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Leptomeningeal collaterals (LMCs) are crucial in mitigating the impact of acute ischemic stroke (AIS) by providing alternate blood flow routes when primary arteries are obstructed. This article explores the evolutionary pathophysiology of LMCs, highlighting their critical function in stroke and the genetic and molecular mechanisms governing their development and remodelling. We address the translational challenges of applying animal model findings to human clinical scenarios, emphasizing the need for further research to validate emerging therapies—such as pharmacological agents, gene therapy and mechanical interventions—in clinical settings, aimed at enhancing collateral perfusion. Computational modelling emerges as a promising method for integrating experimental data, which requires precise parameterization and empirical validation. We introduce the ‘Evolucollateral Dynamics’ hypothesis, proposing a novel framework that incorporates evolutionary biology principles into therapeutic strategies, offering new perspectives on enhancing collateral circulation. This hypothesis emphasizes the role of genetic predispositions and environmental influences on collateral circulation, which may impact therapeutic strategies and optimize treatment outcomes. Future research must incorporate human clinical data to create robust treatment protocols, thereby maximizing the therapeutic potential of LMCs and improving outcomes for stroke patients. [ABSTRACT FROM AUTHOR]

Background: The predictors of intracranial haemorrhagic transformation (HT) in acute ischaemic stroke (AIS) patients undergoing dual antiplatelet therapy (DAPT) are not well known. Objectives: The aim of this study is to identify the possible clinical and radiological predictors of HT in patients, irrespective of clinical indication for this treatment. Design: This study is a monocentric cohort retrospective study. Methods: We enrolled consecutive AIS patients, from our prospective register, admitted to Stroke Unit between June 2021 and June 2023 undergoing DAPT with Acetylsalicylic Acid and Clopidogrel within 72 h from symptoms onset. According to current guidelines, DAPT indication was for patients with a minor stroke, symptomatic intracranial artery stenosis and carotid angioplasty stenting. We collected clinical, demographical and radiological data. We used ABC/2 method to measure stroke volume in magnetic resonance imaging (MRI)/Diffusion-weighted imaging (DWI) sequences performed within 48 h. The primary outcome was the presence of HT at non-contrast brain computed tomography, performed 7 days after commencing DAPT. Results: One hundred ninety-four patients were included. Twenty-eight (14.4%) presented HT. Higher NIH Stroke Scale (NIHSS) and MRI/DWI lesion volume related to increased risk of HT (p < 0.001). Reperfusion therapy and mechanical thrombectomy (MT), stent placement and a loading dose (LD) of dual antiplatelet or Clopidogrel were associated with a higher occurrence of HT (p < 0.05). Furthermore, we individuated an NIHSS cut-off value >4 (area under the curve (AUC) 0.80, sensitivity 0.82, specificity 0.65) and a volume cut-off value >8.2 ml (AUC 0.82, sensitivity 0.79, specificity 0.80) associated with an increased risk of HT (respectively, adjusted odds ratio (adj. OR) 6.5, confidence interval (CI) 1.3–32.7, p = 0.024 and adj. OR 11.0, CI 3.1–39.2, p < 0.001). Conclusion: In clinical practice, MT treatment, antiplatelet LD administration, stent placement and clinical severity may relate to a higher risk of HT in patients with AIS and DAPT in the acute phase. In particular, we found that lesion volume cut-off could help to identify patients at greater risk of HT, regardless of the indication for DAPT. Plain language summary: Possible clinical and radiological features able to predict the risk of haemorrhagic transformation in patients affected by acute cerebral ischemic stroke undergoing treatment with dual antiplatelet, Acid Acetylsalicylic and Clopidogrel This monocentric cohort retrospective study aims to identify predictive factors for haemorrhagic transformation (HT) in patients with acute ischaemic stroke (AIS) and dual antiplatelet therapy (DAPT). DAPT is indicated for minor strokes, symptomatic intracranial artery stenosis and carotid stent placement. Although there are guidelines on this subject, there are some grey areas due to the emergence of new possible uses of DAPT and to a lack of studies addressing some issues (e.g. patients with moderate to severe AIS undergoing DAPT). We selected patients >18 years old from our prospective registry, who were admitted for AIS and started DAPT within 72 hours from the event. We collected clinical and radiological data. All patients underwent brain magnetic resonance imaging (MRI). We calculated the volume of the AIS using an easily reproducible methodology (ABC/2). We then identified which patients developed HT after one week of therapy and examined the factors potentially associated with an increased risk of HT. Our study provided useful insights for clinical practice. We observed an increased risk of HT in patients with higher scores on the stroke clinical severity scale (NIHSS), larger infarcts, treatment with mechanical thrombectomy, administration of antiplatelet loading doses and stent placement. Furthermore, we identified a 11-fold increased risk of HT in patients with acute ischaemic lesion volumes on MRI >8.2 ml, and a 6-fold increased risk for patients with NIHSS >4. This study is easily reproducible in clinical practice, as it utilizes readily available clinical and radiological parameters. It highlights how the integration of clinical and radiological data can assist neurologists in navigating grey areas of treatment. In this way, it might be possible to identify patients at risk of haemorrhage, who should be monitored more closely to prevent adverse effects that could lead to the interruption of DAPT, thereby reducing the risk of a new ischemic stroke. [ABSTRACT FROM AUTHOR]

Background and Purpose Methods Results Conclusions The influence of intracranial arteriosclerosis (ICAR) on acute ischaemic stroke (AIS) prognosis is unclear. This study explored its impact, focusing on ICAR subtypes categorized by intracranial carotid artery calcification (ICAC) patterns: intimal or atherosclerotic versus internal elastic lamina calcification or non‐atherosclerotic. The aim was to determine their effect on AIS prognosis in patients undergoing endovascular treatment (EVT).This prospective cohort study included consecutive AIS patients with anterior circulation large vessel occlusion undergoing EVT. ICAC, the hallmark of ICAR, was assessed using non‐contrast computed tomography to quantify volume and establish the predominant ICAR subtype. The primary outcome was long‐term functional outcome, measured by the 90‐day modified Rankin Scale score. Secondary outcomes included first‐pass effect, revascularization degree, symptomatic intracranial haemorrhage and 24‐h infarct volume. Multivariate‐adjusted linear and logistic regression models were used to assess the association of ICAC volume and subtype with these outcomes.From January 2021 to February 2022, 181 patients were included, of whom 172 (95%) had ICAC. Internal elastic lamina calcification was the predominant subtype in 103 (57%), intimal in 52 (29%) and mixed in 17 (9%). The intimal or atherosclerotic ICAC pattern was linked to poorer functional outcomes (adjusted odds ratio 2.12, 95% confidence interval [CI] 1.10–4.09), decreased first‐pass effect probability (adjusted odds ratio 0.42, 95% CI 0.21–0.84) and higher infarct volume (adjusted β value 22.11, 95% CI 0.55–43.67).A predominant intimal ICAC subtype, linked to underlying atherosclerosis, correlated with larger infarct volume and poorer 90‐day functional outcomes in EVT‐treated AIS patients. Intracranial atherosclerosis appears to be a relevant factor hampering clinical benefits post‐EVT. [ABSTRACT FROM AUTHOR]

Abstract Background The objective of this study was to establish a predictive model utilizing machine learning techniques to anticipate the likelihood of thrombolysis resistance (TR) in acute ischaemic stroke (AIS) patients undergoing recombinant tissue plasminogen activator (rt-PA) intravenous thrombolysis, given that nearly half of such patients exhibit poor clinical outcomes. Methods Retrospective clinical data were collected from AIS patients who underwent intravenous thrombolysis with rt-PA at the First Affiliated Hospital of Bengbu Medical University. Thrombolysis resistance was defined as ([National Institutes of Health Stroke Scale (NIHSS) at admission − 24-hour NIHSS] × 100％/ NIHSS at admission) ≤ 30%. In this study, we developed five machine learning models: logistic regression (LR), extreme gradient boosting (XGBoost), support vector machine (SVM), the least absolute shrinkage and selection operator (LASSO), and random forest (RF). We assessed the model’s performance by using receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA), and presented the results through a nomogram. Results This study included a total of 218 patients with AIS who were treated with intravenous thrombolysis, 88 patients experienced TR. Among the five machine learning models, the LASSO model performed the best. The area under the curve (AUC) on the testing group was 0.765 (sensitivity: 0.767, specificity: 0.694, accuracy: 0.727). The apparent curve in the calibration curve was similar to the ideal curve, and DCA showed a positive net benefit. Key features associated with TR included NIHSS at admission, blood glucose, white blood cell count, neutrophil count, and blood urea nitrogen. Conclusion Machine learning methods with multiple clinical variables can help in early screening of patients at high risk of thrombolysis resistance, particularly in contexts where healthcare resources are limited.

Abstract Background Individually, diabetes mellitus and dementia are associated with poorer outcomes after stroke. However, the combined impact of these pre-existing factors on acute ischemic stroke (AIS) outcomes has not been examined. Methods All consecutive patients with AIS admitted to Norfolk and Norwich University Hospitals between 2003 and 2016 (catchment population ~ 900,000) were divided into four groups: those with neither diabetes nor dementia (reference), with diabetes without dementia, with dementia without diabetes, and with both co-morbidities. In-hospital mortality, length of hospital stay (LoS), and disability outcomes were analysed using logistic regressions. Post-discharge mortality and recurrence were assessed using Cox regressions. Additionally, interaction terms were added to the models for the short-term outcomes and long-term mortality to test for synergistic effects of diabetes and dementia. Models were adjusted for age, sex, Oxfordshire Community Stroke Project classification, comorbidities, hematological and biochemical measures, and antithrombotic medications. Results The cohort was 10,812 patients with 52% females and a median age of 80. The median follow-up was 3.8 years for stroke recurrence and 5.5 years for mortality. No significant differences between the four groups existed for in-hospital mortality and post-stroke disability. Patients with dementia had significantly longer LoS (OR 2.25 [95% CI: 1.34–3.77] and 1.31 [1.02–1.68] with and without diabetes, respectively). Patients with both comorbidities had the highest risk of stroke recurrence (HR 2.06 [1.12–3.77]), followed by those with only dementia (1.59 [1.15–2.20]) and only diabetes (1.25 [1.06–1.49]). Similarly, the patient group with both diabetes and dementia had the highest long-term mortality risk (1.76 [1.33–2.37]). The hazard ratios for patients with only dementia and only diabetes were 1.71 [1.46–2.01] and 1.19 [1.08–1.32], respectively. No significant interactions were seen between diabetes and dementia with regards to their effects on the outcomes. Conclusion Individual and cumulative impacts of the two conditions on long-term mortality and stroke recurrence were notable. However, no synergistic impact of the two comorbidities were seen on the stroke outcomes tested in our study. Therefore, tailoring the management of stroke patients based on additional requirements associated with each pre-existing condition will be more impactful towards improving outcomes.

Background: The objective of this study was to establish a predictive model utilizing machine learning techniques to anticipate the likelihood of thrombolysis resistance (TR) in acute ischaemic stroke (AIS) patients undergoing recombinant tissue plasminogen activator (rt-PA) intravenous thrombolysis, given that nearly half of such patients exhibit poor clinical outcomes. Methods: Retrospective clinical data were collected from AIS patients who underwent intravenous thrombolysis with rt-PA at the First Affiliated Hospital of Bengbu Medical University. Thrombolysis resistance was defined as ([National Institutes of Health Stroke Scale (NIHSS) at admission − 24-hour NIHSS] × 100％/ NIHSS at admission) ≤ 30%. In this study, we developed five machine learning models: logistic regression (LR), extreme gradient boosting (XGBoost), support vector machine (SVM), the least absolute shrinkage and selection operator (LASSO), and random forest (RF). We assessed the model's performance by using receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA), and presented the results through a nomogram. Results: This study included a total of 218 patients with AIS who were treated with intravenous thrombolysis, 88 patients experienced TR. Among the five machine learning models, the LASSO model performed the best. The area under the curve (AUC) on the testing group was 0.765 (sensitivity: 0.767, specificity: 0.694, accuracy: 0.727). The apparent curve in the calibration curve was similar to the ideal curve, and DCA showed a positive net benefit. Key features associated with TR included NIHSS at admission, blood glucose, white blood cell count, neutrophil count, and blood urea nitrogen. Conclusion: Machine learning methods with multiple clinical variables can help in early screening of patients at high risk of thrombolysis resistance, particularly in contexts where healthcare resources are limited. [ABSTRACT FROM AUTHOR]

Background: We sought to examine the feasibility, safety and preliminary efficacy of anterior cerebral artery (ACA) occlusions in patients undergoing endovascular treatment. Methods: Four hundred five consecutive patients with large-vessel occlusion treated with endovascular treatment were analysed to identify all patients with acute ACA occlusion who underwent endovascular treatment. Results: Twenty had ACA occlusion (primary ACA occlusion: 9, rescue ACA occlusion: 11), 395 patients had other occlusions (internal carotid artery and MCA). The median [IQR] mRS score in the third month was significantly higher in the ACA-rescue occlusion group versus the ACA-primary occlusion group. The rate of haematoma in patients with ACA-occlusions was significantly higher compared with the ACA-primary occlusion group. Moreover, the three-month mortality rate was higher in patients with ACA-rescue than the patients with ACA-primary. Conclusions: Although endovascular treatment can be considered in patients with primary ACA occlusions, our data suggest that future clinical trials are needed to determine the efficacy of endovascular treatment for ACA occlusions. Unfavourable outcomes in our study were considered to occur in the rescue ACA occlusions. [ABSTRACT FROM AUTHOR]

We wanted to evaluate if optical coherence tomography angiography OCTA findings could predict the functional outcome in extracranial carotid artery atherosclerotic disease (ECAD) associated stroke. This exploratory study was performed on adults with acute ischaemic stroke due to ECAD at 3–6 weeks following stroke onset with risk factor matched controls without carotid artery stenosis. Twenty-three stroke patients (cases) and 23 controls were enrolled. There was significant difference between cases and controls in deep vessel density at the macula (p =.0007) and in radial peripapillary capillary perfusion density (RPCPD) at the optic nerve head (ONH) (p =.0007). Statistically significant difference was noted in the total superficial vessel density (SVD) at the macula (SVD within 1 standard deviation [SD] versus SVD beyond 1 SD of control data) in the ipsilateral eye and functional outcome at 3 months (poor versus very good outcome, modified Rankin scale [mRS] 0–1 versus mRS 2–6, respectively; p =.0361). There was statistically insignificant correlation between the RPCPD at the ONH and the National Institutes of Health Stroke Scale score at admission, mRS at discharge, and mRS at 3 months following stroke onset (r =.33, r =.35, r =.39; p =.11, p =.09, p =.06, respectively). The findings of this exploratory study suggested that OCTA findings may predict 3 month outcomes in cases of ECAD-related stroke and could be useful in decision making in future intervention studies as to whether intervene or not in patients having critical or non-critical ECAD for preventing stroke. [ABSTRACT FROM AUTHOR]

Background: Individually, diabetes mellitus and dementia are associated with poorer outcomes after stroke. However, the combined impact of these pre-existing factors on acute ischemic stroke (AIS) outcomes has not been examined. Methods: All consecutive patients with AIS admitted to Norfolk and Norwich University Hospitals between 2003 and 2016 (catchment population ~ 900,000) were divided into four groups: those with neither diabetes nor dementia (reference), with diabetes without dementia, with dementia without diabetes, and with both co-morbidities. In-hospital mortality, length of hospital stay (LoS), and disability outcomes were analysed using logistic regressions. Post-discharge mortality and recurrence were assessed using Cox regressions. Additionally, interaction terms were added to the models for the short-term outcomes and long-term mortality to test for synergistic effects of diabetes and dementia. Models were adjusted for age, sex, Oxfordshire Community Stroke Project classification, comorbidities, hematological and biochemical measures, and antithrombotic medications. Results: The cohort was 10,812 patients with 52% females and a median age of 80. The median follow-up was 3.8 years for stroke recurrence and 5.5 years for mortality. No significant differences between the four groups existed for in-hospital mortality and post-stroke disability. Patients with dementia had significantly longer LoS (OR 2.25 [95% CI: 1.34–3.77] and 1.31 [1.02–1.68] with and without diabetes, respectively). Patients with both comorbidities had the highest risk of stroke recurrence (HR 2.06 [1.12–3.77]), followed by those with only dementia (1.59 [1.15–2.20]) and only diabetes (1.25 [1.06–1.49]). Similarly, the patient group with both diabetes and dementia had the highest long-term mortality risk (1.76 [1.33–2.37]). The hazard ratios for patients with only dementia and only diabetes were 1.71 [1.46–2.01] and 1.19 [1.08–1.32], respectively. No significant interactions were seen between diabetes and dementia with regards to their effects on the outcomes. Conclusion: Individual and cumulative impacts of the two conditions on long-term mortality and stroke recurrence were notable. However, no synergistic impact of the two comorbidities were seen on the stroke outcomes tested in our study. Therefore, tailoring the management of stroke patients based on additional requirements associated with each pre-existing condition will be more impactful towards improving outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Evidence-based blood pressure (BP) targets in acute ischaemic stroke are lacking. Previous observational studies have focused on single baseline BP and clinical outcomes, without consideration for dynamic changes. We aim to determine the association between BP parameters including variability, peak, nadir, median and mean during stroke and infarct growth (primary outcome), risk of haemorrhagic transformation, and functional outcome (secondary outcomes). Methods: Suspected stroke patients were prospectively recruited from a single comprehensive stroke centre. Multimodal computed tomography imaging was used to define infarct core. BP was recorded as per national stroke guidelines during the initial 24 h. Infarct growth and evidence of parenchymal haemorrhage were determined by follow-up magnetic resonance imaging at 24 h. Functional outcome at 3 months was assessed using the modified Rankin Scale. Subgroup analysis was performed according to stroke aetiology and treatment for the association between BP, infarct volume growth, and risk of haemorrhagic transformation. The association between BP parameters and outcomes were determined using regression modelling. Results: A total of 229 patients were included in this study. The median age was 67.4, 64.4% were male, and the baseline National Institutes of Health Stroke Scale was 8. BP variability (BPV) was independently associated with increased infarct growth (multivariate coefficient 1.60, 95% CI: 0.27–2.94, p = 0.19) and an increased odds of parenchymal haemorrhage (adjusted OR 1.21, 95% CI: 1.02–1.44, p = 0.028). The odds of a favourable outcome at 90 days were inversely associated with BPV on simple, but not adjusted logistic regression. On subgroup analysis, only in patients with large vessel occlusions, undergoing endovascular clot retrieval, was BPV associated with infarct growth (multivariate-adjusted coefficient 2.62, 95% CI: 0.53–4.70, p = 0.014) and an increased odds of haemorrhagic transformation (adjusted OR 1.26, 95% CI: 1.01–1.57, p = 0.045). Conclusion: An increase in BPV was associated with infarct expansion, increased risk of haemorrhagic transformation and was negatively associated with favourable functional outcomes at 3 months. [ABSTRACT FROM AUTHOR]

Background and purpose: The ratio of serum uric acid (SUA) to serum creatinine (SCr), representing normalized SUA for renal function, is associated with functional outcome in acute ischaemic stroke (AIS) patients. However, its effect on AIS patients undergoing mechanical thrombectomy (MT) remains unknown. This study aimed to investigate the influence of the SUA/SCr ratio on clinical outcome in MT‐treated AIS patients. Methods: Acute ischaemic stroke patients who underwent MT were continuously enrolled from January 2018 to June 2023. Upon admission, SUA and SCr levels were recorded within the initial 24 h. Stroke severity was determined using the National Institutes of Health Stroke Scale (NIHSS) score. Clinical outcome included poor functional outcome (modified Rankin Scale score >2) at 90 days, symptomatic intracranial haemorrhage and death. Results: Amongst 734 patients, 432 (58.8%) exhibited poor functional outcome at 90 days. The SUA/SCr ratio exhibited a negative correlation with NIHSS score (ρ = −0.095, p = 0.010). Univariate analysis revealed a significant association between SUA/SCr ratio and poor functional outcome. After adjusting for confounders, the SUA/SCr ratio remained an independent predictor of functional outcome (adjusted odds ratio 0.348, 95% confidence interval 0.282–0.428, p < 0.001). Receiver operating characteristic curve analysis highlighted the ability of the SUA/SCr ratio to predict functional outcome, with a cutoff value of 3.62 and an area under the curve of 0.757 (95% confidence interval 0.724–0.788, p < 0.001). Conclusion: The SUA/SCr ratio is correlated with stroke severity and may serve as a predictor of 90‐day functional outcome in AIS patients undergoing MT. [ABSTRACT FROM AUTHOR]

Introduction: A consensus on the management of anticoagulated patients in the acute phase of ischaemic stroke has not yet been established. We aimed to evaluate clinical outcomes in such patients based on the continuation or discontinuation of anticoagulation. Methods: Retrospective study of patients with acute ischaemic stroke and cardioembolic source receiving anticoagulant therapy is done. Patients were classified based on the continuation or discontinuation of anticoagulation at admission. Clinical outcomes, haemorrhagic and ischaemic events were assessed. Multivariate logistic regression analysis, propensity score matching (PSM) analysis and a sub-analysis of patients with severe ischaemic stroke at admission (NIHSS score ≥ 15) were performed. Results: Anticoagulation was continued in 147 (78.8%) of 186 patients. Patients continuing anticoagulant had lower NIHSS (median 5 vs 18, p < 0.001). There were no differences in haemorrhagic or ischaemic events. In the multivariate analysis, good functional outcome at discharge was higher in the continuation group, OR (CI95%) 3.77 (1.2–11.2). PSM analysis adjusted for potential confounders such as NIHSS had higher rates of good functional outcomes at discharge (80% vs 36%, p = 0.004) and at 90 days (76% vs 44%, p = 0.042) in the continuation group. Patients with severe stroke in this group had lower 90-day mortality (34.6% vs 62.5%, p = 0.045) and higher rates of good clinical outcome at discharge (33.3% vs 8.3%, p = 0.032). No differences were observed in 90-day haemorrhagic or ischaemic events. Conclusion: Continuation of anticoagulation in patients with acute ischaemic stroke and cardioembolic source did not increase the risk of intracranial haemorrhage and may be associated with better functional outcomes. [ABSTRACT FROM AUTHOR]

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Aim of study. To assess outcomes of mechanical thrombectomy (MT) in nonagenarians suffering from acute ischaemic stroke (AIS) in a 1-year follow-up. Clinical rationale for study. Age is a factor associated with both the occurrence of AIS and a poorer prognosis. As the population ages, the prevalence of AIS among the very old (90 and older) is expected to rise. Data on long-term outcomes of MT, being the optimal treatment of AIS caused by large vessel occlusions, is scarce in the population of nonagenarians. Material and methods. We analysed all AIS patients treated with MT in a single Comprehensive Stroke Centre. We compared two subgroups: nonagenarians (people aged 90-99) and controls (< 90 years) in terms of cardiovascular risk factors profile, stroke severity, treatment course, presence of in-hospital complications, and outcomes (mortality and good functional outcome defined as modified Rankin Scale ≤ 2) at discharge and at 90- and 365-day follow-ups. Results. Nonagenarians were more commonly female and suffering from atrial fibrillation. They more often developed urinary tract infection during hospitalisation. Stroke severity, treatment course and in-hospital outcomes were comparable between the groups. Nonagenarians had non-significantly higher 90-day and 365-day mortality, and a significantly lower rate of good functional outcomes after 90 days (25.0% vs 57.7%, p = 0.011) and 365 days (31.5% vs 61.0%, p = 0.020). Conclusions and clinical implications. Despite worse outcomes than in younger patients, 25% of nonagenarians were functionally independent three months after MT, and almost one in three of them were so a year after the procedure, thereby showing the benefits of the treatment in this group. [ABSTRACT FROM AUTHOR]

Background and purpose: The efficacy of intravenous thrombolysis (IVT) in patients with acute minor ischaemic stroke (AMIS) remains unclear. We performed a meta-analysis to compare the efficacy and safety of IVT and dual antiplatelet therapy (DAPT) in patients with AMIS. Methods: The Embase, Cochrane Library, PubMed, and Web of Science databases were searched up to 10 October, 2023. Prospective and retrospective studies comparing the clinical outcomes of IVT and DAPT were included. Odds ratios (ORs) and 95% confidence intervals (CIs) for early neurological deterioration (END), excellent and favourable functional outcomes, recurrent ischaemic stroke at 3months, mortality at 3 months, and symptomatic intracranial haemorrhage (ICH) were pooled using a random-effects model. Results: Of the five included studies, 6,340 patients were included. In patients with AMIS, IVT was not significantly associated with excellent and favourable functional outcomes, recurrent ischaemic stroke, or all-cause mortality at 3 months compared to early DAPT. However, a higher risk of symptomatic ICH (OR, 9.31; 95% CI, 3.39-25.57) and END (OR, 2.75; 95% CI, 1.76-4.30) were observed with IVT. Conclusion: This meta-analysis indicated that IVT was not superior to DAPT in patients with AMIS, especially in those with nondisabling AIS. However, these findings should be interpreted with caution and have some limitations. Further, well-designed randomised controlled trials are warranted. [ABSTRACT FROM AUTHOR]

Objective: Whether the efficacy of combined stent retriever and contact aspiration (S + A) is superior to stent retriever (S) alone for revascularisation in patients with large vessel occlusive stroke remains uncertain. The aim of this meta-analysis was to assess the safety and efficacy of combined stent retriever and contact aspiration for the treatment of acute ischaemic stroke with large vessel occlusion by comparing it with stent retriever alone. Methods: We systematically searched the PubMed, Embase, Web of Science, and The Cochrane Library databases for randomised controlled trials and observational studies (case-control and cohort studies) published before 1 October 2023 comparing the efficacy of combined stent retriever and contact aspiration versus tent retriever alone in patients with large vessel occlusive stroke. The end point of the primary efficacy observed in this meta-analysis study was the rate of first pass nearly complete or complete recanalisation (mTICI 2c-3). Secondary effectiveness nodes were: rate of first pass successful recanalisation (mTICI 2b-3), rate of near-complete or complete recanalisation of the postoperative vessel, rate of successful recanalisation of the postoperative vessel, and MRS 0--2 within 90 days. Safety endpoints were interoperative embolism, symptomatic intracranial haemorrhage, and mortality within 90 days. Results: A total of 16 studies were included in the literature for this metaanalysis, with a total of 7,320 patients (S + C group: 3,406, S group: 3,914). A comprehensive analysis of the included literature showed that combined stent retriever and contact aspiration had a higher rate of near-complete or complete recanalisation of the postoperative vessel [OR = 1.53, 95% CI (1.24, 1.88), p < 0.0001] and rate of successful recanalisation of the postoperative vessel compared to stent retriever alone [OR = 1.83, 95% CI (1.55, 2.17), p < 0.00001]; there were no statistically significant differences between the two groups in terms of the rate of first pass nearly complete or complete recanalisation [OR = 1.00, 95% CI (0.83, 1.19), p = 0.96], rate of first pass successful recanalisation [OR = 1.02, 95% CI (0.85, 1.24), p = 0.81], interoperative embolism [OR = 0.93, 95% CI (0.72, 1.20), p = 0.56], symptomatic intracranial haemorrhage [OR = 1.14, 95% CI (0.87, 1.48), p = 0.33], MRS 0--2 within 90 days [OR = 0.89, 95% CI (0.76, 1.04), p = 0.14] and mortality within 90 days [OR = 1.11, 95% CI (0.94, 1.31), p = 0.22]. Conclusion: Combined stent retriever and contact aspiration has a higher rate of postprocedural revascularisation (mTICI 2c-3/mTICI 2b-3) compared with stent retriever alone in patients with large vessel occlusion stroke. In addition, it was not superior to stenting alone in terms of the rate of first pass recanalisation (mTICI 2c-3/mTICI 2b-3), interoperative embolisation, symptomatic intracranial haemorrhage, good functional prognosis within 90 days and mortality within 90 days. [ABSTRACT FROM AUTHOR]

Aim Methods Results Conclusion This study explored the impact of different care modes on the outcome of hospitalized patients with acute ischaemic stroke (AIS) during hospitalization and 3 months after discharge.This was a prospective cohort study comparing the outcomes at hospitalization, at discharge, and at 3 months post discharge among AIS patients with different caregiving arrangements from 9, December 2022 to 20, August 2023. The general information questionnaire, Modified Barthel Index, Shortened General Comfort Questionnaire, Perceived Social Support scale, Herth Hope Index, modified Rankin scale and EQ‐5D‐5L were utilized for the investigation.The psychological evaluation scores during hospitalization, including comfort, perceived social support, and hope, did not significantly differ between the two groups of AIS patients (p > .05). Moreover, there were no significant impacts observed in terms of length of stay (LOS) at the hospital or hospitalization expense (p > .05). The proportion of patients with intact functionality was greater in the family caregiver group 3 months after discharge (16.5%). However, when stratified based on prognosis, the difference in outcomes between the two groups of patients did not reach statistical significance (p > .05). The analysis of ADL, quality of life and stroke recurrence in 276 surviving ischaemic stroke patients 3 months post discharge indicated no differences between the two groups across all three aspects (p > .05).Older and divorced or widowed AIS patients tend to prefer professional caregivers. The psychological state during hospitalization, length of hospital stay and hospitalization expenses are not influenced by the caregiving model. Three months post discharge, a greater proportion of patients in the family caregiving group had intact mRS functionality, but this choice did not impact patient prognosis, stroke recurrence, quality of life or independence in ADL. [ABSTRACT FROM AUTHOR]

Acute ischaemic stroke (AIS) is a debilitating disease for which effective therapies are now available. Effective identification of candidates for therapy relies heavily on noninvasive imaging that must be interpreted accurately in a short timeframe. This review summarizes the evolution of AIS therapies and the implications for noninvasive imaging. The review concludes with consideration of longstanding assumptions about imaging of ischaemic stroke and potential paradigm shifts on the horizon. [ABSTRACT FROM AUTHOR]

In this study, we investigated the potential involvement of TNFSF9 in reperfusion injury associated with ferroptosis in acute ischaemic stroke patients, mouse models and BV2 microglia. We first examined TNFSF9 changes in peripheral blood from stroke patients with successful reperfusion, and constructed oxygen–glucose deprivation–reperfusion (OGD‐R) on BV2 microglia, oxygen–glucose deprivation for 6 h followed by reoxygenation and re‐glucose for 24 h, and appropriate over‐expression or knockdown of TNFSF9 manipulation on BV2 cells and found that in the case of BV2 cells encountering OGD‐R over‐expression of TNFSF9 resulted in increased BV2 apoptosis. Still, the knockdown of TNFSF9 ameliorated apoptosis and ferroptosis. In an in vivo experiment, we constructed TNFSF9 over‐expression or knockout mice by intracerebral injection of TNFSF9‐OE or sh‐TNFSF9 adenovirus. We performed the middle cerebral artery occlusion (MCAO) model on day four, 24 h after ligation of the proximal artery, for half an hour to recanalize. As luck would have it, over‐expression of TNFSF9 resulted in increased brain infarct volumes, neurological function scores and abnormalities in TNFSF9‐related TRAF1 and ferroptosis‐related pathways, but knockdown of TNFSF9 improved brain infarcts in mice as well as reversing TNFSF9‐related signalling pathways. In conclusion, our data provide the first evidence that TNFSF9 triggers microglia activation by activating the ferroptosis signalling pathway following ischaemic stroke, leading to brain injury and neurological deficits. [ABSTRACT FROM AUTHOR]

Background and Aims: In recent years, there has been a growing interest in factor XIII in ischaemic stroke. The study's main aim was to assess the usefulness of factor XIII concentration determination in patients with acute ischaemic stroke (AIS) treated with thrombolysis with recombinant tissue plasminogen activator (t-PA). Methods: The study was conducted in two groups of 84 patients with AIS: group I—with thrombolytic therapy and group II—without thrombolysis. A physical examination, neurological status (using the National Institutes of Health Stroke Scale, NIHSS), daily patients' activities measured with the Barthel Index and Modified Rankin Scale (mRS), and blood parameters were conducted on day 1 and day 7. The following parameters were assessed: highly sensitive C-reaction protein (CRP), fibrinogen, D-dimers (DD), neutrophil–lymphocyte ratio (NLR index), and the concentration of factor XIII-A. Results: In group I, the concentration of XIII-A decreased significantly between day 1 and 7 (p < 0.001). In group I, the concentration of XIII-A on day 7 in Total Anterior Circulation Infarct (TACI) was significantly lower than in non-TACI stroke. XIII-A concentration in group I was significantly lower in patients < 31 points with Acute Stroke Registry and Analysis of Lausanne (ASTRAL). A greater decrease in XIII-A between the first sampling on day 1 and the second sampling on day 7 was associated with a worse patient neurological state in group I. Conclusions: In patients with AIS treated with t-PA, factor XIII concentrations decrease in the acute phase of stroke, and the largest decrease occurs in the TACI stroke. Determination of factor XIII concentration in patients with AIS can be used in clinical practice as an additional parameter supporting the assessment of stroke severity and may play a role in the prognosis; lower factor XIII-A activity may be a predictor of a worse prognosis. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to determine the incidence of pressure ulcers (PUs) in patients treated for acute ischaemic stroke (AIS) and to evaluate comorbid/confounding factors. Method: The study included patients treated for AIS who were divided into three treatment groups: those receiving intravenous tissue plasminogen activator therapy (tPA); patients receiving mechanical thrombectomy (MT); and those receiving both tPA and MT. PUs were classified according to the international classification system and factors that may influence their development were investigated. Results: A total of 242 patients were included in this study. The incidence of PUs in patients treated for AIS was 7.4%. Most PUs were located on the sacrum (3.7%), followed by the gluteus (3.3%) and trochanter (2.9%). With regards to PU classification: 29% were stage I; 34% were stage II; and the remainder were stage III. Age was not a significant factor in the development of PUs (p=0.172). Patients in the tPA group had a lower PU incidence (2.3%) than patients in the tPA+MT group (15.7%) and MT group (12.1%) (p=0.001). Patients with PUs had a longer period of hospitalisation (18.5±11.92 days) than patients without a PU (8.0±8.52 days) (p=0.000). National Institute of Health Stroke Scale (NIHSS) scores at admission were higher in patients with PUs than in patients without a PU (14.33±4.38 versus 11.08±5.68, respectively; p=0.010). The difference in presence of comorbidities between patients with and without PUs (p=0.922) and between treatment groups (p=0.677) were not statistically significant. The incidence of PUs was higher in patients requiring intensive care, but this difference was not statistically significant (p=0.089). Conclusion: In this study, patients treated for AIS with high NIHSS scores at admission and/or receiving MT were at higher risk for PUs, and so particular attention should be given to these patients in order to prevent PU development. [ABSTRACT FROM AUTHOR]

Background and Aims: In recent years, there has been a growing interest in factor XIII in ischaemic stroke. The study’s main aim was to assess the usefulness of factor XIII concentration determination in patients with acute ischaemic stroke (AIS) treated with thrombolysis with recombinant tissue plasminogen activator (t-PA). Methods: The study was conducted in two groups of 84 patients with AIS: group I—with thrombolytic therapy and group II—without thrombolysis. A physical examination, neurological status (using the National Institutes of Health Stroke Scale, NIHSS), daily patients’ activities measured with the Barthel Index and Modified Rankin Scale (mRS), and blood parameters were conducted on day 1 and day 7. The following parameters were assessed: highly sensitive C-reaction protein (CRP), fibrinogen, D-dimers (DD), neutrophil–lymphocyte ratio (NLR index), and the concentration of factor XIII-A. Results: In group I, the concentration of XIII-A decreased significantly between day 1 and 7 (p < 0.001). In group I, the concentration of XIII-A on day 7 in Total Anterior Circulation Infarct (TACI) was significantly lower than in non-TACI stroke. XIII-A concentration in group I was significantly lower in patients < 31 points with Acute Stroke Registry and Analysis of Lausanne (ASTRAL). A greater decrease in XIII-A between the first sampling on day 1 and the second sampling on day 7 was associated with a worse patient neurological state in group I. Conclusions: In patients with AIS treated with t-PA, factor XIII concentrations decrease in the acute phase of stroke, and the largest decrease occurs in the TACI stroke. Determination of factor XIII concentration in patients with AIS can be used in clinical practice as an additional parameter supporting the assessment of stroke severity and may play a role in the prognosis; lower factor XIII-A activity may be a predictor of a worse prognosis.

Aim Methods Results Conclusions Patients with acute ischaemic stroke are more likely to develop refeeding syndrome due to increased need for nutritional support when suffering alterations of consciousness and impairment of swallowing. This study aimed to evaluate the incidence, risk factors and outcomes of refeeding syndrome in stroke patients.This was a retrospective observational study, using the prospective stroke database from hospital, included all consecutive acute ischaemic stroke patients who received enteral nutrition for more than 72 h from 1 January 2020 and 31 December 2022. Refeeding syndrome was defined as occurrence of new‐onset hypophosphataemia within 72 h after enteral feeding. Multiple logistic regression analysis was conducted to evaluate risk factors and relationships between refeeding syndrome and stroke outcomes.338 patients were included in the study. 50 patients (14.8%) developed refeeding syndrome. Higher scores on National Institutes of Health Stroke Scale and Nutritional Risk Screening 2002, albumin <30 g/L and BMI <18.5 kg/m2 were risk factors for refeeding syndrome. Moreover, refeeding syndrome was independently associated with a 3‐month modified Rankin Scale score of >2 and 6‐month mortality.Refeeding syndrome was common in stroke patients and higher baseline National Institutes of Health Stroke Scale, higher Nutritional Risk Screening 2002, albumin <30 g/L and BMI <18.5 kg/m2 were independent risk factors of refeeding syndrome. Occurrence of refeeding syndrome was significantly associated with higher 3‐month modified Rankin Scale and 6‐month mortality. [ABSTRACT FROM AUTHOR]

Introduction: Tissue at risk, as estimated by CT perfusion utilizing Tmax+6, correlates with final infarct volume (FIV) in acute ischaemic stroke (AIS) without reperfusion. Tmax thresholds are derived from Western ethnic populations but not from ethnic Asian populations. We aimed to investigate the influence of ethnicity on Tmax thresholds. Methods: From a clinical-imaging registry of Australian and Indonesian stroke patients, we selected a participant subgroup with the following inclusion criteria: AIS under 24 h and absence of reperfusion therapy. Clinical data included demographics, time metrics, stroke severity, pre-morbid, and 3-month Modified Rankin Score. Baseline computed tomography perfusion and MRI <72 h were performed. Volumes of Tmax utilizing different thresholds and FIVs were calculated. Spearman correlation was used to evaluate relationship involving ordinal variables and calculate the optimal Tmax threshold against FIV in both populations. Results: Two hundred patients were included in the study sample, 100 in Jakarta and 100 in Geelong. The median National Institutes of Health Stroke Scale (IQR) were 6 (3–11) and 3 (1–5), respectively. The median Tmax+6 (IQR) was 0 (0–46.5) in Jakarta group and 0 (0–7.5) in Geelong group. The median FIV (IQR) was 0 (0–30.5) and 0 (0–5.5). Tmax+8 s in Jakarta population against FIV showed Spearman's coefficient ρ = 0.72, representing the optimal Tmax threshold. Tmax+6 s showed Spearman's coefficient ρ = 0.51 against FIV in the Geelong population. Conclusion: Tmax thresholds approximating FIV were possibly different in the Asian when compared with the non-Asian populations. Future studies are required to extend and confirm the validity of our findings. [ABSTRACT FROM AUTHOR]

Blocking Transient Receptor Potential Melastatin 4 (TRPM4) in rodents by our antibody M4P has shown to attenuate cerebral ischaemia-reperfusion injury. Since M4P does not interact with human TRPM4, the therapeutic potential of blocking human TRPM4 remains unclear. We developed a monoclonal antibody M4M that inhibited human TRPM4 in cultured cells. However, M4M has no effect on stroke outcome in wild-type rats. Therefore, M4M needs to be evaluated on animal models expressing human TRPM4. We generated a humanised rat model using the CRISPR/Cas technique to knock-in (KI) the human TRPM4 antigen sequence. In primary neurons from human TRPM4 KI rats, M4M binds to hypoxic neurons, but not normoxic nor wild-type neurons. Electrophysiological studies showed that M4M blocked ATP depletion-induced activation of TRPM4 and inhibited hypoxia-associated cell volume increase. In a stroke model, administration of M4M reduced infarct volume in KI rats. Rotarod test and Neurological deficit score revealed improvement following M4M treatment. M4M selectively binds and inhibits hypoxia-induced human TRPM4 channel activation in neurons from the humanised rat model, with no effect on healthy neurons. Use of M4M in stroke rats showed functional improvements, suggesting the potential for anti-human TRPM4 antibodies in treating acute ischaemic stroke patients. [ABSTRACT FROM AUTHOR]

Background: Traditionally, non-contrast computed tomography (CT) alone was used in the initial assessment of acute ischaemic stroke patients mainly to exclude haemorrhage or alternative pathology. Summary: Late-window (beyond 6 h) and recent large-volume endovascular mechanical thrombectomy (MT) trials integrated CT perfusion (CTP) imaging to guide MT and/or intravenous thrombolysis decision-making in stroke patients. Key Messages: In current clinical practice, many patients are being excluded from reperfusion therapy due to a lack of data from urgent investigations to assess cerebral vasculature and perfusion. Here, we explore the potential benefits of CTP incorporated into the initial CT protocol assessment of stroke patients. [ABSTRACT FROM AUTHOR]

Introduction. This study aimed to identify predictors of 90-day good functional outcome (GFO) in patients with acute ischaemic stroke (AIS) who were treated with mechanical thrombectomy but did not achieve a delayed neurological improvement (DNI). Introduction. This study aimed to identify predictors of 90-day good functional outcome (GFO) in patients with acute ischaemic stroke (AIS) who were treated with mechanical thrombectomy but did not achieve a delayed neurological improvement (DNI). Material and methods. This single-centre retrospective study involved 307 patients with anterior circulation AIS treated with mechanical thrombectomy. Multiple clinical, biochemical, radiological, and treatment-related variables were collected and analysed. DNI on day 7 was defined as at least a 10-point reduction in the National Institutes of Health Stroke Scale (NIHSS) score or NIHSS score < 2. GFO on day 90 was defined as a modified Rankin Scale (mRS) score ≤ 2. We compared the characteristics of patients with and without DNI, with special attention paid to patients who achieved 90-GFO despite a lack of DNI. Multivariate analyses were then performed to establish independent predictors of 90-day GFO among patients without DNI. Results. DNI occurred in 150 out of 307 patients (48.7%) and significantly increased the odds for 90-day GFO (odds ratio [OR]: 13.99; p < 0.001). Among patients without DNI, 41.4% achieved 90-day GFO. Younger age (OR: 0.96; 95% confidence interval [CI]: 0.93-0.99; p = 0.008), lower baseline NIHSS score (OR: 0.80; 95% CI: 0.73-0.89; p < 0.001), treatment with intravenous thrombolysis (OR: 3.06; 95% CI: 1.25-7.49; p = 0.014), lack of an undetermined aetiology (OR: 0.40; 95% CI: 0.16-0.998; p = 0.050), lack of pneumonia (OR: 0.08; 95% CI: 0.02-0.31; p < 0.001), and higher haemoglobin concentration on admission (OR: 1.31; 95% CI: 1.04-1.69; p = 0.024) were identified as predictors of 90-day GFO in this subgroup. Conclusion. Almost half of patients with AIS in anterior circulation treated with mechanical thrombectomy experience DNI, which is a good predictor of 90-day GFO. Furthermore, 40% of patients without DNI achieve 90-day GFO which can be independently predicted by younger age, lower baseline NIHSS score, treatment with intravenous thrombolysis, higher haemoglobin concentration on admission, lack of undetermined ischaemic stroke aetiology, and lack of pneumonia. [ABSTRACT FROM AUTHOR]

Summary: Background: Endovascular therapy (EVT) was demonstrated effective in acute large vessel occlusion (LVO) with large infarction. Revealing subgroups of patients who would or would not benefit from EVT will further inform patient selection for EVT. Methods: This post-hoc analysis of the ANGEL-ASPECT trial, a randomised controlled trial of 456 adult patients with acute anterior-circulation LVO and large infarction, defined by ASPECTS 3–5 or infarct core volume 70–100 mL, enrolled from 46 centres across China, between October 2, 2020 and May 18, 2022. Patients were randomly assigned (1:1) to receiving EVT and medical management or medical management alone. One patient withdrew consent, 455 patients were included in this post-hoc analysis and categorised into 4 subgroups by lower or higher NIHSS (< or ≥16) and smaller or larger infarct core (< or ≥70 mL). Those with lower NIHSS & smaller core, and higher NIHSS & larger core were considered clinical-radiological matched subgroups; otherwise clinical-radiological mismatched subgroups. Primary outcome was 90-day modified Rankin Scale (mRS). ANGEL-ASPECT is registered with ClinicalTrials.gov, NCT04551664. Findings: Overall, 139 (30.5%) patients had lower NIHSS & smaller core, 106 (23.3%) higher NIHSS & larger core, 130 (28.6%) higher NIHSS & smaller core, and 80 (17.6%) lower NIHSS & larger core. There was significant ordinal shift in the 90-day mRS toward a better outcome with EVT in clinical-radiological matched subgroups: lower NIHSS & smaller core (generalised OR, 1.76; 95% CI, 1.18–2.62; p = 0.01) and higher NIHSS & larger core (1.64; 1.06–2.54; 0.01); but not in the two clinical-radiological mismatched subgroups. Interpretation: Our findings suggested that in patients with anterior-circulation LVO and large infarction, EVT was associated with improved 90-day functional outcomes in those with matched clinical and radiological severities, but not in those with mismatched clinical and radiological severities. Simultaneous consideration of stroke severity and infarct core volume may inform patient selection for EVT. Funding: Unrestricted grants from industry [Covidien Healthcare International Trading (Shanghai), Johnson & Johnson MedTech, Genesis MedTech (Shanghai), and Shanghai HeartCare Medical Technology].

Abstract Objective This study aims to evaluate the efficacy and safety of adjunctive hyperbaric oxygen therapy (HBOT) in acute ischaemic stroke (AIS) based on existing evidence. Methods We conducted a comprehensive search through April 15, 2023, of seven major databases for randomized controlled trials (RCTs) comparing adjunctive hyperbaric HBOT with non-HBOT (no HBOT or sham HBOT) treatments for AIS. Data extraction and assessment were independently performed by two researchers. The quality of included studies was evaluated using the tool provided by the Cochrane Collaboration. Meta-analysis was conducted using Rev Man 5.3. Results A total of 8 studies involving 493 patients were included. The meta-analysis showed no statistically significant differences between HBOT and the control group in terms of NIHSS score (MD = -1.41, 95%CI = -7.41 to 4.58), Barthel index (MD = 8.85, 95%CI = -5.84 to 23.54), TNF-α (MD = -5.78, 95%CI = -19.93 to 8.36), sICAM (MD = -308.47, 95%CI = -844.13 to 13227.19), sVCAM (MD = -122.84, 95%CI = -728.26 to 482.58), sE-selectin (MD = 0.11, 95%CI = -21.86 to 22.08), CRP (MD = -5.76, 95%CI = -15.02 to 3.51), adverse event incidence within ≤ 6 months of follow-up (OR = 0.98, 95%CI = 0.25 to 3.79). However, HBOT showed significant improvement in modified Rankin score (MD = 0.10, 95%CI = 0.03 to 0.17), and adverse event incidence at the end of treatment (OR = 0.42, 95%CI = 0.19 to 0.94) compared to the control group. Conclusion While our findings do not support the routine use of HBOT for improving clinical outcomes in AIS, further research is needed to explore its potential efficacy within specific therapeutic windows and for different cerebral occlusion scenarios. Therefore, the possibility of HBOT offering clinical benefits for AIS cannot be entirely ruled out.

Fifteen to 20% of patients with an acute ischaemic stroke have a tandem lesion defined by the combination of an intracranial large vessel thrombo-embolic occlusion and a high grade stenosis or occlusion of the ipsilateral internal carotid artery. These patients tend to have worse outcomes than patients with isolated intracranial occlusions, with higher rates of disability and death. The introduction of endovascular thrombectomy to treat the intracranial lesion clearly improved the outcome compared with treatment with intravenous thrombolysis alone. However, the best treatment strategy for managing the extracranial carotid artery lesion in patients with tandem lesions remains unknown. Current guidelines recommend carotid endarterectomy for patients with transient ischaemic attack or non-disabling stroke and moderate or severe stenosis of the internal carotid artery, within two weeks of the initial event, to prevent major stroke recurrence and death. Alternatively, the symptomatic carotid artery could be treated by endovascular placement of a stent during endovascular thrombectomy (EVT). This would negate the need for a second procedure, immediately reduce the risk of stroke recurrence, increase patient satisfaction, and could be cost effective. However, the administration of dual antiplatelet therapy could potentially increase the risk of symptomatic intracranial haemorrhage in patients with acute ischaemic stroke. Randomised controlled trials evaluating the efficacy and safety of immediate carotid artery stenting during EVT in acute stroke patients with tandem lesions are currently ongoing and will impact the current guidelines regarding the treatment of patients with acute ischaemic stroke due to these tandem lesions.

Introduction: In acute stroke, identifying early changes (parenchymal hypodensity) on non-contrast CT (NCCT) can be challenging. We aimed to identify whether the accuracy of clinicians in detecting acute hypodensity in ischaemic stroke patients on a non-contrast CT is improved with the use of an Artificial Intelligence (AI) based, automated hypodensity detection algorithm (HDT) using MRI-DWI as the gold standard. Methods: The study employed a case-crossover within-clinician design, where 32 clinicians were tasked with identifying hypodensity lesions on NCCT scans for five a priori selected patient cases, before and after viewing the AI-based HDT. The DICE similarity coefficient (DICE score) was the primary measure of accuracy. Statistical analysis compared DICE scores with and without AI-based HDT using mixed-effects linear regression, with individual NCCT scans and clinicians as nested random effects. Results: The AI-based HDT had a mean DICE score of 0.62 for detecting hypodensity across all NCCT scans. Clinicians' overall mean DICE score was 0.33 (SD 0.31) before AI-based HDT implementation and 0.40 (SD 0.27) after implementation. AI-based HDT use was associated with an increase of 0.07 (95% CI: 0.02-0.11, p = 0.003) in DICE score accounting for individual scan and clinician effects. For scans with small lesions, clinicians achieved a mean increase in DICE score of 0.08 (95% CI: 0.02, 0.13, p = 0.004) following AI-based HDT use. In a subgroup of 15 trainees, DICE score improved with AI-based HDT implementation [mean difference in DICE 0.09 (95% CI: 0.03, 0.14, p = 0.004)]. Discussion: AI-based automated hypodensity detection has potential to enhance clinician accuracy of detecting hypodensity in acute stroke diagnosis, especially for smaller lesions, and notably for less experienced clinicians. [ABSTRACT FROM AUTHOR]

Objective: This study aims to evaluate the efficacy and safety of adjunctive hyperbaric oxygen therapy (HBOT) in acute ischaemic stroke (AIS) based on existing evidence. Methods: We conducted a comprehensive search through April 15, 2023, of seven major databases for randomized controlled trials (RCTs) comparing adjunctive hyperbaric HBOT with non-HBOT (no HBOT or sham HBOT) treatments for AIS. Data extraction and assessment were independently performed by two researchers. The quality of included studies was evaluated using the tool provided by the Cochrane Collaboration. Meta-analysis was conducted using Rev Man 5.3. Results: A total of 8 studies involving 493 patients were included. The meta-analysis showed no statistically significant differences between HBOT and the control group in terms of NIHSS score (MD = -1.41, 95%CI = -7.41 to 4.58), Barthel index (MD = 8.85, 95%CI = -5.84 to 23.54), TNF-α (MD = -5.78, 95%CI = -19.93 to 8.36), sICAM (MD = -308.47, 95%CI = -844.13 to 13227.19), sVCAM (MD = -122.84, 95%CI = -728.26 to 482.58), sE-selectin (MD = 0.11, 95%CI = -21.86 to 22.08), CRP (MD = -5.76, 95%CI = -15.02 to 3.51), adverse event incidence within ≤ 6 months of follow-up (OR = 0.98, 95%CI = 0.25 to 3.79). However, HBOT showed significant improvement in modified Rankin score (MD = 0.10, 95%CI = 0.03 to 0.17), and adverse event incidence at the end of treatment (OR = 0.42, 95%CI = 0.19 to 0.94) compared to the control group. Conclusion: While our findings do not support the routine use of HBOT for improving clinical outcomes in AIS, further research is needed to explore its potential efficacy within specific therapeutic windows and for different cerebral occlusion scenarios. Therefore, the possibility of HBOT offering clinical benefits for AIS cannot be entirely ruled out. [ABSTRACT FROM AUTHOR]

Background Antithrombotic therapy in acute patients with both high ischaemic and bleeding risks remains challenging. Case summary We presented a challenging case involving a 48-year-old man referred to our hospital for headache and a left superior quadrantanopia. A CT scan revealed a right inferior occipital lobe ischaemic stroke. During the hospital stay, the patients developed pulmonary embolism (PE), and ST-elevation myocardial infarction (STEMI). A triple antithrombotic therapy was indicated, but the patient presented with high bleeding (anaemia, active malignancy, ischaemic stroke) and ischaemic (ischaemic stroke, PE, and superimposed STEMI) risks. In this critical acute setting, prolonged cangrelor infusion of reduced dosage, coupled with aspirin and enoxaparin, proved an effective and safe antithrombotic approach. Discussion Prolonged cangrelor bridging at a reduced dose of 0.75 μg/kg/min may represent an effective and safe option in acute patients requiring P2Y12 inhibition and presenting both high ischaemic and high bleeding risks. [ABSTRACT FROM AUTHOR]

Stroke, a neurovascular disorder, is one of the main causes of mortality and disability worldwide. There are several mechanisms of stroke, with inflammatory response being a key factor, with previous studies have concluding the involvement of oncostatin M (OSM) in inflammatory response. This review aims to analyze current knowledge to explain the elevation of serum OSM expression in acute ischaemic stroke (AIS). Information was gathered from the PubMed database on landmark studies on the relevance of serum OSM in AIS, and it was concluded that hypoxia and stagnant blood flow, which are involved in the typical pathophysiology of AIS, induced an inflammatory signalling pathway. OSM, a member of cytokine interleukin-6, participates in inflammatory responses in a dual manner: pro-inflammatory and anti-inflammatory. We concluded the elevation of serum OSM level in patients with AIS was due to an inflammatory response triggered by AIS. Cardioembolic stroke, a subtype of AIS, triggered a higher inflammatory substrate response in the circulatory system, explaining why serum OSM elevation is significant compared to other subtypes of acute ischaemic stroke. [ABSTRACT FROM AUTHOR]

Introduction: Patients with cancer (CP) need a different approach to acute ischaemic stroke (AIS) treatment as intravenous thrombolysis (IVT) may be contraindicated. Mechanical thrombectomy (MT) is a treatment of choice for otherwise eligible patients, although the literature on its long-term outcomes in CP is limited. Aim: Assessing outcomes of MT-treated AIS patients with concomitant malignancy in a year-long follow-up. Material and methods: The study included 593 MT-treated AIS patients admitted in 2019–2021. The group was divided into CP (defined as a diagnosis of malignancy and undergoing/qualified for cancer treatment within previous 5 years) and a control group. The profile of cardiovascular risk factors, stroke severity and discharge, 90-day and 365-day outcomes were compared between the groups. Results: CP and controls had a similar profile of cardiovascular risk factors and comparable stroke severity. CP were less frequently treated with IVT (25.7% vs. 59.1%, p < 0.001). There were no differences between the groups in the successful reperfusion rate and occurrence of haemorrhagic complications. Discharge and 90-day outcomes were similar. CP had higher 365-day mortality (48.6% vs. 29.9%, p = 0.024) but the percentage of patients achieving good functional outcome in a year-long observation was comparable. Conclusions: Treatment with MT seems beneficial for AIS patients with concomitant malignancy both in short- and long-term observation. [ABSTRACT FROM AUTHOR]

BACKGROUND: The range of software available to radiologists has increased enormously with the advancement of AI. A good example of this is software to determine ASPECTS in the treatment of potential stroke patients. OBJECTIVE: In this study, two software packages (eASPECTS from Brainomix and VIA_ASPECTS from Siemens) were tested and compared for their performance in the daily clinical routine of a maximum care provider with a 24/7 stroke unit. METHODS: A total of 637 noncontrast CT images were obtained from consecutive patients with suspected stroke, of whom 73 were finally diagnosed with MCA infarction. Differences in agreement and quantification of agreement were analysed, as well as the correlation and sensitivity, specificity and accuracy compared to raters. RESULTS: Compared to VIA_ASPECTS, eASPECTS shows good agreement and strong correlation with the raters. VIA_ASPECTS has lower accuracy and low specificity than eASPECTS but a higher sensitivity. CONCLUSION: Both software products have the potential to be decision support tools for radiologists. There are, however, differences between the two software products in terms of their intended use. [ABSTRACT FROM AUTHOR]

Introduction: Telemedicine can alleviate the problems faced in rural settings in providing access to specialist stroke care. The evidence of the cost-effectiveness of this model of care outside high-income countries is limited. This study aimed to conduct: (a) a systematic review of economic evaluations of telestroke and (b) a cost–utility analysis of telestroke, using China as a case study. Methods: We systematically searched Embase, Medline Complete and Cochrane databases. Inclusion criteria: full economic evaluations of telemedicine/telestroke networks examining the use of thrombolysis in patients with acute ischaemic stroke, published in English. A cost–utility analysis was undertaken using a Markov model incorporating a decision tree to simulate the delivery of telestroke for acute ischaemic stroke in rural China, compared to no telestroke from a societal and healthcare perspective. One-way deterministic sensitivity analyses and probabilistic sensitivity analyses were performed to test the robustness of results. Results: Of 559 publications found, eight met the eligibility criteria and were included in the systematic review (two cost-effectiveness analyses and six cost–utility analyses, all performed in high-income countries). Telestroke was a cost-saving/cost-effective intervention in five out of the eight studies. In our modelled analysis for rural China, telestroke was the dominant strategy, with estimated cost savings of Chinese yuan 4,328 (US$627) and additional 0.0925 quality-adjusted life years per patient. Sensitivity analyses confirmed the base case results. Discussion: Consistent with published economic evaluations of telestroke in other jurisdictions, telestroke represents a cost-effective solution to enhance stroke care in rural China. [ABSTRACT FROM AUTHOR]

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Objective: In the RECO study, we investigated the impact of the operator's choice of stent retriever size on patients with internal carotid artery (ICA) occlusion. Methods: Data from the RECO Registry, a prospective multicentre study, were utilized. Patients who underwent mechanical thrombectomy (MT) were divided according to the size of the stent into the RECO 4 × 20 group, the RECO 5 × 30 group and the RECO 6 × 30 group. The outcome measures assessed in the study were the 3-month modified Rankin Scale (mRS) score, occurrence of any intracranial haemorrhage (aICH), workflow timing, recanalization success rate, number of attempts, and all-cause mortality within a 3-month period. Results: Analysis was conducted on a total of 89 patients with ICA occlusion. RECO 4 × 20, 5 × 30, and 6 × 30 stent retrievers were used in 19 (21.3%), 52 (58.4%), and 18 (20.2%) patients, respectively. The demographic and baseline characteristics showed considerable similarity across the three groups. The puncture-to-recanalization time of the RECO 6 × 30 group [56.5 min (IQR, 41.5–80.8)] was significantly shorter than that of the RECO 4 × 20 group [110 min (IQR, 47–135)]. In 10 out of 18 patients (55.6%), the RECO 6 × 30 stent retriever achieved reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score 2b-3) after the initial attempt, surpassing the rates of 31.6% in the RECO 4 × 20 group and 32.7% in the RECO 5 × 30 group. In the RECO 4 × 20 group, the median number of passes was 2 (IQR, 1–3); in the RECO 5 × 30 group, it was 2 (IQR, 1–3); and in the RECO 6 × 30 groups, it was 1 (IQR, 1–2.5). There were no statistically significant differences observed among the three groups concerning aICH or good outcomes (mRS score 0–2). Conclusion: Our study demonstrated the practical implications of stent-retriever size selection in the context of the MT for ICA occlusion. The routine use of a RECO 6 × 30 stent retriever holds the potential for early revascularization in clinical practice. The significant reduction in the puncture-to-reperfusion time and the greater first-pass effect associated with this stent size underscore its efficiency in treating ICA occlusion.

Immune thrombocytopenia (ITP) is an autoimmune blood disorder characterised by isolated severe thrombocytopenia. Arterial thrombotic events, such as acute ischaemic stroke (AIS), are rare complications. A 56-year-old woman with chronic ITP on eltrombopag and dexamethasone therapy presented to the emergency department due to AIS in the vertebrobasilar territory, and lower abdominal pain. The computed tomography (CT) scan of the head was unremarkable, whereas CT angiography revealed left vertebral artery occlusion. As the platelet count was sufficient, intravenous thrombolysis (IVT) was initiated. However, after 15 min, an anaphylactic reaction occurred, which was appropriately solved. Although the IVT was prematurely stopped, the NIHSS score improved from 7 to 2, and the follow-up head CT scan remained unremarkable. CT angiography of the thoracoabdominal aorta revealed multiple thrombi in the infrarenal aorta, inferior mesenteric artery (IMA), and left renal artery. The abdominal pain subsided after IVT, but recurred within 24 h. Repeated CT angiography showed ischaemia of the descending colon, with persistent IMA occlusion. After the hemicolectomy condition stabilised. Discrete left-sided ataxia and impaired sensation were the only neurological sequelae. We found two articles reporting only three patients with ITP who suffered AIS and were treated with IVT. A favourable outcome was observed in two cases, while one patient suffered an intracranial haemorrhage (ICH) and died. A review of AIS cases with undefined thrombocytopenia treated with IVT reported ICH in up to 6.8% of patients. Our case suggests that IVT for AIS may be effective in patients with ITP. Further data are needed to better clarify this issue.

Abstract Purpose To investigate the predictive role of pre-thrombolytic high sensitivity C-reactive protein (hs-CRP) on the safety and efficacy of intravenous thrombolysis in patients with acute ischemic stroke (AIS). Methods Patients with AIS who underwent intravenous thrombolysis with recombinant plasminogen activator (rtPA) or urokinase without endovascular therapy from June 2019 to June 2022 were retrospectively analysed. All patients were grouped into two groups (high or low hs-CRP group) according to the median value of hs-CRP before intravenous thrombolysis. The baseline NIHSS, NIHSS changes before and after thrombolysis (ΔNIHSS), the rate of good thrombolysis response (NIHSS decreased ≥ 2 points from baseline), the rate of any intracranial hemorrhage, age, sex, hypertension, diabetes, uric acid and platelet count were compared between the two groups. Logistic regression analysis was performed to identify possible prognostic factors for a good thrombolysis response. Results A total of 212 patients were included in the analysis, with a mean age of 66.3 ± 12.5 years. In total, 145 patients received rtPA, and 67 patients received urokinase. Patients were divided into a high hs-CRP group (> 1.60 mg/L) and a low hs-CRP group (≤ 1.60 mg/L) according to the median hs-CRP level (1.60 mg/L). The ΔNIHSS of the high hs-CRP group was significantly smaller than that of the low hs-CRP group (0 [-1 ~ 0] vs. -1 [-2 ~ 0], P 1.60 mg/L was negatively correlated with a good thrombolysis response rate (OR = 0.496, 95% CI = 0.266–0.927, P = 0.028). Conclusion hs-CRP > 1.6 mg/L may serve as a poor prognosis predictive factor for patients with AIS receiving intravenous thrombolysis. However, due to the small sample size of this study, further studies are needed to verify our results.

IntroductionIn acute stroke, identifying early changes (parenchymal hypodensity) on non-contrast CT (NCCT) can be challenging. We aimed to identify whether the accuracy of clinicians in detecting acute hypodensity in ischaemic stroke patients on a non-contrast CT is improved with the use of an Artificial Intelligence (AI) based, automated hypodensity detection algorithm (HDT) using MRI-DWI as the gold standard.MethodsThe study employed a case-crossover within-clinician design, where 32 clinicians were tasked with identifying hypodensity lesions on NCCT scans for five a priori selected patient cases, before and after viewing the AI-based HDT. The DICE similarity coefficient (DICE score) was the primary measure of accuracy. Statistical analysis compared DICE scores with and without AI-based HDT using mixed-effects linear regression, with individual NCCT scans and clinicians as nested random effects.ResultsThe AI-based HDT had a mean DICE score of 0.62 for detecting hypodensity across all NCCT scans. Clinicians’ overall mean DICE score was 0.33 (SD 0.31) before AI-based HDT implementation and 0.40 (SD 0.27) after implementation. AI-based HDT use was associated with an increase of 0.07 (95% CI: 0.02–0.11, p = 0.003) in DICE score accounting for individual scan and clinician effects. For scans with small lesions, clinicians achieved a mean increase in DICE score of 0.08 (95% CI: 0.02, 0.13, p = 0.004) following AI-based HDT use. In a subgroup of 15 trainees, DICE score improved with AI-based HDT implementation [mean difference in DICE 0.09 (95% CI: 0.03, 0.14, p = 0.004)].DiscussionAI-based automated hypodensity detection has potential to enhance clinician accuracy of detecting hypodensity in acute stroke diagnosis, especially for smaller lesions, and notably for less experienced clinicians.

Background and purpose: The present study analyzed the relationship between circulating trimethylamine N‐oxide (TMAO) levels and stroke severity in diabetic patients with acute ischaemic stroke. A further aim was to investigate whether higher TMAO levels were associated with platelet aggregation and glycemic variability. Methods: This was a cross‐sectional analysis of 108 patients with type 2 diabetes mellitus (DM) undergoing acute ischaemic stroke and 60 healthy controls. Fasting plasma TMAO was measured using high‐performance liquid chromatography with online electrospray ionization tandem mass spectrometry. Results: Plasma TMAO levels of patients with acute ischaemic stroke were significantly higher than those of healthy controls. Amongst stroke patients, 50 were defined as undergoing mild stroke, and their plasma TMAO levels were lower compared to those with moderate to severe stroke. Platelet aggregation and mean amplitude of glycemic excursions were both correlated with plasma TMAO levels and these relationships remained significant in multiple linear regression analyses. Moreover, in streptozotocin‐induced diabetic rats fed a diet enriched with choline to increase TMAO synthesis, platelet aggregation was significantly increased in the DM + choline and fluctuating DM (FDM) + choline groups compared to the control group. This increase was abolished in rats receiving oral antibiotics, which markedly reduced plasma TMAO levels. Importantly, compared with the DM + choline group, the FDM + choline group displayed significantly elevated TMAO levels and higher platelet aggregation. Conclusions: Our results demonstrated that higher plasma TMAO levels were associated with stroke severity and suggested a novel link between plasma TMAO levels and glycemic variability in diabetic patients with acute ischaemic stroke. [ABSTRACT FROM AUTHOR]

Introduction. Our study analysed the safety and effectiveness of idarucizumab in enabling intravenous thrombolysis (IVT) in dabigatran-treated patients with acute ischaemic stroke (AIS). Clinical rationale for the study. New oral anticoagulants (NOAC), including dabigatran, are the first-choice treatment option for preventing ischaemic stroke in patients with non-valvular atrial fibrillation (AF). However, a significant percentage of AF patients develops AIS despite NOAC treatment. According to current guidelines, treatment with IVT is contraindicated in patients who have received NOAC within the last 48 hours. Idarucizumab is a fragment of a monoclonal antibody that reverses the anticoagulation effect of dabigatran. The latest research shows that it can enable safe and successful IVT in patients with recent dabigatran intake, but more data is needed to confirm the safety and effectiveness of such treatment. Material and methods. Our study included dabigatran-treated patients who received idarucizumab to allow AIS treatment with IVT in the University Hospital in Kraków (Poland) from December 2018 to June 2023. We gathered data on their past medical history, stroke severity, course of treatment and outcomes as defined by modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS) scores at discharge. A good functional outcome was defined as mRS 0-2 points at discharge. Results. This observational study included 19 patients (13 male and six female) with a median age of 74 (IQR = 13) years. In all patients (100%), the reason for dabigatran treatment was AF. A good functional outcome after treatment (mRS 0-2) was achieved in 68.4% of patients, but mRS was already = 3 points before stroke onset in three (15.8%) patients. Haemorrhagic transformation of stroke occurred in three (15.8%) patients, including symptomatic intracranial haemorrhage in two (10.5%). The mortality rate was 5.3%. Conclusions and clinical implications. Our study results are in line with previous research on this topic, showing that IVT after idarucizumab can be successfully administered and is reasonably safe in dabigatran-treated patients with AIS. [ABSTRACT FROM AUTHOR]