspirin owing to thrombosis, antiplatelet resistance, and platelet reactivity. AIMS:The aim of the study is to examine the efficacy and safety of clopidogrel-aspirin in patients with mild ischemic stroke or high-risk transient ischemic attack (TIA) according to different hypertension status. METHODS:In the Intensive Statin and Antiplatelet Therapy for Acute High-Risk Intracranial or Extracranial Atherosclerosis (INSPIRES) trial, patients were randomized to either clopidogrel-aspirin or aspirin group. The primary outcome was any new ischemic or hemorrhagic stroke within 90 days. Hypertension status was classified into two categories based on medical history: patients with or without hypertension. RESULTS:Among 6100 patients with complete data of hypertension status, 3915 (64.2%) were men. Clopidogrel-aspirin compared with aspirin was associated with reduced incidence of new stroke in patients without hypertension (hazard ratio (HR): 0.62, 95% confidence interval (CI): 0.44-0.86, p = 0.004), but not in patients with hypertension (HR: 0.87, 95% CI: 0.71-1.07, p = 0.18; p = 0.085 for interaction). CONCLUSIONS:In this study, patients without hypertension may have more benefit from receiving treatment with clopidogrel-aspirin than those with hypertension. This finding can be used as an enrichment strategy in the future secondary stroke prevention randomized clinical trials of dual antiplatelet therapy. TRIAL REGISTRATION:The INSPIRES trial was registered at http://www. CLINICALTRIALS:gov (unique identifier: NCT03635749).

Background Heart failure (HF) constitutes the source of various damaging pathophysiological mechanisms in acute ischemic stroke (AIS). The effect of a previous HF on the in‐hospital outcomes for patients with AIS still lacks effective research. We aimed to evaluate the severity of stroke, in‐hospital mortality, major adverse cardiovascular events, and complications associated with a previous HF in these patients. Methods and Results This cross‐sectional study was conducted at 1476 hospitals in the Chinese Stroke Center Alliance. Multivariable logistic regression and propensity score–matched analyses were used to evaluate the association between a history of HF and in‐hospital outcomes. Of 836 885 patients with AIS, 1.1% (n=8950) patients had a history of HF. Patients with a history of HF had a higher National Institutes of Health Stroke Scale score at admission (6.0 versus 3.0) than those without a history of HF. Multivariable analysis revealed that a history of HF was associated with an 80% higher risk of all‐cause mortality (odds ratio [OR], 1.80 [95% CI, 1.54–2.10]), a 34% higher risk of major adverse cardiovascular events (OR, 1.34 [95% CI, 1.26–1.43]), and a 92% higher risk of complications (OR, 1.92 [95% CI, 1.83–2.02]). Further propensity score matching showed that patients with a history of HF had higher risks of adverse in‐hospital outcomes (all‐cause mortality: OR, 1.62 [95% CI, 1.30–2.02]; major adverse cardiovascular events: OR, 1.39 [95% CI, 1.26–1.53]; complications: OR, 1.70 [95% CI, 1.58–1.82]). Conclusions Patients with AIS and a history of HF have increased risks of severe stroke, in‐hospital mortality, major adverse cardiovascular events, and complications. Systematic cardiovascular evaluation and integrated multidisciplinary care for patients with AIS in clinical practice are warranted.

BACKGROUND:A comprehensive epidemiological investigation of the coexistence between diabetes and stroke/TIA in China is urged. METHODS:Data from the Chinese Stroke Center Alliance program, a nationwide multi-center registry study, were used to detect the prevalence, awareness, treatment, and control of diabetes among stroke/TIA. The distribution of diagnosed and undiagnosed diabetes and prediabetes among stroke/TIA patients was investigated, the medical care around diabetes and their respective risk predictors were analyzed, and the association of all above diabetes characteristics with in-hospital death was evaluated using multi-variable Cox regression models. RESULTS:Of 980 625 patients included, 308 426 (31.5%) had prediabetes, while 365 052 (37.2%) had diabetes, with nearly a third of them undiagnosed (112 969, 30.9%). Of residual aware diabetic patients, 59.0% were treated, with 27.3% controlled. Compared to Han ethnicity, Zhuang ethnicity had a lower prevalence of diabetes (37.3% vs. 35.1%) but were less aware (69.4% vs. 56.5%), treated (59.4% vs. 47.8%), and controlled (27.4% vs. 26.0%). Patients with prediabetes, diagnosed, and undiagnosed diabetes had increasingly higher risks of in-hospital death (adjusted HR [95% CI]: 1.47 [1.35-1.60]; 2.15 [1.97-2.34]; 4.20 [3.87-4.56], all p < 0.001). Unaware and untreated diabetes were independently associated with in-hospital death (adjusted HR [95% CI]: 1.99 [1.85-2.14]; 2.84 [2.63-3.07, both p < 0.001]). Compared with controlled diabetes, those with uncontrolled diabetes had a lower risk of in-hospital death (adjusted HR [95% CI]: 0.77[0.68-0.88], p < 0.001). CONCLUSIONS:The findings indicate that over two-thirds of stroke/TIA patients are exposed to diabetes in China, causing higher in-hospital mortality, which should be screened and intervened early.

Background Stroke remains a major global health challenge, with China experiencing a significant burden due to its high incidence and severe outcomes. Reperfusion therapies, such as intravenous thrombolysis and endovascular thrombectomy, have shown substantial benefits in improving early outcomes for ischaemic stroke. Recent clinical trials have validated the safety and efficacy of a broader range of thrombolytic agents and expanded the eligible patient populations for both intravenous thrombolysis and mechanical thrombectomy. This guideline aims to provide the latest evidence-based insights in the field of reperfusion therapy.Methods The Chinese Stroke Association (CSA) established a writing group to develop updated guidelines on reperfusion therapy for acute ischaemic stroke. A comprehensive search of MEDLINE (via PubMed) was conducted up to 30 September 2024. Experts in the field of stroke engaged in extensive discussions, both online and offline, to evaluate the latest evidence. Each recommendation was graded using the CSA’s class of recommendation and level of evidence in the Guideline Development Manual of the CSA.Results This guideline, reviewed and approved by the CSA Guidelines Writing Group, outlines the criteria for patient selection for thrombolysis and thrombectomy and summarises the latest evidence on various thrombolytic drug options to support decision-making in reperfusion therapy. Additionally, the guideline includes green channel flow charts for intravenous thrombolysis and mechanical thrombectomy, designed to assist clinicians in optimising their clinical decisions.Conclusion This guideline updates the latest advancements in the field of reperfusion therapy for acute ischaemic stroke. It is anticipated that future clinical research will further advance areas such as innovative thrombolytic agents, expanded indications for thrombolysis and mechanical thrombectomy.

Background and purposeTo date, no large cohort study has investigated the effects of intravenous thrombolysis (IVT) in Chinese patients aged over 80 years who had a stroke. This study aimed to assess the trends in the use of alteplase, the clinical characteristics and the outcomes of Chinese patients aged above 80 years who had an acute ischaemic stroke.MethodsData for this analysis were obtained from the China Stroke Center Alliance programme, a nationwide, multicentre, prospective registry encompassing 1751 hospitals across 31 provinces, covering the period from 1 January 2018 to 14 December 2022. The primary outcome was defined as a modified Rankin Scale (mRS) Score of 0–2 at discharge. Secondary outcomes included an mRS Score of 0–1 and independent ambulation on discharge. Safety outcomes assessed were in-hospital mortality and symptomatic intracranial haemorrhage (sICH).ResultsOut of 30 902 patients over 80 years old who qualified for thrombolysis, 8673 (median age (IQR), 84 (82–87) years) received alteplase treatment. Patients administered alteplase demonstrated improved short-term functional outcomes, such as an mRS Score of 0–2 (adjusted OR (aOR) 1.12, 95% CI, 1.06 to 1.18, p<0.001), an mRS Score of 0–1 (aOR 1.14, 95% CI, 1.08 to 1.19, p<0.001) and independent ambulation at discharge (aOR 1.14, 95% CI, 1.08 to 1.20, p<0.001). Moreover, no significant increase was observed in the risk of in-hospital mortality (aOR 1.12, 95% CI, 0.93 to 1.35; p=0.23). However, the risk of sICH was significantly higher among patients treated with alteplase (aOR 3.22, 95% CI, 2.77 to 3.75; p<0.001).ConclusionsIVT with alteplase in elderly patients who had a stroke resulted in improved short-term functional outcomes without elevating the risk of in-hospital mortality. Nonetheless, this population remains at a higher risk of sICH.

OBJECTIVE:The objective was to investigate the efficacy and safety of clopidogrel-aspirin versus aspirin alone in patients after ischemic stroke by glycemic status using data from the Intensive Statin and Antiplatelet Therapy for Acute High-risk Intracranial or Extracranial Atherosclerosis (INSPIRES) trial. METHODS:Patients with mild ischemic stroke or high-risk transient ischemic attack (TIA) were randomized to clopidogrel-aspirin or aspirin alone. They were categorized into 3 subgroups according to glycemic status based on medical history and diagnosis by a clinician during hospitalization: without type 2 diabetes mellitus, with newly diagnosed type 2 diabetes, and with a history of type 2 diabetes mellitus. The primary efficacy and safety outcomes were new stroke and moderate-to-severe bleeding risk within 90-day follow-up. RESULTS:A total of 6,100 patients were enrolled (3,050 in each arm), with a median age of 65 years (interquartile range [IQR], 57-71) and 2,185 female (35.8%). Clopidogrel-aspirin treatment was associated with a reduction in recurrent stroke compared with aspirin alone in patients without type 2 diabetes mellitus (6.3% vs 8.4%; hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.59-0.94; p = 0.01) and those with newly diagnosed type 2 diabetes mellitus (5.8% vs 13.0%; HR, 0.30; 95% CI, 0.14-0.66; p = 0.002), but not in those with a history of type 2 diabetes mellitus (10.0% vs 9.9%; HR, 0.98; 95% CI, 0.72-1.33; p = 0.88) (p for interaction = 0.03). Moderate-to-severe bleeding events did not differ significantly by treatment across glycemic subgroups. INTERPRETATION:In the INSPIRES trial, patients without or with type 2 diabetes mellitus derived greater benefit from clopidogrel-aspirin than those with a history of type 2 diabetes mellitus after mild ischemic stroke or high-risk TIA. TRIAL REGISTRATION:INSPIRES, NCT03635749. Registered 15 August 2018, https://clinicaltrials.gov/search?cond=NCT03635749. ANN NEUROL 2025;98:174-182.

Acute minor ischemic stroke patients often experience recurrence shortly after symptom onset, highlighting the importance of predicting stroke recurrence for guiding treatment decisions. This study evaluated the effectiveness of machine learning models in predicting in-hospital recurrence. The study cohort comprised 322,135 patients with acute minor ischemic stroke from 1439 centers, as established by Chinese Stroke Center Alliance. Patients were randomly allocated into training and test sets by different centers. Models including extreme gradient boosting (XGB), light gradient boosting (LGB), and adaptive boosting (ADA) were developed using fivefold cross-validation on the training set. Optimization was performed for all models based on the most important variable, history of ischemic stroke. Compared with the traditional generalized linear model (GLM), the XGB, LGB, ADA models yielded area under the curve (AUC) values ranging from 0.788 to 0.803 after optimization. All models showed significant improvements in AUC compared with GLM, with LGB exhibiting the most substantial enhancement after optimization. For the first time, this study developed models specifically designed to predict in-hospital stroke recurrence in acute minor ischemic stroke patients. This finding aids in identifying high-risk patients and prompts physicians to provide targeted treatment. However, further external validation is warranted to confirm the model's generalizability.

BACKGROUND:Metabolic syndrome (MetS) attenuates antiplatelet agent effects. This study investigated the efficacy and safety of clopidogrel-aspirin therapy for secondary stroke prevention in patients with MetS. METHODS:Data were obtained from the INSPIRES (Intensive Statin and Antiplatelet Therapy for Acute High-Risk Intracranial or Extracranial Atherosclerosis) trial. Patients with mild ischemic stroke or high-risk transient ischemic attack were randomized to treatment with clopidogrel-aspirin or aspirin alone within 72 hours after symptom onset. MetS was defined according to the Adult Treatment Panel-III. The primary efficacy outcome was new stroke, and the primary safety outcome was moderate - to - severe bleeding within 90-day follow-up. Differences between groups were estimated with Cox proportional hazards models, with hazard ratio (HR) and 95% CI presented. RESULTS:This study included 4715 patients, with a mean age of 63.7±9.6 years, 35.8% of women, and 75.8% of patients having MetS. After adjustment for potential confounders, patients with MetS were at higher risk of recurrent stroke (HR, 1.39 [95% CI, 1.06-1.82]; P=0.02) but not moderate - to - severe bleeding events (HR, 1.02 [95% CI, 0.47-2.21]; P=0.97) as compared with patients without MetS. However, MetS state did not impact the efficacy of clopidogrel-aspirin therapy for recurrent stroke (P for interaction=0.44) and the safety for moderate-to-severe bleeding events (P for interaction=0.54). CONCLUSIONS:MetS was associated with higher risk of recurrent stroke at 90 days. There was no difference in the effect of clopidogrel-aspirin therapy on reducing new stroke and increasing moderate-to-severe bleeding events between patients with and without MetS. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT03635749.