Risultati per: Stroke

Certain hormonal contraceptives are associated with a greater risk of ischemic stroke and myocardial infarction, or heart attack, according to a study of more than 2 million Danish women. The absolute risk remained low for all the contraceptive methods, the researchers stated.

Our study indicates that collateral status may help identify patients at risk from intensive blood pressure lowering treatment to a systolic target of 120 mm Hg or lower, in patients undergoing endovascular therapy for acute ischaemic stroke from large-vessel occlusion.

Stroke, Ahead of Print. BACKGROUND:Atrial fibrillation detected after stroke (AFDAS) affects secondary stroke prevention, yet identification can be challenging. Easily accessible cardiac blood biomarkers such as NT-proBNP (N-terminal pro-B-type natriuretic peptide) could guide diagnostic workup, but optimal cutoff values and the time-dependent relationship between NT-proBNP and AFDAS are unclear. We aimed (1) to externally validate earlier presented NT-proBNP cutoffs for atrial fibrillation prediction and (2) to assess the time-dependent relationship of NT-proBNP and early in-hospital AFDAS versus AFDAS after discharge.METHODS:We conducted a pooled data analysis of patients with ischemic stroke from the prospective international multicenter BIOSIGNAL (Biomarker Signature of Stroke Aetiology) cohort study (European Stroke Centers from October 2014 to October 2017) and the prospective single-center Graz stroke pathway study (Austria from May 2018 to August 2020). AFDAS was defined as ≥30-s atrial fibrillation/flutter diagnosed within 1 year post-admission and categorized in in-hospital versus after discharge. NT-proBNP was assessed ≤24 hours of symptom onset. The association between NT-proBNP and AFDAS was evaluated by a multivariable logistic regression analysis.RESULTS:AFDAS was diagnosed in 374 (16%) of 2292 patients with ischemic stroke (median age, 74 years; 42% female), 268 (72%) during hospitalization, and 106 (28%) after discharge (median duration of hospitalization, 15 days). NT-proBNP levels at admission had a good predictive capacity for in-hospital AFDAS (area under the receiver operating characteristic curve, 0.83 [95% CI, 0.81–0.86]). For patients diagnosed with AFDAS after discharge, the predictive capacity of NT-proBNP was poor (area under the receiver operating characteristic curve, 0.65 [95% CI, 0.60–0.70]), and 20% had normal NT-proBNP values

Stroke, Ahead of Print. Secondary stroke prevention encompasses many approaches, including antithrombotic therapy, risk factor management, and a healthy lifestyle. Recommendations are typically based on the results of randomized clinical trials that provide evidence of benefit. However, in some situations, clinicians extrapolate the results of clinical trials into everyday practice, or trials have not provided sufficient information to make treatment decisions. This review will discuss 4 scenarios: dual-antiplatelet therapy, the perils of combining antiplatelet and anticoagulation, indications for statin therapy, and therapeutic considerations for patients with paroxysmal atrial fibrillation.

Circulation, Volume 151, Issue 16, Page e961-e961, April 22, 2025.

Stroke, Ahead of Print. BACKGROUND:Stroke often results in significant impairments across various domains, including movement, language, cognition, and mood. Neurostimulants have been proposed as potential therapeutic interventions to enhance recovery in these areas.METHODS:This narrative literature review examines clinical trials investigating the efficacy of neurostimulants in poststroke recovery. It evaluates outcomes related to aphasia, motor deficits, cognition, fatigue, and depression.RESULTS:The qualitative analysis included 34 trials testing the following neurostimulants: methylphenidate (n=6), amphetamines (n=8), memantine (n=2), modafinil (n=2), levodopa (n=14), amantadine (n=1), bromocriptine (n=3), and ropinirole (n=1). Of the 34 studies, 31 were randomized, placebo-controlled (double-blind, n=27; single-blind, n=2; unblinded n=2), 2 were randomized and not placebo-controlled, and 1 was not randomized. Study design was either multiarm (n=23), crossover (n=10), or used subjects as their own control (n=1). Mean sample size was 49.4 (5–593).CONCLUSIONS:Current evidence suggests that memantine may be effective for aphasia, although few phase III trials exist, whereas bromocriptine and amphetamines lack sufficient evidence for long-term recovery of aphasia. Levodopa may improve motor aphasias but has not shown long-term benefits for motor recovery. Similarly, ropinirole has not been shown to improve poststroke motor outcomes. Methylphenidate has limited efficacy for cognitive improvement but may enhance poststroke functionality and mood. Modafinil may help with poststroke fatigue. In conclusion, there are promising results of positive effects of neurostimulants with few side effects, though studies are limited by heterogeneous designs and small sample sizes. Neurostimulant efficacy must be assessed in conjunction with specific rehabilitation modalities as part of larger, well-designed studies to best understand their effects on impairment.

Stroke, Ahead of Print. BACKGROUND:The international trial AVERT (A Very Early Rehabilitation Trial) found that very early mobilization (VEM; commenced 2/3 of an arterial territory) from brain imaging obtained ≤7 days poststroke. The association between LVO, VEM, and 3- and 12-month mRS was tested using logistic regression, adjusted for age, treatment with thrombolysis, and baseline National Institutes of Health Stroke Scale.RESULTS:Interrater reliability for LVO signs was high (weighted κ, 0.842 [95% CI, 0.631–0.969]). Of 689 participants (37.2% female; median age, 74.5 [interquartile range, 65.0–81.2] years) included in the primary analysis, 192 (28%) showed direct or indirect evidence of LVO. Computed tomography/magnetic resonance imaging angiography were available in 179 (26%) of those 689 participants. While LVO was associated with poor mRS ( >2) at 3 months (adjusted odds ratio, 2.15 [95% CI, 1.29–3.64]) and 12 months (adjusted odds ratio, 1.76 [95% CI, 1.1–2.84];P=0.02), there was no significant interaction between VEM, LVO, and mRS (P=0.16).CONCLUSIONS:We found no evidence that VEM was specifically harmful in patients with LVO. However, as arterial imaging was not consistently obtained before first mobilization, larger prospective studies with standardized measures of LVO are needed to fully address this question.REGISTRATION:URL: xxx; Unique identifier: ACTRN12606000185561.

Stroke, Ahead of Print. Atrial fibrillation is a frequent cardiac arrhythmia and is associated with an increased risk of cardioembolic stroke. The left atrial appendage is a finger-like extension originating from the main body of the left atrium and the main location of thrombus formation in patients with atrial fibrillation. Surgical or percutaneous left atrial appendage occlusion (LAAO) aims at preventing clot formation in the left atrial appendage. Here, we describe available surgical and percutaneous approaches to achieve LAAO and discuss the available evidence for LAAO in patients with atrial fibrillation. We discuss the role of LAAO and its role in stroke prevention in frequent scenarios in cerebrovascular medicine: LAAO as a potential alternative to oral anticoagulation in patients with a history of intracranial hemorrhage, and LAAO as a promising add-on therapy to direct oral anticoagulant therapy in patients with breakthrough stroke despite anticoagulation. Finally, we provide an outlook on currently ongoing trials that will provide further evidence in the next years.

Stroke, Ahead of Print. BACKGROUND:Blood-brain barrier (BBB) leakage measured with dynamic susceptibility contrast-enhanced magnetic resonance imaging (MRI) has been associated with hemorrhagic transformation in acute ischemic stroke. However, the influence of prethrombolysis BBB leakage on infarct growth has not been studied. Therefore, we aimed to characterize BBB integrity according to tissue state at admission and tissue fate on follow-up MRI.METHODS:This is a post hoc analysis of the WAKE-UP trial (Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke). Ischemic cores were segmented on diffusion-weighted imaging at baseline and on fluid-attenuated inversion recovery images at follow-up (22–36 hours). Dynamic susceptibility contrast-enhanced–MRI provided penumbra masks (time to maximum of the tissue residue function >6 s minus ischemic core) and BBB leakage (extraction fraction [EF],Zscored) maps via automated analysis. EF was averaged within the ischemic core, total penumbra, 2 penumbra subtypes (salvaged/infarcted penumbra), and normal tissue. Adjusted linear mixed-effects models tested for differences between tissue types and associations of EF with clinical/imaging outcomes. Complementary voxel-wise analyses were performed.RESULTS:Of 503 patients enrolled in the trial, 165 with suitable dynamic susceptibility contrast-enhanced–MRI data were included in this analysis (mean age 66 years, 38% women, median National Institutes of Health Stroke Scale score of 6; 53% receiving alteplase). EF was significantly increased in the ischemic core and penumbra relative to normally perfused tissue, while differences between total penumbra and ischemic core were statistically nonsignificant. Infarcted penumbra exhibited higher EF than salvaged penumbra, even after adjusting for hypoperfusion severity (P

Stroke, Ahead of Print. BACKGROUND:The incidence of young-onset ischemic stroke is rising, driven by cryptogenic ischemic stroke (CIS) and patients without vascular risk factors. This study examines the burden and associations of modifiable traditional, nontraditional, and female sex–specific risk factors with young-onset CIS, stratified by clinically relevant patent foramen ovale (PFO), defined by high-risk features of atrial septal aneurysm or large right-to-left shunt.METHODS:We enrolled consecutive patients aged 18 to 49 years with recent CIS and frequency-matched stroke-free controls of the same age and sex from 19 European sites. Logistic regression assessed the association of risk factor counts (12 traditional, 10 nontraditional, 5 female sex–specific) and individual risk factors, stratified by PFO. Analyses were stratified by sex and age (18–39 and 40–49 years), with computation of population-attributable risk.RESULTS:We included 523 patients (median age, 41 years; 47.3% women; 196 [37.5%] with PFO) and 523 controls. In patients with CIS without PFO, each additional traditional (odds ratio, 1.417 [95% CI, 1.282–1.568]), nontraditional (odds ratio, 1.702 [95% CI, 1.338–2.164]), and female sex–specific risk factor (odds ratio, 1.700 [95% CI, 1.107.1–2.611]) increased CIS risk. For patients with CIS with PFO, each traditional risk factor increased the risk (odds ratio, 1.185 [1.057–1.328]), but only nontraditional risk factors remained significant when fully adjusted (odds ratio, 2.656 [2.036–3.464]). Population-attributable risks for CIS without PFO were 64.7%, 26.5%, and 18.9% for traditional, nontraditional, and female sex–specific risk factors. For CIS with PFO, population-attributable risks were 33.8%, 49.4%, and 21.8%, respectively. Migraine with aura was the most significant contributor, with population-attributable risks of 45.8% for CIS with PFO and 22.7% for CIS without PFO, showing a stronger impact in women.CONCLUSIONS:Despite the initial cryptogenic label of these strokes, traditional risk factors significantly contribute to CIS without PFO, while nontraditional factors seem more critical for CIS with PFO. Migraine with aura plays a prominent role in young-onset CIS development, particularly in women.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT01934725.

Stroke, Ahead of Print. BACKGROUND:Obtaining timely informed consent is a key barrier in acute ischemic stroke clinical trial recruitment. Electronic consent (eConsent) allows electronic delivery and documentation of the informed consent process, which may optimize recruitment. eConsent in acute ischemic stroke clinical trials, however, is limited and understudied. We conducted a post hoc analysis of eConsent adoption in MOST (Multi-Arm Optimization of Stroke Thrombolysis Trial), a phase III acute ischemic stroke clinical trial, and studied the impact on recruitment.METHODS:From October 10, 2019, to July 5, 2023, MOST enrolled 514 participants at 57 sites in the United States. Study databases were reviewed to determine informed consent modality for each participant: paper—in person, paper—remote, eConsent—in person, and eConsent—remote. Study sites could use paper consent or eConsent for each enrollment. eConsent adoption trends and participant demographic diversity were reported using descriptive statistics. We utilized χ2and Kruskal-Wallis tests to compare individual site enrollment, remote consent utilization, baseline neuroimaging-to-randomization times, data clarification requests, and reportable consent-related unanticipated events.RESULTS:eConsent was utilized for 173 (33.7%) of 514 participants. Of 57 sites, 32 (56.1%) utilized eConsent at least once: those sites had higher median enrollment over the course of the entire trial than non-eConsent sites (7.5 [interquartile range, 5–17] versus 3 [interquartile range, 2–4];P

Stroke, Ahead of Print. BACKGROUND:Neuronal pyroptosis is involved in neuronal cell death and neurological damage after cerebral ischemia-reperfusion. 14,15-Epoxyeicosatrienoic acid (14,15-EET) can reduce neuronal loss induced by cerebral ischemia-reperfusion by regulating mitochondrial biological processes. However, it remains unclear how 14,15-EET regulates mitochondrial homeostasis, inhibits neuronal pyroptosis, and promotes neurological functional recovery after cerebral ischemia-reperfusion.METHODS:Mice with middle cerebral artery occlusion and reperfusion were used as an animal model to study the cerebral ischemia-reperfusion disease. The neurological function of mice was performed at 1, 3, and 5 days to test the therapeutic effects of 14,15-EET. Transmission electron microscope imaging and Nissl staining were used to analyze neuronal morphological structure, mitophagy, and neuronal pyroptosis. Western blot and transcriptome were used to detect the levels of mitophagy and neuronal pyroptosis signaling pathway–related molecules. HT22 cells were used in in vitro studies to detect the mechanism by which 14,15-EET reduces neuronal pyroptosis after oxygen-glucose deprivation/reoxygenation treatment.RESULTS:14,15-EET treatment reduced cerebral infarct volumes and improved neurological functional recovery in mice after cerebral ischemia-reperfusion. 14,15-EET treatment maintained the morphological structure of neurons in the ischemic penumbra area as well as the dendritic spine density in mice after cerebral ischemia-reperfusion. The upregulation of NLRP1 (NOD-like receptor thermal protein domain associated protein 1), IL (interleukin)-1β, caspase-1, and GSDMD (gasdermin D) induced by cerebral ischemia-reperfusion was inhibited, and the expression of mitophagy proteins Parkin and LC3B was increased by 14,15-EET treatment. Transcriptome profiling found that 14,15-EET exerts a neuroprotection role in promoting neural function recovery by activating the WNT (wingless-type MMTV integration site family) signaling pathway. We found that 14,15-EET upregulated the WNT pathway proteins such as WNT1, WNT3A, β-catenin, and p-GSK-3β (phosphorylation of glycogen synthase kinase 3β) in vivo and in vitro. The WNT signaling pathway inhibitor XAV-939 reduced the expression of mitophagy protein Parkin and upregulated the expression of caspase-1 and GSDMD in HT22 cells with oxygen-glucose deprivation/reoxygenation and 14,15-EET treatment.CONCLUSIONS:14,15-EET regulates mitochondrial homeostasis to inhibit neuronal pyroptosis, thereby promoting the recovery of neurological function in mice after cerebral ischemia-reperfusion. These results provide new ideas for maintaining mitochondrial homeostasis and inhibiting neuronal pyroptosis after cerebral ischemia-reperfusion.

Stroke, Ahead of Print.

Stroke, Ahead of Print. Stroke remains a significant cause of disability worldwide. In addition to multidisciplinary rehabilitation approaches, various forms of technology, including vagus nerve stimulation, have emerged to facilitate neuroplasticity and, thereby, improve functional status after stroke. Vagus nerve stimulation was recently approved by the Food and Drug Administration, but questions remain regarding its mechanism of action. Here, a potential role for dopaminergic signaling is considered. This review first examines evidence that dopamine is important to neuroplasticity after stroke. Next, 2 different dopaminergic pathways are considered potential mechanisms underlying vagus nerve stimulation–related benefits after stroke, direct modulation of brain dopaminergic pathways, and engagement of systemic dopaminergic pathways such as those found in the gut-brain axis. A contribution of dopamine signaling to vagus nerve stimulation efficacy could have therapeutic implications that extend to a precision medicine approach to stroke rehabilitation.

Objectives
Following a stroke, people often receive informal care from friends and family. Some carers adopt the role quickly, whereas others find it more difficult to see themselves as a ‘carer’ and do not access relevant support. To understand the process of how and when informal carers start to see themselves as such, and their preferred terminology and experiences of support in this role.

Design
The study adopted an exploratory qualitative design, collecting data through semistructured interviews with participants and a brief survey of participant demographics. Data were analysed thematically using a template analysis approach. Patient, carer and public involvement collaboration, through a formed carer advisory group, enhanced the study methodology.

Setting
The project was a nationwide study, with participants residing across the UK. The study took place from September 2021 to April 2024.

Participants
18 adults (aged 18 years and above) who had provided care or support to a friend or family member after a stroke that occurred at least 1 year prior to participation completed the study.

Results
Five main themes were developed: (1) adopting and adjusting to the care role, (2) accessibility of support, (3) perceptions of support, (4) acceptability of care-related language and terminology and (5) function of care-related language and terminology. Facilitators and barriers to participants self-identifying with the care role were identified. Self-identification was found to commonly occur at four key points along the stroke trajectory: instant recognition at the time of the stroke event; at the point of planning discharge from hospital; on initial return home from hospital; and at a later stage in the caregiving experience. Two main contrasting opinions around the acceptability of care-related terminology were shared: a favourable view of care-related language and a depreciative view. Accessibility of support services and suggestions for future support provision were discussed.

Conclusions
Individuals identify as ‘carers’ at different points and to different extents throughout the stroke trajectory. Findings outline the factors that facilitate this self-identification process and those which constitute challenges to adjusting to the role. Recommendations are made relating to the accessibility of support for informal carers of stroke survivors, including: use of more accessible and inclusive care-related language, educational needs relating to what a ‘carer’ is and involvement of carers and wider family in the rehabilitation process.

Stroke, Ahead of Print. BACKGROUND:Hemorrhagic infarction (HI) of acute ischemic stroke is frequent. Whether radiologically detected HI affects stroke outcomes has been less explored.METHODS:This was a secondary analysis of the PACIFIC-STROKE trial (Proper Dosing and Safety of the Oral FXIa Inhibitor BAY 2433334 in Patients Following Acute Noncardioembolic Stroke), which enrolled patients with acute noncardioembolic ischemic stroke receiving either asundexian or placebo in addition to guideline-based antiplatelet therapy. All patients received brain magnetic resonance imaging within 120 hours after stroke onset. Patients with hemorrhagic transformation detected on iron-sensitive sequences and classified as HI (H1 and H2) by the Heidelberg Bleeding Classification were included in the analysis. Primary outcome was poor functional outcome, defined by a modified Rankin Scale score of 2 to 6 at 90 days after stroke.RESULTS:From 1745 patients with adequate baseline brain magnetic resonance imaging (median, 47.8 hours; interquartile range, 28.2–69.4 hours after symptom onset), 10 with parenchymal hemorrhage and 191 without modified Rankin Scale score were excluded. Of the 1544 patients (mean age, 67 years; 67% male), 248 (16.1%) had HI type 1, and 189 (12.2%) had HI type 2. The proportion of patients with poor functional outcome was 27.4% (68/248) in HI type 1, 25.9% (49/189) in HI type 2, and 23.0% (255/1107) in no HI groups. In the multivariable logistic regression model adjusting for stroke severity, infarct size, type of iron-sensitive sequences used, and other covariates, the presence of HI type 1 (adjusted odds ratio, 1.05 [95% CI, 0.74–1.51]) or HI type 2 (adjusted odds ratio, 0.88 [95% CI, 0.57–1.34]) were not associated with poor functional outcome. Of note, the type of iron-sensitive sequences did not modify the results.CONCLUSIONS:The presence of HI did not lead to poor functional outcome on the modified Rankin Scale in patients with acute noncardioembolic ischemic stroke.