Background: We previously found patent foramen ovale (PFO) stroke patients may have increased white matter hyperintensities (WMH) and that PFO shunting raises blood homocysteine (bHcy) which can injure brain tissue in vitro. While emerging evidence suggests cardiac shunting may augment brain injury via clot independent pathway, it remains unclear how PFO can cause brain injury besides embolic strokes. In this pilot study, we hypothesized that elevated bHcy level may be a culprit for WMH in PFO patients. Method: 231 PFO patients were prospectively recruited in accordance to IRB protocol. WMH burden was evaluated on MRI by investigators blinded to clinical outcome, and WMH severity was quantified by validated Fazekas and Scheltens scales. Regression and mediation analysis were performed. Result: Consistent with our previous findings, circulating bHcy levels in PFO patients increased proportionally with their shunt size (β: 1.14; 95% CI: 0.45 ~ 1.82; p = 0.001) ( Figure 1A ). Elevated bHcy was strongly associated with greater WMH burden (Fazekas, OR: 1.14; 95% CI: 1.06 ~ 1.21; p < 0.001; Scheltens, OR: 1.15; 95% CI: 1.08 ~ 1.23; p < 0.001) ( Figure 1B, 1C ). PFO shunt itself was associated with WMH (Fazekas, OR: 1.58; 95% CI: 1.16 ~ 2.14; p = 0.004; Scheltens, OR: 1.74; 95% CI: 1.29 ~ 2.35; p < 0.001) ( Figure 1D ), which was particularly evident in deep white matter region ( Figure 1E ). Notably, mediation analysis confirmed a mediating role of bHcy ( Table 1 ). bHcy exhibited significant indirect effect, mediating 19~22% of the effect of PFO on WMH ( Figure 1F ). These results remained robust after accounting for age, a well-known risk factor of bHcy elevation WMH ( Table 1 ). Conclusion: Our pilot results suggest that PFO shunting may contribute to WMH by promoting bHcy elevation. This effect is shunt-size dependent and most pronounced in deep white matter. These preliminary findings provide new insight into PFO shunt related brain injury. Further studies are warranted to understand the underlying mechanism and assess whether cardiac shunt elimination or bHy lowering may impact PFO related white matter disease.

Accurate neuroprognostication of cardiac arrest survivors who are initially comatose after restoration of spontaneous circulation is crucial for guiding patient management. Because hypoxic-ischaemic injury is typically diffuse, damage to a network of brain regions is likely involved in the patient's disorder of consciousness. To quantify these complex brain network changes, graph theoretical methods were applied. We hypothesize that structural connectivity metrics may provide insights into which patients will likely recover consciousness. Eighteen comatose patients (50 ± 22 years, 44% male) and four healthy participants (40 ± 20 years, 50% male) underwent multi-shell high angular diffusion MRI as part of a prospective study. Structural connectivity matrices were constructed using probabilistic tractography to measure the likelihood of connections between anatomical regions. Network topology alterations were quantified using clustering coefficient, global efficiency and degree. Hub index analysis was performed to explore the impact of anoxic injury on high-degree hubs. Network parameters were compared between patients with arousal recovery (AR, eye-opening to auditory or noxious stimulation) and without arousal recovery (No AR). Analyses were repeated for AR patients who achieved emergence from the minimally conscious state (EMCS) within one-year post-cardiac arrest and AR patients who did not achieve EMCS (AR'). Significant differences were observed between the Controls, AR and No AR for all four metrics (Kruskal-Wallis Tests, P < 0.05). Worsening disorders of consciousness were associated with decreasing brain complexity (Kendall's tau, P<0.01). Post-hoc testing showed Control values were significantly greater than No AR for all metrics (Wilcoxon rank sum, P < 0.05). Control values were greater than AR for all metrics (P < 0.05), except the clustering coefficient (P = 0.36). AR was significantly greater than No AR for all metrics (P < 0.05), except for the hub index (P = 0.12). Notable differences between AR' and Controls were observed for all metrics (P < 0.05), except clustering coefficient (P = 0.11). No significant differences were found between AR' and No AR groups. In contrast, for all metrics, EMCS values were not significantly different compared with the Controls but were significantly different than the No AR cohort values (P < 0.05). The hub index analysis revealed disproportionate damage to high-degree nodes such as the thalamus, putamen and precuneus, further linking topological disruption to the severity of outcomes. This study highlights the potential of graph theoretical measures of structural connectivity to guide decisions in the care of comatose cardiac arrest patients. By bridging structural connectivity with clinical outcomes, this research provides valuable insights into the neural mechanisms underlying consciousness and recovery after cardiac arrest.

BACKGROUND:The antithrombotic strategies for symptomatic intracranial atherosclerotic stenosis (sICAS) remains challenging. Dual pathway inhibition (DPI) has demonstrated clinical benefit in coronary and peripheral artery disease. AIMS:This study aimed to evaluate the efficacy of DPI with low-dose rivaroxaban plus antiplatelet therapy (APT) compared with APT alone on recurrent stroke with sICAS. METHODS:This prospective cohort study included patients with sICAS identified from the Ischemic Cerebrovascular Disease Database of the First Affiliated Hospital of Zhengzhou University between January 2019 to August 2023. Low-dose rivaroxaban was prescribed off-label to patients in the DPI group. The outcomes were ischemic stroke, transient ischemic attack (TIA), acute coronary syndrome (ACS), all-cause death and cardio-cerebrovascular death within 1 year of discharge. Cox regression with inverse probability of treatment weighting (IPTW) was applied to compare outcomes between the DPI and APT groups. The win-ratio method was used to assess the major adverse cardiovascular events (MACE), prioritized in the order of all-cause death, recurrent ischemic stroke or TIA, and ACS. RESULTS:Among the 1217 patients with sICAS, 131 (10.8%) received DPI therapy. The recurrence rate of ischemic stroke was lower in the DPI group compared to the APT group (8/131 [6.1%] vs 136/1086 [12.5%]). DPI significantly reduced the risk of ischemic stroke recurrence (HR = 0.46, 95% CI: 0.23-0.94, p = 0.034) and the incidence of MACE (HR = 0.53, 95% CI: 0.29-0.97, p = 0.041) during the 1-year follow-up, consistent with the IPTW-based cohort (HR = 0.35, 95% CI: 0.16-0.76, p = 0.008; HR = 0.43, 95% CI: 0.22-0.83, p = 0.012). The win-ratio analysis of MACE favored DPI therapy (win ratio = 2.34, 95% CI: 1.41-3.90, p = 0.001). Symptomatic intracranial hemorrhage, fatal bleeding, and hospitalization for gastrointestinal bleeding were infrequent in this cohort. CONCLUSIONS:DPI therapy may be associated with a lower risk of recurrent stroke compared with antiplatelet therapy alone in patients with sICAS. These findings warrant further investigation through large-scale randomized controlled trials.

Background Neutrophil extracellular traps contribute to thrombolytic resistance and the no‐reflow phenomenon after acute ischemic stroke, thereby impairing microvascular reperfusion and leading to unfavorable clinical outcomes. This study investigated the association between prethrombolytic circulating neutrophil extracellular trap biomarkers, CitH3 (citrullinated histone 3) and MPO (myeloperoxidase)‐DNA complexes, and early neurological deterioration (END) in patients with acute ischemic stroke treated with intravenous thrombolysis alone. Methods We prospectively enrolled patients with acute ischemic stroke who received standard‐dose alteplase within 4.5 hours of symptom onset (January 2019–April 2023). Venous blood was drawn before intravenous thrombolysis to measure serum CitH3 and MPO‐DNA. The primary outcome was END, defined as an increase of ≥4 points in NIHSS score at 24 hours versus baseline. Logistic regression with restricted cubic splines assessed associations between neutrophil extracellular trap biomarkers and END. Results Among 287 patients (mean age 61.69±12.41 years, 70.4% male), 45 (15.7%) developed END. Serum CitH3 >17.67 ng/mL (odds ratio [OR], 3.81 [95% CI, 1.75–8.29]) and MPO‐DNA >79.72 ng/mL (OR, 5.58 [95% CI, 2.36–13.21]) were independently associated with END. The associations remained significant when treated as continuous variables. Restricted cubic splines confirmed a linear dose–response relationship between higher CitH3 levels and END risk (P for nonlinearity=0.475). Subgroup analyses revealed stronger associations for CitH3 in patients with coronary artery disease or stroke history (P for interaction=0.018) and D‐dimer <0.50 μg/mL (P for interaction=0.013). A significant interaction of smoking was found between MPO‐DNA and END (P for interaction=0.026). Conclusions Serum neutrophil extracellular traps may serve as promising biomarkers associated with END after intravenous thrombolysis in patients with acute ischemic stroke.

AIM:Atrial cardiomyopathy (AC) is associated with cardiovascular events, but the benefit of anticoagulation in embolic stroke of an undetermined source (ESUS) remains unclear. We aimed to prospectively evaluate the prognostic value of AC in patients with ESUS. METHODS:We prospectively enrolled patients with ESUS who were hospitalized within 7 days of onset (January 2019 - December 2021). AC was defined as an N-terminal pro-B-type natriuretic peptide level ＞250 pg/ml, P-wave terminal force in lead V1 ＞5000 µV·ms, or enlarged left atrial diameter. Ischemic stroke/transient ischemic attack (TIA) recurrence was evaluated using Fine-Gray sub-distribution hazard models with death as a competing event. Cox proportional hazards models were used for supportive analyses and all-cause mortality. RESULTS:Among the 345 patients (mean age 59.22±13.19 years; 69.0% men), 42.0% met the criteria for AC. During a median follow-up of 18.1 months, 36 patients experienced ischemic stroke, 2 had TIA, and 18 died. AC was strongly associated with ischemic stroke/TIA recurrence in competing risk analyses (adjusted subdistribution hazard ratio [aSHR] 3.36, 95% CI 1.65-6.86; P＜0.001). For all-cause mortality, AC was associated with a higher risk after adjusting for age and sex (adjusted hazard ratio 3.80, 95% CI 1.19-12.08; P = 0.024). Adding AC to conventional risk models significantly improved the NRI (ischemic stroke/transient ischemic attack: 72.45%, P＜0.001; mortality: 66.16%, P = 0.002) and IDI (4.52%, P＜0.001; 3.89%, P = 0.041). CONCLUSIONS:AC independently predicts recurrent ischemic stroke/TIA in ESUS and improves risk stratification, while its association with mortality requires cautious interpretation due to limited events.

Abstract Background and aims The incidence, severity, progression, and long-term outcome of acute ischemic stroke vary across the 24-hour day. Data on the link between patients’ circadian chronotype, e.g. morningness (“larks”) and eveningness (“owls”), and stroke, however, are missing. We aim to characterize the association of chronotype with presentation and outcome of patients with acute cerebral ischemia. Methods The CIRCA Chronotype and Stroke Registry is a prospective observational study enrolling adult patients within 24 hours of last-known-well time across five centers in the United States and Europe. Chronotypes (sleep timing midpoints on work-free days) were assessed using the Ultra-Short Munich Chronotype Questionnaire. Associations between chronotype and baseline NIHSS score/functional outcome (mRS score) were assessed through multiple linear/logistic regression respectively. Results 691 patients (median age 71 years, 41% female) were enrolled from February 2024 to February 2026. Chronotypes between 02:31 and 03:30 were the most prevalent (35.5%) (Fig. 1). Early chronotypes were older and more frequently hypertensive than intermediate and late chronotypes (Table 1). Earlier chronotype was associated with higher NIHSS at presentation independent of age (β −0.51; 95% CI - 0.91 to −0.12; p=0.01) (Fig. 2) and with worse functional outcomes at day 90 (OR 0.69; 95% CI 0.54 - 0.86; p=b 0.001), persistent after additional adjustment for baseline NIHSS (OR 0.75; 95% CI 0.59 - 0.95; p=0.02) and other variables (Fig. 3). Conclusions Our study links early chronotype to higher stroke severity and poorer functional outcomes, providing evidence for relationship(s) between chronobiology and stroke. Further studies should investigate mechanisms and potential treatment-effect modification. Conflict of interest Table 1 - belongs to Conclusions Figure 1 - belongs to Conclusions Figure 2 - belongs to Conclusions Figure 3 - belongs to Conclusions

Background: Patent foramen ovale (PFO) is an independent risk factor for neurovascular injury such as stroke. We previously found that large PFO shunt is associated with increased long-term risk of vascular dementia. However, the mechanism underlying this association remains poorly understood. Our previous research revealed that PFO shunt enables the accumulation of homocysteine in circulation (Deng, Neurology 2021). It is thus possible that homocysteine may mediate the effect of PFO shunt on cognitive decline. This study aims to explore the relationship among PFO shunt, total homocysteine (tHcy) levels and the risk of vascular cognitive impairment and dementia (VCID). Method: A total of 1282 PFO patients were prospectively recruited and followed for over 11 years post their PFO closure in accordance with IRB protocol. All the patients were cognitively normal at the time of PFO diagnosis. Residual shunt post PFO closure was assessed using transthoracic echocardiogram (TTE) with saline contrast. Cognitive function was evaluated using Montreal Cognitive Assessment (MoCA). tHcy levels in peripheral venous blood was measured using mass spectrometry. Result Among the patients, 67 (5.2%) developed VCID as measured by MoCA < 26 and NINDS AIREN criteria. The risk of VCID was significantly high in patients with residual shunt, particularly those with large shunt size (no shunt: 5.0%; small shunt: 6.4%; large shunt: 11.5%), suggesting a dose effect of PFO shunt (OR: 1.53; 95% CI: 1.09 ~ 2.16; p = 0.014) (Figure 1A, Table 1). Moreover, residual PFO shunt also contributed to tHcy elevation in circulation (β: 0.44; 95% CI: 0.19 ~ 0.69; p < 0.001) (Figure 1B, Table 1), and high tHcy levels were linked to increased risk of VCID (OR: 1.87; 95% CI: 1.14 ~ 3.07; p = 0.013) (Figure 1C, Table 1). Further mediation analyses revealed a significant indirect effect of PFO shunt on VCID through tHcy (OR: 1.29; 95% CI: 1.01 ~ 1.66; p = 0.047) (Figure 1D, Table 1). tHcy mediated 40% (95% CI: 6% ~ 74%; p = 0.021) of the total association between PFO shunt and VCID risk (Figure 1D, Table 1). These findings remained robust after adjusting for other VCID risk factors, such as age, diabetes, hyperlipidemia and hypertension (Table 1). Conclusion: Our study suggested that that PFO shunt may contribute to the development of VCID by promoting circulatory tHcy elevation. Further mechanistic investigation of neurovascular injury and cognitive decline associated with PFO shunt is ongoing.

Background: Our recently reported that patent foramen ovale (PFO) shunt enables the elevation of total homocysteine (tHcy) in patients’ circulation (Deng, Neurology 2021). However, the underlying molecular mechanism of how tHcy causes PFO-related injury is unclear. Considering that brain vascular endothelial cells are among the first to respond to the alterations in bloodstream, we hypothesized that elevated tHcy acts on brain endothelial cells, opens blood brain barrier (BBB) and leads to further neurovascular injury. Method: Brain microvascular endothelial cells were exposed to high concentration of tHcy for 72 hr and subjected to RNA sequencing analysis. The viability of the cells was evaluated using MTT method. Additionally, mass spectrometry was employed to measure tHcy levels in both plasma and cerebrospinal fluid (CSF) samples collected from 56 patients with cerebrovascular disease. BBB permeability was assessed by CSF/plasma albumin ratio, a highly reliable clinical indicator of BBB integrity. Result: Gene set enrichment analysis (GSEA) revealed significant activation of apoptosis in brain endothelial cells following exposure to high tHcy levels (NES: 1.80; p < 0.001) (Figure 1A). Many pro-apoptotic factors, such as Bax, Bak and FAS, were upregulated in response to tHcy (Figure 1B). Consistent with this, cell viability decreased with increasing tHcy concentrations (Figure 1C), suggesting that tHcy induces damages to brain endothelial cells. Supporting this, plasma tHcy levels in stroke patients were well correlated with those in CSF (r = 0.46, p = 0.001) (Figure 1D). Patients with high tHcy in plasma (> 12 μM) demonstrated increased BBB permeability (Figure 1E). Conclusion: Our findings suggest that elevated circulatory tHcy may injure brain endothelium and increase BBB permeability, potentially contributing to downstream neurovascular dysfunction. The impact of tHcy on BBB and other brain cell types are ongoing to explore its important role in PFO related neurovascular injury.

Important advances have been made in reperfusion therapies for acute ischemic stroke. However, a majority of patients are either ineligible for or do not respond to treatments and continue to have considerable functional deficits. Stroke results in a pathological disruption of the neurovascular unit (NVU) that involves blood-brain barrier leakage, glial activation, neuronal damage and chronic inflammation, all of which create a microenvironment that hinders recovery. Therefore, finding ways to promote central nervous system recovery remains the holy grail of stroke research. Here we propose a conceptual framework to synthesize recent progress in the field, which is currently dispersed and disconnected in the literature. We suggest that stroke recovery requires an integrated reprogramming process throughout the brain that occurs at multiple levels, including changes in gene expression, endogenous cellular transdifferentiation within the NVU, and reorganization of larger-scale neural and social networks.

Background: Acute hyperglycemia is common post ischemic stroke, and is a robust predictor of poor stroke outcome. Even transient glucose elevation substantially increases the risk of mortality and long-term disability. Tight glucose control with insulin is effective in correcting hyperglycemia, but lacks efficacy in improving patient outcome, suggesting the presence of early hyperglycemic injuries that are resistant to later glucose control. Our recent clinical research revealed that abnormal red blood cells (RBCs) could be a novel mediator of the adverse effect of acute hyperglycemia on stroke outcome. Here, using in vitro and ex vivo models, we aim the explore the underlying mechanism. Method: RBCs were isolated from healthy C57BL6 mice (10~12 wk) and exposed to in vitro normal glucose (NG: 5 mM) or high glucose (HG: 15 mM) for 24 hr. HG-exposed RBCs were also treated with ROS scavenger TEMPOL (HG+TEMPOL). The treated RBCs were then incubated with mouse brain blood vessels for additional 24 hr. Changes in vascular gene expression were profiled via RNA sequencing. Result: HG exposure increased reactive oxygen species (ROS) production within RBCs, which was mitigated by TEMPOL (Figure 1A). Importantly, HG-challenged RBCs (HG-RBCs) led to a significant shift in brain vascular gene expression and function (Figure 1B-D). Specifically, the expression of endothelial nitric oxide synthase (eNOS), the enzyme responsible nitric oxide (NO) production, was decreased by HG-RBCs treatment, potentially reducing NO availability and compromising cerebral blood flow (Figure 2A). These changes were further validated by immunohistochemistry (Figure 2B, 2C). Moreover, RBCs affected vascular pathways linked to Alzheimer’s disease (Figure 1D). HG-RBCs suppressed Adam10 (α-secretase)-mediated non-amyloidogenic process and activated Bace1 (β-secretase)-mediated amyloidogenic process, potentially contributing to β-amyloid accumulation (Figure 2D, 2E). Most of these detrimental effects could be reversed by TEMPOL pretreatment (Figure 2A-E), and the overall vascular gene expression pattern was closer to those treated by NG-RBCs (Figure 1B, 1C), suggesting that hyperglycemia-induced RBC oxidative stress play a causal role in brain vascular dysfunction. Conclusion: RBCs, beyond their oxygen transport role, are crucial regulators of vascular function and could be a previously overlooked contributor to vascular dysfunction in acute hyperglycemia post stroke (Figure 3).

BACKGROUND:Multimorbidity may influence biological aging, particularly in acute ischemic stroke (AIS) patients with high comorbidity burden. However, evidence on associations between multimorbidity and biological aging in AIS remains limited, with unclear differential impacts of specific multimorbidity clusters. This study evaluated latent multimorbidity patterns in AIS patients and quantified relationships between multimorbidity and biological age (BA) acceleration. METHODS:This study included AIS patients from the Ischemic Cerebrovascular Disease Database of the First Affiliated Hospital of Zhengzhou University between 2018 and 2019. Biological age was assessed using the Klemera-Doubal method biological age (KDM-BA) and Phenotypic Age. Latent class analysis (LCA) identified multimorbidity clusters. A generalized linear model evaluated associations between multimorbidity and BA acceleration. RESULTS:A total of 2539 AIS patients were included, with 90% exhibiting multimorbidity (≥2 comorbidities). Each additional chronic condition was associated with a 3.78-year increase in KDM-based age acceleration (95%CI: 3.00-4.55, fully adjusted) and a 0.78-year increase in phenotypic age acceleration (95%CI: 0.56-1.00, fully adjusted). Among multimorbidity patterns, the hyperglycemia-hypertension pattern showed the strongest association with KDM-AA (β = 11.59, 95% CI: 9.61-13.58), followed by cardiac dysfunction (β = 7.89, 95% CI: 3.11-12.66). CONCLUSION:The overwhelming majority of AIS patients exhibit multimorbidity, which is associated with accelerated biological aging. Metabolic-vascular multimorbidity shows the strongest links to this association. Prospective studies are needed to further explore the causal relationship between multimorbidity and biological aging acceleration.

The benefits of intravenous thrombolysis in patients with acute minor stroke remain controversial. For the aim of providing a better therapeutic strategy, high-quality trials are required to validate the efficacy of thrombolytic medicine other than intravenous recombinant tissue plasminogen and tenecteplase. In the trial, we evaluate the efficacy and safety of urokinase (UK) in acute minor stroke. This multicenter, open-label, blinded-endpoint, randomized controlled clinical trial enrolled patients with minor stroke within 6 h of symptom onset, with a NIHSS score ≤ 5. The trial was conducted at 25 hospitals in China between October 2020 and February 2023. Eligible patients were randomized to the UK group (1,000,000 U) or the best medicine treatment group. The responsible investigator recommended and implemented the best medicine treatment based on guidelines. The primary endpoint was an excellent functional outcome, defined as a modified Rankin scale (mRS) score of 0–1 at 90 days. The primary safety outcome was symptomatic intracranial hemorrhage (sICH) within 36 h. A total of 999 patients were enrolled in the trial, the median age was 64 years, 371 (36.9

BACKGROUND:Substantial gaps exist in the neuroprognostication of cardiac arrest patients who remain comatose after the restoration of spontaneous circulation. Most studies focus on predicting survival, a measure confounded by the withdrawal of life-sustaining treatment decisions. Severe cerebral edema (SCE) may serve as an objective proximal imaging-based surrogate of neurologic injury. METHODS:We retrospectively analyzed data from 288 patients to automate SCE detection with machine learning (ML) and to test the hypothesis that the quantitative values produced by these algorithms (ML_SCE) can improve predictions of neurologic outcomes. Ground-truth SCE (GT_SCE) classification was based on radiology reports. RESULTS:The model attained a cross-validated testing accuracy of 87% [95% CI: 84%, 89%] for detecting SCE. Attention maps explaining SCE classification focused on cisternal regions (p < 0.05). Multivariable analyses showed that older age (p < 0.001), non-shockable initial cardiac rhythm (p = 0.004), and greater ML_SCE values (p < 0.001) were significant predictors of poor neurologic outcomes, with GT_SCE (p = 0.064) as a non-significant covariate. CONCLUSION:Our results support the feasibility of automated SCE detection. Future prospective studies with standardized neurologic assessments are needed to substantiate the utility of quantitative ML_SCE values to improve neuroprognostication.