Risultati per: Stroke

Stroke, Volume 56, Issue 4, Page 807-807, April 1, 2025.

Stroke, Volume 56, Issue 4, Page 948-956, April 1, 2025. BACKGROUND:Evidence of the cost implications and health outcomes associated with the use of mobile stroke units (MSU) is required to support their utilization. We aimed to evaluate the causal effect of the use of an MSU compared with a standard ambulance on hospitalization costs and 90- to 180-day health outcomes.METHODS:Causal effect estimation was performed using patient-level data from a cohort of patients with stroke in 2018 identified from the Australian Stroke Clinical Registry (Victoria) and Melbourne MSU. These data were linked to Ambulance Victoria and government-held administrative data sets. In total, linked data from 8657 patients were available. Propensity score matching was used to define comparator groups within a target trial framework. Costs included emergency department and hospital admission costs in the first 180 days after stroke. Multivariable regression analyses of the matched data were used to compare costs and outcomes (mortality and modified Rankin Scale) between MSU and standard ambulance groups.RESULTS:The target trial sample included 96 patients transported by the MSU (intervention) and 198 patients transported by standard ambulance services (control). Of these, the mean age was 76 years and 157 (53%) were men. A greater proportion of patients received mechanical thrombectomy in the intervention group than the control group (40% versus 23%;P

Stroke, Volume 56, Issue 4, Page 915-925, April 1, 2025. BACKGROUND:Diffusion-weighted magnetic resonance imaging is essential for diagnosing ischemic stroke and identifying targets for emergency revascularization. Apparent diffusion coefficient (ADC) maps derived from diffusion-weighted magnetic resonance imaging are commonly used to locate the infarct core, but they are not strictly quantitative and can vary across platforms and sites due to technical factors. This retrospective study was conducted to examine how differences in ADC map generation, resulting from varied protocols across platforms and sites, affect the determination of infarct core size, location, and related clinical outcomes in acute stroke.METHODS:In this retrospective study, 726 patients with acute anterior circulation stroke from a cohort of 1210 unique visits to the Lausanne University Hospital between May 2018 and January 2021 were selected, excluding patients with poor quality imaging or no magnetic resonance imaging or clinical information available. Diffusion-weighted magnetic resonance imaging data were used to generate ADC maps as they would appear from different protocols: 2 simulated with low- and medium-angular resolution (4 and 12 diffusion gradient directions) and 1 with high-angular resolution (20 directions). Using DEFUSE criteria and image postprocessing, ischemic cores were localized; core volume, location, and associations to the National Institutes of Health Stroke Scale and modified Rankin Scale scores were compared between the 2 imaging sequences.RESULTS:Significant differences were observed in the ADC distribution within white matter, particularly in the kurtosis and skewness, with the segmented infarct core volume being higher in protocols with reduced angular resolution compared with the 20-directions data (7.63 mL versus 3.78 mL). The volumetric differences persisted after correcting for age, sex, and type of intervention. Infarcted voxel’s locations varied significantly between the 2 protocols. This variability affected associations between infarct core volume and clinical scores, with lower associations observed for 4-direction data compared with 20-direction data for the National Institutes of Health Stroke Scale at admission and after 24 hours, and modified Rankin Scale after 3 months, further confirmed by multivariate regression.CONCLUSIONS:Imaging protocol heterogeneity leads to significant changes in the ADC distribution, ischemic core location, size, and association with clinical scores. Work is needed in standardizing imaging protocols to improve the reliability of ADC as an imaging biomarker in stroke management protocols to improve the reliability of ADC as an imaging biomarker in stroke management.

Città della salute e della scienza: “Emergenza senza precedenti”

Objective
Aspiration pneumonia is a common complication post-stroke that increases the patient’s duration of stay in hospital, mortality and morbidity. We examined the incidence, clinical characteristics and outcomes among ischaemic stroke-related aspiration pneumonia patients in Qatar.

Settings and participants
The Qatar Stroke database was reviewed for patients with acute ischaemic stroke admitted to Hamad General Hospital, a tertiary care medical facility, between January 2014 and April 2024.

Outcomes
Patients were retrospectively assessed for mortality at 90 days, modified Rankin Score at 90 days and length of stay. Several clinical characteristics were also compared between patients with acute ischaemic stroke who developed aspiration pneumonia versus those without.

Results
Patients with stroke who developed aspiration pneumonia tended to be older and of the male sex. Patients who developed aspiration pneumonia were also more likely to present with a higher National Institute of Health Stroke Scale (NIHSS) at admission (p10). They were also more likely to have higher mortality rates at 90 days (16.9% vs 1.9% for an NIHSS admission score of 5–9 and 22.3% vs 13.8% for an NIHSS admission score >10) and major adverse cardiovascular events at 1 year (23.7% vs 3.8% for an NIHSS admission score of 5–9 and 27.5% vs 16.2% for NIHSS >10).

Conclusion
Age, sex, admission NIHSS severity, stroke subtypes and admission location are independent predictors of aspiration pneumonia post-stroke.

Introduction
The cause of ischaemic stroke at a young age remains unknown in 30% of cases, highlighting the need to identify hidden causes and risk factors in young patients. Transient and chronic risk factors may interact with the inflammatory and haemostatic systems, potentially driving key mechanisms in the pathogenesis. The ‘Observational Dutch Young StrokE study—Extended’ (ODYSSEY-nEXT) aims to enhance our understanding of these complex interactions through detailed phenotyping of the immune and haemostatic system and explore their relationship with long-term prognosis.

Methods and analysis
The ODYSSEY-nEXT is a multicentre prospective controlled cohort study of patients aged 18–50 years with a first neuroimaging-proven ischaemic stroke or transient ischaemic attack and healthy controls. We aim to include a total of 200 patients and 60 controls between January 2023 and January 2027. Blood samples will be collected within 72 hours after the index event and at 3 months to assess inflammatory and haemostatic markers. In a subgroup of 20 patients, whole blood analysis will be performed to investigate ex vivo immune cell functionality, the capacity of platelets to release granules and thrombin generation. All patients will complete a questionnaire about trigger and risk factors. Advanced intracranial and extracranial vessel wall imaging with MRI will be performed within a week. Long-term prognosis will be monitored through annual questionnaires about recurrent events for ten years.

Ethics and dissemination
This study was approved by the Medical Ethical Committee region ‘Oost-Nederland’ (NL77518.091.21) and will adhere to the Declaration of Helsinki and its later amendments. Participants have to provide written informed consent, but in cases where the patient cannot sign due to physical limitations as a result of the stroke, such as paresis, verbal consent is obtained from the patient and a legal representative will be asked to sign the consent form on their behalf. The findings of this study will be disseminated to healthcare professionals and the scientific community through peer-reviewed publications and to participants through accessible formats such as summary reports or newsletters.

Trial registration number
NCT05853796.

Stroke, Ahead of Print. BACKGROUND:Robotic rehabilitation, which provides a high-intensity, high-frequency therapy to improve neuroplasticity, is gaining traction. However, its effectiveness for upper extremity stroke rehabilitation remains uncertain. This study comprehensively reviewed meta-analyses on the effectiveness of upper extremity robot-assisted therapy in patients with stroke.METHODS:We combined results from 396 randomized controlled trials (RCTs) in 16 meta-analyses and conducted a new meta-analysis using nonoverlapping RCTs and 6 additional RCTs published after 2024. Duplicate studies were removed, all data were from RCTs, and a random-effects model resolved heterogeneity. Effects were analyzed by comparing robot-assisted therapy with conventional therapy at the same dose and as an add-on to conventional therapy.RESULTS:Compared with conventional therapy, the effect of robot-assisted therapy on the Fugl-Meyer assessment was summarized as a significant standardized mean difference (SMD) of 0.29 (95% CI, 0.14–0.44; number of individual RCTs reanalyzed, 100 RCTs), and the additional effect of robot-assisted therapy was an SMD of 0.42 (95% CI, 0.23–0.61; 16 RCTs). However, these Fugl-Meyer assessment improvements did not meet the minimum clinically important difference thresholds identified in previous studies: 12.4 for subacute and 3.5 for chronic stroke. For activities of daily living, only the additional effect was significant by SMD of 0.35 (95% CI, 0.17–0.54; 26 RCTs), muscle strength was significant by SMD of 0.46 (95% CI, 0.22–0.70; 31 RCTs), and spasticity was not significant by SMD of −0.25 (95% CI, −0.55 to 0.06; 25 RCTs).CONCLUSIONS:Robot-assisted therapy shows statistically significant improvements in motor recovery as measured by the Fugl-Meyer assessment in patients with stroke, both at the same dose and as an add-on to conventional therapy; however, these improvements do not meet the minimum clinically important difference. These benefits are consistent across different stages of stroke recovery, different types of robotic devices, duration of intervention, and training sites. However, the heterogeneity of included studies in patient population, stroke severity, intervention protocol, and robot type limits generalizability. High-quality trials are needed to better define the value of robot-assisted therapy across various devices and strategies.

Stroke, Ahead of Print. BACKGROUND:Social determinants are known to impact stroke risk and poststroke outcomes. Using complexity science, we examined interrelations between county- and individual-level social and clinical determinants influencing stroke functional outcomes.METHODS:We examined a retrospective cohort of 2 961 664 patients diagnosed with acute ischemic or hemorrhagic stroke from 2218 US hospitals participating in the Get With The Guidelines-Stroke Registry from 2013 to 2019, linked by ZIP code with the county-level institute for health metrics and evaluation data. We constructed multilayer networks, estimating mixed graphical models of 32 nodes representing social and clinical factors. Networks included 4 layers of factors: (1) county-level social, (2) individual-level social, (3) clinical comorbidities, and (4) hospital encounters. Networks were estimated for patients with less favorable (modified Rankin Scale score 3–6) versus favorable (modified Rankin Scale score 0–2) outcomes. We compared network structure and node centrality measures between groups using bootstrap permutation analyses, identifying influential (hub) nodes.RESULTS:The overall influence of social determinants (global connectivity) was greater in patients with less favorable outcomes (P

Stroke, Ahead of Print. The devastating physical, emotional, and social effects of stroke can disrupt all aspects of life for the stroke survivor. Ensuring that survivor and caregiver needs are met after a stroke is essential in ongoing care to ensure optimal quality of life. Despite health care professionals making significant strides in poststroke symptom management, education, and rehabilitative support, the common poststroke symptom of sexual dysfunction is rarely addressed. Multiple barriers across health care settings and systems have contributed to this gap. The purpose of this article is to provide evidence that supports the importance of addressing sexual health by health care providers with the stroke survivor and their partner as they transition through the recovery process. We have the following recommendations to optimize care and quality of life for stroke survivors: (1) comprehensive sex education must include information on healthy sex and sexuality for people with neurological disabilities; (2) rehabilitation programs offered in postacute settings should include a structured culturally sensitive interprofessional sexual rehabilitation component that addresses sexuality of the stroke survivor in collaboration with their intimate partners; (3) sexual rehabilitation programs should be tailored for each person based on a thorough assessment of the person’s health literacy and learning needs; and (4) the American Heart Association should develop an extensive toolkit for health care providers and survivors that is easily and readily available to the public. Health care providers, survivors, and their partners have a stake in optimal stroke recovery. Sexuality and sexual function are important quality of life indicators thus conversations addressing issues must be included as part of the recovery process. This discussion is best initiated by a health care provider to address system barriers and misconceptions across care transitions. Likewise, survivors and their partners must be encouraged to take ownership to address sexuality issues and initiate the conversation with their health care partners to achieve full recovery.

Stroke, Ahead of Print. BACKGROUND:Neuroscience research has contributed significantly to understanding alterations in brain structure and function after ischemic stroke. Technical limitations have excluded the spinal cord from imaging-based research. Available data are restricted to a few microstructural analyses, and functional connectivity data are absent. The present study attempted to close this knowledge gap and assess alterations in corticospinal coupling in chronic stroke and their relation to motor deficits.METHODS:In this cross-sectional study, patients with chronic stroke and healthy controls underwent corticospinal functional magnetic resonance imaging while performing a simple force generation task at the University Medical Center Hamburg-Eppendorf between September 2021 and June 2023. Task-related activation was localized in the ipsilesional ventral premotor cortex, the supplementary motor area, and the cervical spinal cord. Psycho-physiological interactions and linear modeling were used to infer functional connectivity between cortical motor regions and the cervical spinal cord and their associations with clinical scores.RESULTS:Thirteen well-recovered patients with stroke (1 woman, 12 men; mean age, 62.6 years; mean time after stroke: 47.6 months) and 13 healthy controls (5 women, 8 men; mean age, 64.5 years) were included. The main finding was that ventral premotor cortex and supplementary motor area showed topographically distinct alterations in their connectivity with the spinal cord. Specifically, we found a reduced coupling between the supplementary motor area and the ipsilateral ventral spinal cord and an enhanced coupling between the ventral premotor cortex and ventral and intermediate central spinal zones. Lower supplementary motor area and higher ventral premotor cortex–related spinal cord couplings were correlated with residual deficits.CONCLUSIONS:This work provides first-in-human functional insights into stroke-related alterations in the functional connectivity between cortical premotor areas and the spinal cord, suggesting that different premotor areas and spinal neuronal assemblies might be involved in coupling changes. It adds a novel, promising approach to better understanding stroke recovery and developing innovative models to comprehend treatment strategies with spinal cord stimulation.

Stroke, Ahead of Print. BACKGROUND:Sex and social determinants of health predict stroke, yet few studies focus exclusively on women at high social risk. Understanding associations between stroke and modifiable risk factors that are disproportionately common in high-risk populations may aid in tailoring primary and secondary prevention services. We sought a better understanding of the association between polysubstance use, with an emphasis on stimulant use, and stroke in women who experience homelessness and unstable housing.METHODS:We recruited women who experience homelessness and unstable housing from San Francisco community–based venues to participate in a cohort study. We identified stroke from electronic health records during the 2.5-year study period and prospectively for up to 2 years after study completion. We then assessed associations with baseline study factors, including social determinants of health, toxicology-confirmed use of multiple substances, and traditional stroke risk factors. We used multiple logistic regression and the Akaike Information Criterion to construct the most parsimonious adjusted model to determine independent relationships between study factors and stroke risk.RESULTS:Of 245 participants, 238 had a complete data set and were included. The median participant age was 53.4 (interquartile range, 45.4–59.4) years. Nine (3.8%) participants had documented strokes. After adjusting for age, hyperlipidemia, and opioid use, cocaethylene—a biomarker signaling alcohol and cocaine concurrent co-use—had a particularly strong association with stroke (odds ratio, 3.22 [95% CI, 1.02–10.20]).CONCLUSIONS:Cocaethylene and opioids were strongly associated with stroke among women who experience homelessness and unstable housing. This suggests 2 possible opportunities for prevention in an environment where opioid use is already closely monitored. First, women reporting cocaine and alcohol co-use should be counseled about the especially harmful effects of this substance combination on their cerebrovascular health. Second, the utility of cocaethylene to assess stroke risk in high-risk populations may be currently underestimated.

Stroke, Ahead of Print. BACKGROUND:The purpose of this study is to examine the association between race and ethnicity and ischemic stroke severity in the United States.METHODS:We performed an analysis of adult hospital discharges in the National Inpatient Sample from 2018 to 2021 with a primary discharge diagnosis of ischemic stroke. We stratified our cohort based on self-reported race and ethnicity and evaluated stroke severity using the National Institutes of Health Stroke Scale. Age- and sex-adjusted estimates of the National Institutes of Health Stroke Scale were derived from linear regression models.RESULTS:We included 231 396 stroke discharges with a mean National Institutes of Health Stroke Scale of 6.5±7.2. The cohort was 68.1% White, 17.4% Black, 8.2% Hispanic, and 6.3% other. The age- and sex-adjusted National Institutes of Health Stroke Scale for White patients was 6.25 (95% CI, 6.22–6.29), for Black patients was 7.12 (95% CI, 7.05–7.19), for Hispanic patients was 6.86 (95% CI, 6.76–6.97), and for patients of other races and ethnicities was 7.29 (95% CI, 7.18–7.41). Further adjustment for the Charlson Comorbidity Index, socioeconomic factors, and poorly controlled hypertension or diabetes did not significantly alter these findings.CONCLUSIONS:In a large, contemporary, and nationally representative sample of patients with acute ischemic stroke, we show an association between non-White race and ethnicity and higher stroke severity. These results are concerning for an underappreciated health disparity in acute ischemic stroke.

Stroke, Ahead of Print. BACKGROUND:Past failures in translating stroke cerebroprotection provoked calls for a more rigorous methodological approach, leading to the stroke preclinical assessment network SPAN (Stroke Preclinical Assessment Network), where uric acid (UA) treatment exceeded a prespecified efficacy boundary for the primary functional outcome. Still, successful translation to humans requires confirmation of the effect of UA across key biological variables relevant to patients with stroke.METHODS:We measured the effects of intravenous UA treatment (16 mg/kg) versus intravenous saline in groups of animals enrolled in the SPAN network with diverse comorbidities, sex, and age. The masked study drug or placebo was administered during reperfusion in rodents undergoing a transient middle cerebral artery filament occlusion. The primary outcome was the modified corner test index at day 30 poststroke, and numerous secondary outcomes were collected. A modified intention-to-treat population was used in the analysis. We tested for any interactions with sex, age, and comorbidities (obesity-induced hyperglycemia and hypertension).RESULTS:In total, 710 animals were randomized to receive either intravenous UA or saline. After accounting for procedural dropouts and exclusions from treatment, a total of 687 animals were qualified and analyzed, including 458 assigned to UA and 229 to intravenous saline control. UA-treated animals exhibited a better primary functional outcome at day 30 (probability, 0.56 [95% CI, 0.52–0.60];P=0.006). UA-treated animals also had a better corner test index at day 7 (probability, 0.55 [95% CI, 0.5–0.59];P=0.035) and a higher survival rate at day 30 (hazard ratio, 1.41 [95% CI, 1.08–1.83];P=0.011). Brain morphometry at day 2 and 30 was comparable between the treatment groups. The improved functional outcome and survival in UA-treated animals were preserved across different species, sexes, ages, and comorbidities.CONCLUSIONS:UA provides ischemic stroke cerebroprotection across key relevant biological variables, making it a promising intervention to be further tested in human clinical trials.

Stroke, Ahead of Print. BACKGROUND:Providing equitable health care to rural stroke patients is challenging and associated with less intervention and poorer outcomes. We assessed how several distinct patient-related geographic classifications influenced stroke care and outcomes in Scotland, United Kingdom.METHODS:We conducted a population-level data-linkage study of ischemic stroke patients admitted to the hospital (2010–2018). Geographic classifications included 2 binary (urban versus rural; accessible versus remote) and 1 six-category classification encompassing both rurality and accessibility (large urban areas, other urban areas, accessible small towns, remote small towns, accessible rural areas, and remote rural areas). Process outcomes included achievement of a stroke care bundle and thrombolysis administration. Clinical outcomes included 30-day discharge from hospital care, 90-day home time, inpatient and 1-year all-cause mortality.RESULTS:We included 42 917 ischemic stroke patients (35 766 urban and 7151 rural). Binary classifications of rurality or accessibility missed important differences in stroke care and outcomes revealed using 6-category classification. Using the latter, compared with large urban areas, patients in accessible rural areas were more likely to receive a complete stroke care bundle (adjusted odds ratio, 1.21 [95% CI, 1.12–1.31]); patients in remote rural areas were less likely (adjusted odds ratio, 0.85 [95% CI, 0.78–0.93]). Compared with large urban areas, 30-day discharge from hospital care was more likely for patients residing elsewhere (eg, remote rural areas adjusted subdistribution hazards ratio, 1.11 [95% CI, 1.05–1.17]); home time within 90 days was higher for other urban areas (adjusted incidence rate ratio, 1.05 [95% CI, 1.03–1.07]) and accessible rural areas (adjusted incidence rate ratio, 1.03 [95% CI, 1.01–1.06]); and 1-year mortality was less likely in other urban areas (adjusted hazard ratio, 0.93 [95% CI, 0.88–0.98]) and remote small towns (adjusted hazard ratio, 0.89 [95% CI, 0.80–0.99]).CONCLUSIONS:When considering geographic disparities in stroke care and outcomes across Scotland, it is important to account for both home location and accessibility of care. Despite patients residing in remote rural areas being less likely to achieve a complete stroke care bundle, this did not translate into poorer outcomes.

Stroke, Ahead of Print. Brain arteriovenous malformations (AVMs), cerebral cavernous malformations (CCMs), and intracranial aneurysms are major causes of hemorrhagic stroke, yet noninvasive therapies to prevent growth or rupture are lacking. Understanding the genetic basis of these malformations is critical for uncovering underlying mechanisms, developing targeted prevention strategies, and identifying novel therapeutic targets. This review highlights the causal genes and signaling pathways in AVMs, CCMs, and intracranial aneurysms, noting both their commonalities and differences. For AVMs, somatic mutations in the Ras/MAPK (mitogen-activated protein kinase) and MAPK/ERK (extracellular signal–regulated kinase) pathway are key, particularly in sporadic cases, whereas hereditary conditions like hereditary hemorrhagic telangiectasia and capillary malformation–AVM involve the TGF-β (transforming growth factor β), Ephrin receptor, and angiopoietin-VEGF (vascular endothelial growth factor) signaling pathways. In CCMs, pathways affecting endothelial junctions and vascular stability, such as the ROCK (RhoA/Rho–associated coiled-coil containing kinases) pathway, play a central role. Although the genetic drivers of intracranial aneurysms are more diverse and less clearly linked to specific pathways, there is some overlap with genes in the TGF-β and endothelial function pathways seen in AVMs and CCMs. Emerging therapies for AVMs and CCMs include MAPK/ERK inhibitors, anti-VEGF treatments, and RhoA/ROCK inhibitors, showing potential in preclinical models. Due to the genetic overlap, these advancements may also offer future therapeutic strategies for intracranial aneurysms. As personalized medicine progresses, the development of reliable biomarkers, such as the candidate biomarker VEGF for AVMs and CCMs, will be crucial for guiding treatment decisions. In conclusion, ongoing research into genetic pathways holds promise for novel therapeutic targets that could transform the management of vascular malformations and reduce the risk of hemorrhagic stroke.

Objectives
This systematic review examines prehospital and in-hospital delays in acute stroke care in Indonesia.

Design
Systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Data sources
We conducted a thorough search across 11 databases, ClinicalTrials.gov registries and three preprint repositories up until October 2024.

Eligibility criteria
Studies that examined risk variables associated with hospital delays in the treatment of acute stroke in Indonesian individuals were included.

Data extraction and synthesis
Two reviewers each carried out the data extraction and risk-of-bias evaluation separately. The quality of the study was evaluated using the Risk of Bias in Non-randomised Studies of Exposures tool. The ‘combining p values’ approach and albatross plots were used to synthesise the findings.

Results
A total of 27 studies with 3610 patients were included. Key factors contributing to prehospital delays included low educational level (p=0.014, 6 studies), low socioeconomic status (p=0.003, 5 studies), cultural beliefs affecting decision-making (p