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  • Editorial
    Int. J. Stroke (IF 4.466) Pub Date : 2019-12-13
    Geoffrey Donnan

    It is with some heaviness of heart that I pen my last editorial. I signaled my intention to step down from the role as Editor-in-Chief of the International Journal of Stroke (IJS) in January 2019, to be effective from 31 December 2019. This has enabled the World Stroke Organization (WSO) to have adequate time to have undertaken a rigorous global search and interview process to find a new Editor-in-Chief for IJS.

    更新日期:2019-12-13
  • Oral anticoagulation versus antiplatelet or placebo for stroke prevention in patients with heart failure and sinus rhythm: Systematic review and meta-analysis of randomized controlled trials
    Int. J. Stroke (IF 4.466) Pub Date : 2019-09-16
    George Ntaios; Konstantinos Vemmos; Gregory YH Lip

    Background Previous meta-analyses of randomized controlled trials of oral anticoagulation in patients with heart failure and sinus rhythm reported reduced stroke risk and increased bleeding risk compared to antiplatelets or placebo. However, the effect estimates may be subject to imprecision, as all included trials were prematurely terminated; stroke was not the primary outcome and overall results were primarily driven by a single trial. Recently, new trial data became available. Aim To provide more accurate estimates of the effect of oral anticoagulation on stroke risk in heart failure patients with sinus rhythm by systematic review and meta-analysis of available randomized controlled trials including recently published evidence. Methods We searched PubMed and Scopus for full-text articles of randomized controlled trials of oral anticoagulation versus antiplatelet or placebo in heart failure patients with sinus rhythm published between inception and 28 August 2018. The outcomes assessed were any stroke, major bleeding, and death. Results In five trials (9490 patients; 21,067 patient-years), oral anticoagulation-treated patients had lower stroke risk (odds ratio (OR) 0.60, 95%CI: 0.46–0.78, absolute-risk-reduction: 1.3%, number-needed-to-treat: 77), higher major bleeding risk (OR: 1.92, 95%CI: 1.51–2.45, absolute-risk-increase: 2.0%, number-needed-to-harm: 50), and no significant difference in death rates (OR: 0.90, 95%CI: 0.73–1.11) compared to antiplatelets or placebo. Conclusions In the largest meta-analysis to date, oral anticoagulation is associated with a considerable reduction of stroke risk, which is offset by a significant increase in major bleeding risk. For every 1000 patients treated with oral anticoagulation rather than antiplatelet or no antithrombotic treatment for 2.21 years, 13 strokes are prevented but 20 additional major hemorrhages occur, without significant difference in death rates.

    更新日期:2019-12-13
  • Evaluation of the Swedish National Stroke Campaign: A population-based time-series study
    Int. J. Stroke (IF 4.466) Pub Date : 2019-04-10
    Annika Nordanstig; Bo Palaszewski; Kjell Asplund; Bo Norrving; Nils Wahlgren; Per Wester; Katarina Jood; Lars Rosengren

    Background Time delay from stroke onset to hospital arrival is an important obstacle to recanalization therapy. To increase knowledge about stroke symptoms and potentially reduce delayed hospital arrival, a 27-month national public information campaign was conducted in Sweden. Aim To assess the effects of a national stroke campaign in Sweden. Methods This nationwide study included 97,840 patients with acute stroke, admitted to hospital and registered in the Swedish Stroke Register from 1 October 2010 to 31 December 2014 (one year before the campaign started to one year after the campaign ended). End points were (1) proportion of patients arriving at hospital within 3 h of stroke onset and (2) the proportion < 80 years of age receiving recanalization therapy. Results During the campaign, both the proportion of patients arriving at hospital within 3 h (p < 0.05) and the proportion receiving recanalization therapy (p < 0.001) increased. These proportions remained stable the year after the campaign, and no significant improvements with respect to the two end points were observed during the year preceding the campaign. In a multivariable logistic regression model comparing the last year of the campaign with the year preceding the campaign, the odds ratio of arriving at hospital within 3 h was 1.05 (95% confidence interval (CI): 1.00–1.09) and that of receiving recanalization was 1.34 (95% CI: 1.24–1.46). Conclusion The Swedish National Stroke Campaign was associated with a sustained increase in the proportion of patients receiving recanalization therapy and a small but significant improvement in the proportion arriving at hospital within 3 h.

    更新日期:2019-12-13
  • Small vessel occlusion is a high-risk etiology for early recurrent stroke after transient ischemic attack
    Int. J. Stroke (IF 4.466) Pub Date : 2019-03-27
    Tomoyuki Ohara; Toshiyuki Uehara; Shoichiro Sato; Mikito Hayakawa; Kazumi Kimura; Yasushi Okada; Yasuhiro Hasegawa; Norio Tanahashi; Akifumi Suzuki; Jyoji Nakagawara; Kazumasa Arii; Shinji Nagahiro; Kuniaki Ogasawara; Shinichiro Uchiyama; Masayasu Matsumoto; Koji Iihara; Kazunori Toyoda; Kazuo Minematsu; on Behalf of the PROMISE-TIA Study Investigators

    Background Recent prospective registration studies of transient ischemic attack in Western countries demonstrated that large artery atherosclerosis is the highest risk etiology for early stroke recurrence under urgent evaluation and treatment. On the other hand, some limited transient ischemic attack studies from East Asian countries showed transient ischemic attack patients due to small vessel occlusion were at a higher early stroke risk. Aims We aimed to assess the risk for early stroke in small vessel occlusion-transient ischemic attack patients in a Japanese large transient ischemic attack registry. Methods We analyzed the data of a prospective Japanese transient ischemic attack registry including 1320 transient ischemic attack patients within seven days after onset. Small vessel occlusion-transient ischemic attack was defined as the presence of lacunar transient ischemic attack syndrome, without other etiologies. The outcome measure was recurrent stroke within 30 days after transient ischemic attack. The predictors of 30-day recurrent stroke were estimated using the Cox proportional hazards model. Results The study population had a mean age of 69 ± 12 years and 470 were women. Recurrent stroke was observed in 61 patients (4.6%), and the highest rate was observed with small vessel occlusion-transient ischemic attack (7.8%), followed by large artery atherosclerosis (5.4%). In multivariate analysis, recurrent stroke was independently associated with small vessel occlusion-transient ischemic attack (hazard ratio (HR): 2.01, 95% confidence interval (CI): 1.19–3.35), higher systolic blood pressure (HR: 1.18, 95% CI: 1.08–1.28), and presentation within 3 h after onset (HR: 2.21, 95% CI: 1.27–4.04). Furthermore, small vessel occlusion-transient ischemic attack with acute small deep infarct on diffusion-weighted imaging was a stronger predictor of recurrent stroke (HR: 4.87, 95% CI: 2.09–10.0). Conclusion Small vessel occlusion-transient ischemic attack, especially with acute small deep infarct, had a higher early stroke risk compared with other etiologies in Japanese transient ischemic attack patients who received early management.

    更新日期:2019-12-13
  • Outcome after intravenous thrombolysis in patients with acute lacunar stroke: An observational study based on SITS international registry and a meta-analysis
    Int. J. Stroke (IF 4.466) Pub Date : 2019-04-01
    Marius Matusevicius; Maurizio Paciaroni; Valeria Caso; Matteo Bottai; Dheeraj Khurana; Mario de Bastos; Sheila CO Martins; Yakup Krespi; Charith Cooray; Danilo Toni; Niaz Ahmed

    Background Intravenous thrombolysis (IVT) for lacunar stroke (LS) is debated, as the underlying pathophysiological mechanism may not be thrombogenic. Aims To investigate outcomes after IVT in LS in the SITS International Stroke Thrombolysis Register and perform a meta-analysis. Methods LS was identified by both baseline NIHSS-subscores and discharge ICD-10 codes, and contrasted by IVT to non-IVT treated. IVT patients were predominantly from Europe, non-IVT patients predominantly from South America and Asia. Outcome measurements were functional independence (modified Rankin Scale [mRS] score ≤2), excellent outcome (mRS ≤ 1), and mortality at three months. Matched-control comparisons of symptomatic intracerebral hemorrhage (SICH) between IVT-treated LS and IVT-treated non-LS patients were performed. Additionally, we performed a meta-analysis. Results Median age for IVT-treated LS patients (n = 4610) was 66 years vs. 64 years and NIHSS score was 6 vs. 3, compared to non-IVT-treated LS (n = 1221). Univariate outcomes did not differ; however, IVT-treated LS patients had higher adjusted odds ratios (aOR) for functional independence (aOR = 1.65, 95% CI = 1.28–2.13) but similar mortality at three months (aOR = 0.57, 0.29–1.13) than non-IVT-LS. Propensity-score matched analysis showed that IVT-treated LS patients had a 7.1% higher chance of functional independency than non-IVT LS patients (p < 0.001). IVT-treated LS patients had lower odds for SICH (aOR = 0.33, 0.19–0.58 per SITS, aOR = 0.40, 0.27–0.57 per ECASS-2) than matched non-LS controls, which was mirrored in the meta-analysis. Conclusions Our adjusted results show that IVT treatment in LS patients was associated with better functional outcome than non-IVT-treated LS and less SICH than IVT-treated non-LS patients.

    更新日期:2019-12-13
  • Impact of previous stroke on outcome after thrombectomy in patients with large vessel occlusion
    Int. J. Stroke (IF 4.466) Pub Date : 2019-04-04
    Ronen R Leker; Jose E Cohen; Anat Horev; David Tanne; David Orion; Guy Raphaeli; Jacob Amsalem; Jonathan Y Streifler; Hen Hallevi; Natan M Bornstein; Nour E Yaghmour; Gregory Telman; On Behalf of the NASIS-REVASC Study Group

    Background Many patients with large vessel occlusion (LVO) who are otherwise candidates for endovascular treatment (EVT) have had previous strokes. We aimed to examine the effect of previous stroke on outcome after EVT. Methods Consecutive patients with LVO were prospectively entered into a National Acute Stroke registry of patients undergoing EVT. Patients treated with EVT were divided into those with and without previous strokes. The rates of favorable reperfusion status, mortality, and excellent outcome at 90 days post-stroke as well as symptomatic intracranial hemorrhage (sICH) were evaluated. Results A total of 390 underwent EVT and 35 had previous strokes. Patients with previous strokes were significantly older; more frequently had a history of prior myocardial infarction and more often had pre-existing functional disability. Favorable target vessel recanalization was less frequently achieved in patients with previous strokes (60% vs. 82%; p = 0.005) and ordinal regression analysis for functional outcome revealed higher frequency of deterioration at three months in patients with previous strokes. Nevertheless, 9% of these patients maintained their previous disability state and sICH rates did not differ between the groups. Mortality rates at one year post stroke were significantly higher in patients with previous strokes (37% vs. 16%; p = 0.005). Conclusions Previous strokes are associated with higher likelihoods of mortality and unfavorable outcome in patients with LVO undergoing EVT. However, because some of these patients maintain their previous disability state, the presence of previous stroke should not be used as an exclusion criterion from EVT.

    更新日期:2019-12-13
  • Acute ischemic myelopathy treated with intravenous thrombolysis: Four new cases and literature review
    Int. J. Stroke (IF 4.466) Pub Date : 2019-05-15
    Jeremy Jankovic; Vincianne Rey Bataillard; Noëlle Mercier; Christophe Bonvin; Patrik Michel

    Background Intravenous thrombolysis is a well-established treatment of ischemic stroke within 4.5 h. However, its effectiveness in acute ischemic myelopathy is unknown. Purpose We describe a series of four acute ischemic myelopathy patients treated with intravenous thrombolysis within 4.5 h and review the current literature to explore this treatment feasibility, potential safety, and efficacy. Methods We reviewed all routinely collected clinical, radiological, and follow-up data of patients with a final acute ischemic myelopathy diagnosis who received acute intravenous thrombolysis in our stroke network. We also reviewed thrombolyzed acute ischemic myelopathy patients in the literature. Results Four patients (three women) aged 57 to 83 years presented with acute uni- or bilateral extremity paresis, considered initially as cerebral strokes in two of them. After excluding contraindications by brain imaging in three, spinal computed tomography in one and confirmation of acute ischemic myelopathy on spinal magnetic resonance imaging in one patient, intravenous thrombolysis was administered at 135, 190, 240, and 245 min accordingly. Subacute diffusion-weighted imaging-magnetic resonance imaging confirmed acute ischemic myelopathy in all but one patient. Favorable outcome was achieved in two patients rapidly and in three patients at three-month follow-up. We identified seven other thrombolyzed acute ischemic myelopathy patients in the literature, who showed variable recovery and no hemorrhagic complications. Conclusions With appropriate acute imaging, intravenous thrombolysis after acute ischemic myelopathy is feasible and potentially safe within 4.5 h. Given the potential of benefit of thrombolysis in acute ischemic myelopathy, this treatment warrants further efficacy and safety studies.

    更新日期:2019-12-13
  • Combined intravenous and endovascular treatment versus primary mechanical thrombectomy. The Italian Registry of Endovascular Treatment in Acute Stroke
    Int. J. Stroke (IF 4.466) Pub Date : 2019-05-24
    Ilaria Casetta; Giovanni Pracucci; Andrea Saletti; Valentina Saia; Marina Padroni; Alessandro De Vito; Domenico Inzitari; Andrea Zini; Stefano Vallone; Mauro Bergui; Paolo Cerrato; Sandra Bracco; Rossana Tassi; Roberto Gandini; Fabrizio Sallustio; Mariangela Piano; Cristina Motto; Paolino La Spina; Sergio L Vinci; Francesco Causin; Claudio Baracchini; Roberto Gasparotti; Mauro Magoni; Lucio Castellan; Carlo Serrati; Salvatore Mangiafico; Danilo Toni; on behalf of the The Italian Registry of Endovascular Treatment in Acute Stroke

    Background Whether mechanical thrombectomy alone may achieve better or at least equal clinical outcome than mechanical thrombectomy combined with intravenous thrombolysis is a matter of debate. Methods From the Italian Registry of Endovascular Stroke Treatment, we extracted all cases treated with intravenous thrombolysis followed by mechanical thrombectomy or with primary mechanical thrombectomy for anterior circulation stroke due to proximal vessel occlusion. We included only patients who would have qualified for intravenous thrombolysis. We compared outcomes of the two groups by using multivariate regression analysis and propensity score method. Results We included 1148 patients, treated with combined intravenous thrombolysis and mechanical thrombectomy therapy (n = 635; 55.3%), or with mechanical thrombectomy alone (n = 513; 44.7%). Demographic and baseline clinical characteristics did not differ between the two groups, except for a shorter onset to groin puncture time (p < 0.05) in the mechanical thrombectomy group. A shift in the 90-day modified Rankin Scale distributions toward a better outcome was found in favor of the combined treatment (adjusted common odds ratio = 1.3; 95% confidence interval: 1.04–1.66). Multivariate analyses on binary outcome show that subjects who underwent combined treatment had higher probability to survive with modified Rankin Scale 0–3 (odds ratio = 1.42; 95% confidence interval: 1.04–1.95) and lower case fatality rate (odds ratio = 0.6; 95% confidence interval: 0.44–0.9). Hemorrhagic transformation did not differ between the two groups. Conclusion These data seem to indicate that combined intravenous thrombolysis and mechanical thrombectomy could be associated with lower probability of death or severe dependency after three months from stroke due to large vessel occlusion, supporting the current guidelines of treating eligible patients with intravenous thrombolysis before mechanical thrombectomy.

    更新日期:2019-12-13
  • Estimated treatment effect of ticagrelor versus aspirin by investigator-assessed events compared with judgement by an independent event adjudication committee in the SOCRATES trial
    Int. J. Stroke (IF 4.466) Pub Date : 2019-05-15
    J Donald Easton; Hans Denison; Scott R Evans; Mikael Knutsson; Pierre Amarenco; Gregory W Albers; Per Ladenvall; Kazuo Minematsu; Carlos A Molina; Yongjun Wang; KS Lawrence Wong; S Claiborne Johnston; for the SOCRATES Steering Committee and Investigators

    Background Adjudication of endpoints is a standard procedure in cardiovascular clinical trials. However, several studies indicate that the benefit of adjudication in estimating treatment effect may be limited. Aims This post hoc analysis of SOCRATES (NCT01994720) compared the treatment effects and investigated the agreement of clinical event assessment by site investigators and independent adjudicators. Methods SOCRATES compared ticagrelor and aspirin in 13,199 patients with acute minor stroke or high-risk transient ischemic attack. The primary endpoint was stroke, myocardial infarction, or death. Stroke was the major component of the primary endpoint and a secondary endpoint. The endpoints were adjudicated by a blinded independent committee. We compared the treatment effect on the primary endpoint and stroke alone based on the investigators' and adjudicators' assessments, and investigated the agreement rate on the stroke endpoint and major hemorrhages. Results The hazard ratios (95% confidence interval) for ticagrelor versus aspirin therapy for the primary endpoint were 0.89 (0.78–1.01) when calculated on adjudicator-assessed events and 0.88 (0.78–1.00) for investigator-assessed events. The hazard ratios (95% confidence intervals) for stroke were 0.86 (0.75–0.99) based on the adjudicators' diagnoses and 0.85 (0.75–0.97) based on the investigators' diagnoses. The overall agreement between adjudicator- and investigator-diagnosed stroke was 91%, and for major hemorrhages was 88%. Conclusions In SOCRATES, there was no clinically meaningful difference in the estimated treatment effect, on either the primary endpoint or stroke, by using investigator- or adjudicator-assessed events. Double-blind treatment outcome studies with stroke endpoints may not benefit from adjudication. Trial Registration ClinicalTrials.gov Identifier: NCT01994720.

    更新日期:2019-12-13
  • Branch atheromatous disease diagnosed as embolic stroke of undetermined source: A sub-analysis of NAVIGATE ESUS
    Int. J. Stroke (IF 4.466) Pub Date : 2019-05-27
    Shinichiro Uchiyama; Kazunori Toyoda; Kazuo Kitagawa; Yasushi Okada; Sebastian Ameriso; Hardi Mundl; Scott Berkowitz; Takashi Yamada; Yan Yun Liu; Robert G Hart; on behalf of the NAVIGATE ESUS Investigators

    Background Branch atheromatous disease (BAD) is distinctive from large and small arterial diseases, which is single subcortical infarction larger than lacunar stroke in the territories of deep perforators without relevant arterial stenosis. BAD meets the current criteria of embolic stroke of undetermined source. We performed an exploratory analysis of BAD in patients recruited to NAVIGATE embolic stroke of undetermined source, a randomized controlled trial to compare rivaroxaban and aspirin in embolic stroke of undetermined source patients. Methods and results Among 3972 stroke patients in cerebral hemispheres with intracranial arterial imaging, 502 (12.6%) patients met the criteria for BAD. BAD was associated with younger age (years; OR: 0.97, 95% CI: 0.96–0.98), race (Asian; OR: 1.78, 95% CI: 1.44–2.21), region (Eastern Europe; OR: 2.49, 95% CI: 1.87–3.32), and higher National Institute of Health Stroke Scale (OR: 1.17, 95% CI: 1.12–1.22) at randomization. During follow-up, stroke or systemic embolism (2.5%/year vs. 6.2%/year, p = 0.0022), stroke (2.1%/year vs. 6.2%/year, p = 0.0008), and ischemic stroke (2.1%/year vs. 5.9%/year, p = 0.0013) occurred less frequently in BAD than non-BAD patients. There were no differences in annual rates of stroke or systemic embolism (2.5%/year vs. 2.5%/year, HR: 1.01, 95% CI: 0.33–3.14) or major bleeding (1.3%/year vs. 0.8%/year, HR: 1.51, 95% CI: 0.25–9.05) between rivaroxaban and aspirin groups among BAD patients. Conclusions BAD was relatively common, especially in Asian and from Eastern Europe among embolic stroke of undetermined source patients. Stroke severity was higher at randomization but recurrence of stroke was fewer in BAD than non-BAD patients. The efficacy and safety of rivaroxaban and aspirin did not differ among BAD patients.

    更新日期:2019-12-13
  • Choroid plexus volume after stroke
    Int. J. Stroke (IF 4.466) Pub Date : 2019-05-17
    Natalia Egorova; Elie Gottlieb; Mohamed Salah Khlif; Neil J Spratt; Amy Brodtmann

    Background Cerebrospinal fluid circulation is crucial for the functioning of the brain. Aging and brain pathologies such as Alzheimer’s disease have been associated with a change in the morphology of the ventricles and the choroid plexus. Despite the evidence from animal models that the cerebrospinal fluid system plays an important role in neuroinflammation and the restoration of the brain after ischemic brain injury, little is known about changes to the choroid plexus after stroke in humans. Aims Our goal was to characterize structural choroid plexus changes poststroke. Methods We used an automatic segmentation tool to estimate the volumes of choroid plexus and lateral ventricles in stroke and control participants at three time points (at baseline, 3 and 12 months) over the first year after stroke. We assessed group differences cross-sectionally at each time point and longitudinally. For stroke participants, we specifically differentiated between ipsi- and contra-lesional volumes. Statistical analyses were conducted for each region separately and included covariates such as age, sex, total intracranial volume, and years of education. Results We observed significantly larger choroid plexus volumes in stroke participants compared to controls in both cross-sectional and longitudinal analyses. Choroid plexus volumes did not exhibit any change over the first year after stroke, with no difference between ipsi- and contra-lesional volumes. This was in contrast to the volume of lateral ventricles that we found to enlarge over time in all participants, with more accelerated expansion in stroke survivors ipsi-lesionally. Conclusions Our results suggest that chronic stages of stroke are characterized by larger choroid plexus volumes, but the enlargement likely takes place prior to or very early after the stroke incident.

    更新日期:2019-12-13
  • Trends in recruitment of women and reporting of sex differences in large-scale published randomized controlled trials in stroke
    Int. J. Stroke (IF 4.466) Pub Date : 2019-05-27
    Cheryl Carcel; Mark Woodward; Grace Balicki; Georgia Louise Koroneos; Diana Aguiar de Sousa; Charlotte Cordonnier; Caroline Lukaszyk; Kelly Thompson; Xia Wang; Leo Davies; Meenakshi Bassi; Craig S Anderson; Sanne AE Peters; Else Charlotte Sandset

    Background Understanding of sex differences, especially in terms of the influence of sex on therapeutic interventions, can lead to improved treatment and management for all. Aim We examined temporal and regional trends in female participation and the reporting of sex differences in stroke randomized controlled trials. Methods Randomized controlled trials from 1990 to 2018 were identified from ClinicalTrials.gov, using keywords “stroke” and “cerebrovascular accidents.” Studies were selected if they enrolled ≥100 participants, included both sexes and were published trials (identified using PubMed, Google Scholar, and Scopus). Results Of 1700 stroke randomized controlled trials identified, 277 were published and eligible for analysis. Overall, these randomized controlled trials enrolled only 40% females, and in the past 10 years, this percentage barely changed, peaking at 41% in 2008–2009 and 2012–2013. North American randomized controlled trials recruited the most women, at 43%, and Asia the lowest, at 40%. Among the 277 randomized controlled trials, 101 (36%) reported results according to sex, of which 91 (33%) were pre-specified analyses. The increasing trend in the number of studies reporting sex-differentiated results from 2008 to 2018 merely paralleled the increase in the number of papers published during the same time period. North American randomized controlled trials most often reported sex-specific results (42%), and Australia and Europe least often (31%). Conclusion Little progress has been made in the inclusion of females and the reporting of sex in stroke randomized controlled trials. This highlights the need for key stakeholders, such as funders and journal editors, to provide clear guidance and effective implementation strategies to researchers in the scientific reporting of sex.

    更新日期:2019-12-13
  • Radiosurgical, neurosurgical, or no intervention for cerebral cavernous malformations: A decision analysis
    Int. J. Stroke (IF 4.466) Pub Date : 2019-05-23
    Leon A Rinkel; Rustam Al-Shahi Salman; Gabriel JE Rinkel; Jacoba P Greving

    Cerebral cavernous malformations (CCM) may present with intracerebral hemorrhage (ICH), seizures, or focal neurological deficit (FND) anatomically related to CCM location or may be incidental findings during cerebral imaging for other reasons.1 The untreated clinical course of CCM is mainly determined by their location and mode of presentation.2,3

    更新日期:2019-12-13
  • Stroke progression and clinical outcome in ischemic stroke patients with a history of migraine
    Int. J. Stroke (IF 4.466) Pub Date : 2019-05-27
    Inge A Mulder; Ghislaine Holswilder; Marianne AA van Walderveen; Irene C van der Schaaf; Edwin Bennink; Alexander D Horsch; L Jaap Kappelle; Birgitta K Velthuis; Jan Willem Dankbaar; Gisela M Terwindt; Wouter J Schonewille; Marieke C Visser; Michel D Ferrari; Ale Algra; Marieke JH Wermer; for the DUST investigators

    Migraine patients, especially with aura, have an increased risk of ischemic stroke.1 The association between ischemic stroke and migraine is complex and probably multifactorial.2,3 One interesting mechanism involved in the association is spreading depolarization (SD). SDs are waves of depolarizing neuronal and glia cells, spreading through brain tissue and are the presumed underlying neurovascular mechanism of a migraine aura. SDs have been linked directly to ischemia in pure migrainous infarction. Besides that, it has been shown in mice that micro-emboli can also trigger SDs, with or without causing microinfarctions4,5 and increased migraine with aura (MA) and stroke occurrence is reported in patients with patent foramen ovale.6 SDs in healthy brain tissue are probably a benign phenomenon but in ischemic tissue they may increase (secondary) tissue changes after stroke.2,7,8

    更新日期:2019-12-13
  • Advancing diagnostic criteria for sporadic cerebral amyloid angiopathy: Study protocol for a multicenter MRI-pathology validation of Boston criteria v2.0
    Int. J. Stroke (IF 4.466) Pub Date : 2019-09-12
    Andreas Charidimou; Matthew P Frosch; Rustam Al-Shahi Salman; Jean-Claude Baron; Charlotte Cordonnier; Mar Hernandez-Guillamon; Jennifer Linn; Nicolas Raposo; Mark Rodrigues; Jose Rafael Romero; Julie A Schneider; Stefanie Schreiber; Eric E Smith; Mark A van Buchem; Anand Viswanathan; Frank A Wollenweber; David J Werring; Steven M Greenberg; for the International CAA Association

    Rationale The Boston criteria are used worldwide for the in vivo diagnosis of cerebral amyloid angiopathy and are the basis for clinical decision-making and research in the field. Given substantial advances in cerebral amyloid angiopathy's clinical aspects and MRI biomarkers, we designed a multicenter study within the International cerebral amyloid angiopathy Association aimed at further validating the diagnostic accuracy of the Boston and potentially improving and updating them. Aim We aim to derive and validate an updated “version 2.0” of the Boston criteria across the spectrum of cerebral amyloid angiopathy-related presentations and MRI biomarkers. Sample size estimates Participating centers with suitable available data (see Methods) were identified from existing collaborations and an open invitation to the International Cerebral Amyloid Angiopathy Association emailing list. Our study sample will include: (1) a derivation cohort – Massachusetts General Hospital (MGH), Boston cases from inception to 2012 (∼150 patients); (2) temporal external validation cohort – MGH, Boston cases from 2012 to 2018 (∼100 patients); and (3) geographical external validation cohort – non-Boston cases (∼85 patients). Methods and design Multicenter collaborative study. We will collect and analyze data from patients' age ≥ 50 with any potential sporadic cerebral amyloid angiopathy-related clinical presentations (spontaneous intracerebral hemorrhage, transient focal neurological episodes and cognitive impairment), available brain MRI (“index test”), and histopathologic assessment for cerebral amyloid angiopathy (“reference standard” for diagnosis). Trained raters will assess MRI for all prespecified hemorrhagic and non-hemorrhagic small vessel disease markers of interest, according to validated criteria and a prespecified protocol, masked to clinical and histopathologic features. Brain tissue samples will be rated for cerebral amyloid angiopathy, defined as Vonsattel grade ≥2 for whole brain autopsies and ≥1 for cortical biopsies or hematoma evacuation. Based on our estimated available sample size, we will undertake pre-specified cohort splitting as above. We will: (a) pre-specify variables and statistical cut-offs; (b) examine univariable and multivariable associations; and (c) then assess classification measures (sensitivity, specificity etc.) for each MRI biomarker individually, in relation to the cerebral amyloid angiopathy diagnosis reference standard on neuropathology in a derivation cohort. The MRI biomarkers strongly associated with cerebral amyloid angiopathy diagnosis will be selected for inclusion in provisional (probable and possible cerebral amyloid angiopathy) Boston criteria v2.0 and validated using appropriate metrics and models. Study outcomes Boston criteria v2.0 for clinical cerebral amyloid angiopathy diagnosis. Discussion This work aims to potentially update and improve the diagnostic test accuracy of the Boston criteria for cerebral amyloid angiopathy and to provide wider validation of the criteria in a large sample. We envision that this work will meet the needs of clinicians and investigators and help accelerate progress towards better treatment of cerebral amyloid angiopathy.

    更新日期:2019-12-13
  • Constraint-induced or multi-modal personalized aphasia rehabilitation (COMPARE): A randomized controlled trial for stroke-related chronic aphasia
    Int. J. Stroke (IF 4.466) Pub Date : 2019-09-07
    Miranda L Rose; David Copland; Lyndsey Nickels; Leanne Togher; Marcus Meinzer; Tapan Rai; Dominique A Cadilhac; Joosup Kim; Abby Foster; Marcella Carragher; Melanie Hurley; Erin Godecke

    Rationale The comparative efficacy and cost-effectiveness of constraint-induced and multi-modality aphasia therapy in chronic stroke are unknown. Aims and hypotheses In the COMPARE trial, we aim to determine whether Multi-Modal Aphasia Treatment (M-MAT) and Constraint-Induced Aphasia Therapy Plus (CIAT-Plus) are superior to usual care (UC) for chronic post-stroke aphasia. Primary hypothesis: CIAT-Plus and M-MAT will reduce aphasia severity (Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ)) compared with UC: CIAT-Plus superior for moderate aphasia; M-MAT superior for mild and severe aphasia. Sample size estimates A total of 216 participants (72 per arm) will provide 90% power to detect a 5-point difference on the WAB-R-AQ between CIAT-Plus or M-MAT and UC at α = 0.05. Methods and design Prospective, randomized, parallel group, open-label, assessor blinded trial. Participants: Stroke >6 months; aphasia severity categorized using WAB-R-AQ. Computer-generated blocked and stratified randomization by aphasia severity (mild, moderate, and severe), to 3 arms: CIAT-Plus, M-MAT (both 30 h therapy over two weeks); UC (self-reported usual community care). Study outcomes WAB-R-AQ immediately post-intervention. Secondary outcomes: WAB-R-AQ at 12-week follow-up; naming scores, discourse measures, Communicative Effectiveness Index, Scenario Test, and Stroke and Aphasia Quality of Life Scale-39 g immediately and at 12 weeks post-intervention; incremental cost-effectiveness ratios compared with UC at 12 weeks. Discussion This trial will determine whether CIAT-Plus and M-MAT are superior and more cost-effective than UC in chronic aphasia. Participant subgroups with the greatest response to CIAT-Plus and M-MAT will be described.

    更新日期:2019-12-13
  • Optimal delay time to initiate anticoagulation after ischemic stroke in atrial fibrillation (START): Methodology of a pragmatic, response-adaptive, prospective randomized clinical trial
    Int. J. Stroke (IF 4.466) Pub Date : 2019-08-18
    Benjamin T King; Patrick D Lawrence; Truman J Milling; Steven J Warach

    Rationale An estimated 15% of all strokes are associated with untreated atrial fibrillation. Long-term secondary stroke prevention in atrial fibrillation is anticoagulation, increasingly with non-vitamin K oral anticoagulants. The optimal time to initiate anticoagulation following an atrial fibrillation-related stroke that balances hemorrhagic conversion with recurrent stroke is not yet known. Aims To determine if there is an optimal delay time to initiate anticoagulation after atrial fibrillation-related stroke that optimizes the composite outcome of hemorrhagic conversion and recurrent ischemic stroke. Sample size estimates The study will enroll 1500 total subjects split between a mild to moderate stroke cohort (1000) and a severe stroke cohort (500). Methods and design This study is a multi-center, prospective, randomized, pragmatic, adaptive trial that randomizes subjects to four arms of time to start of anticoagulation. The four arms for mild to moderate stroke are: Day 3, Day 6, Day 10, and Day 14. The time intervals for severe stroke are: Day 6, Day 10, Day 14, and Day 21. Allocation involves a response adaptive randomization via interim analyses to favor the arms that have a better risk–benefit profile. Study outcomes The primary outcome event is the composite occurrence of an ischemic or hemorrhagic event within 30 days of the index stroke. Secondary outcomes are also collected at 30 and 90 days. Discussion The optimal timing of direct oral anticoagulants post-ischemic stroke requires prospective randomized testing. A pragmatically designed trial with adaptive allocation and randomization to multiple time intervals such as the START trial is best suited to answer this question in order to directly inform current practice on this question.

    更新日期:2019-12-13
  • The Mild and Rapidly Improving Stroke Study (MaRISS): Rationale and design
    Int. J. Stroke (IF 4.466) Pub Date : 2019-09-07
    Jose G Romano; Hannah Gardener; Iszet Campo-Bustillo; Yosef Khan; Nikesha Riley; Sofie Tai; Ralph L Sacco; Pooja Khatri; Eric E Smith; Lee H Schwamm

    Rationale Although mild and rapidly improving stroke symptoms are the most common first stroke presentation, this group has been understudied in acute stroke trials. Observational and retrospective studies suggest residual disability in one third of patients. Aims To elucidate long-term outcomes of patients with mild and rapidly improving stroke, evaluate the predictors of outcome, and examine the association with alteplase treatment. Sample size The initial estimate of 2650 participants to detect a 9% difference in non-disabled 90-day outcomes between alteplase-treated and untreated participants was revised to 2000 after a pre-planned re-estimation based on actual treatment rates. Methods and design Prospective observational study of patients with mild ischemic stroke (NIHSS ≤ 5) or rapidly improving stroke symptoms evaluated within 4.5 h from onset. Outcomes The primary outcome is the proportion of patients with modified Rankin Scale (mRS) ≥ 2 at 90 days; the primary safety outcome is symptomatic hemorrhagic transformation within 36 h among those treated with alteplase. Secondary outcomes include the 90-day Barthel Index, Stroke Impact Scale 16, European Quality of Life scale, mRS at 30 days, and 30- and 90-day mortality. Discussion MaRISS will define outcomes and their predictors and clarify the effects of alteplase in patients with mild and rapidly improving stroke symptoms, providing clinicians with important information to manage this population.

    更新日期:2019-12-13
  • High in-hospital blood pressure variability and severe disability or death in primary intracerebral hemorrhage patients
    Int. J. Stroke (IF 4.466) Pub Date : 2019-01-25
    Jennifer R Meeks; Arvind B Bambhroliya; Elizabeth G Meyer; Kristen B Slaughter; Christopher J Fraher; Anjail Z Sharrief; Ritvij Bowry; Wamda O Ahmed; Jon E Tyson; Charles C Miller; Steve Warach; Babar A Khan; Louise D McCullough; Sean I Savitz; Farhaan S Vahidy

    Objective To quantify in-hospital systolic blood pressure variability among patients with intracerebral hemorrhage, determine the association between high systolic blood pressure variability (HSBPV) and 90-day severe disability or death, and examine the association between pre-hospital factors and HSBPV. Methods Adult, radiologically confirmed, intracerebral hemorrhage patients enrolled in a multi-site cohort were included. Using a semi-automated algorithm, systolic blood pressure values recorded from routine non-invasive systolic blood pressure monitoring in critical and acute care settings were extracted for the duration of hospitalization. Inter and intra-patient systolic blood pressure variability was quantified using generalized estimating equation methods. Modified Poisson and logistic regression models were fit to determine the association between HSBPV and 90-day severe disability or death and between pre-hospital characteristics and HSBPV, respectively. Results A total of 566 patients managed at four certified stroke centers were included. Over 120,000 systolic blood pressure readings were analyzed, and a standard deviation (SD) of 13.0 was parameterized as a cut-off point to categorize HSBPV. Patients with HSBPV had a greater risk of 90-day severe disability or death (relative risk: 1.20, 95% confidence interval: 1.04–1.39), after controlling for age, pre-morbid functional status, and other disease severity measures. Greater likelihood of in-hospital HSBPV was independently observed in elderly, female patients, and in patients with high admission systolic blood pressure. Conclusion Quantification of HSBPV is feasible utilizing routinely collected systolic blood pressure readings, and a singular cut-off parameter for systolic blood pressure variability demonstrated association with 90-day severe disability or death. Elderly, female, and patients with high admission systolic blood pressure may be more likely to demonstrate HSBPV during hospitalization.

    更新日期:2019-12-13
  • Corrigendum
    Int. J. Stroke (IF 4.466) Pub Date : 2019-10-01

    Cappellari M, Mangiafico S, Saia V, et al. IER-START nomogram for prediction of 3-month unfavorable outcome after thrombectomy for stroke. Int J Stroke. DOI: 10.1177/1747493019837756.

    更新日期:2019-12-13
  • Corrigendum
    Int. J. Stroke (IF 4.466) Pub Date : 2019-10-30

    Wang ML, Zhang LX, Wei JJ, et al. Granulocyte colony-stimulating factor and stromal cell-derived factor-1 combination therapy: A more effective treatment for cerebral ischemic stroke. Int J Stroke. Epub ahead of print 30 September 2019. DOI:10.1177/1747493019879666.

    更新日期:2019-12-13
  • Corrigendum
    Int. J. Stroke (IF 4.466) Pub Date : 2019-11-01

    Annie McCluskey, Louise Ada, Patrick J Kelly, et al. A behavior change program to increase outings delivered during therapy to stroke survivors by community rehabilitation teams: The Out-and-About trial. Int J Stroke 2016; 11(4): 425–437.

    更新日期:2019-12-13
  • Reducing the burden of stroke: Opportunities and mechanisms
    Int. J. Stroke (IF 4.466) Pub Date : 2019-09-07
    Valery Feigin; Michael Brainin

    Stroke, as a devastating disease of huge and increasing medical and socio-economic significance, can be called a disease of the 21st century. Almost unheard of as a public health problem before the 19th century and the first three quarters of the 20th century, it is now the second leading cause of death and disability worldwide. From 2005 onwards (Figure 1), stroke prevalence has been increasing exponentially and we now have over 104 million people in the world living with stroke aftermath. The resulting disability-adjusted life-years lost have already reached 132 million, which is more than that from lung, breast, cervical, colon/rectum, stomach, and liver cancers combined. If the current trend continues, by 2030 we will have over 154 million stroke survivors and almost 10 million people dying from stroke every year. Moreover, with over 60% of stroke burden occurring in people younger than 70 years, stroke is no longer a disease of the elderly, and we are witnessing an ominous trend towards increasing stroke incidence and mortality rates in young adults and children in many countries.

    更新日期:2019-10-29
  • Implementing the SRRR taskforce recommendations to transform stroke recovery research
    Int. J. Stroke (IF 4.466) Pub Date : 2019-10-29
    Kate Holmes; Dale Corbett; Sharon McGowan

    Stroke is the second biggest killer worldwide in people over 60 and disproportionately affects people in resource-poor countries. Research implementation over the past 25 years has successfully led to a number of acute treatments that have dramatically improved survival and outcomes for people with stroke.

    更新日期:2019-10-29
  • Moving stroke rehabilitation research evidence into clinical practice: Consensus-based core recommendations from the Stroke Recovery and Rehabilitation Roundtable
    Int. J. Stroke (IF 4.466) Pub Date : 2019-09-30
    Janice J Eng; Marie-Louise Bird; Erin Godecke; Tammy C Hoffmann; Carole Laurin; Olumide A Olaoye; John Solomon; Robert Teasell; Caroline L Watkins; Marion F Walker

    In recent years, there has been an exponential rise in the publication of randomized controlled trials in stroke rehabilitation; more than 2000 trials inform our practice.1 Given the significant resources invested in this production and the importance of the knowledge generated, concerted efforts should be taken to move relevant research evidence into practice.

    更新日期:2019-10-29
  • Cognition in stroke rehabilitation and recovery research: Consensus-based core recommendations from the second Stroke Recovery and Rehabilitation Roundtable
    Int. J. Stroke (IF 4.466) Pub Date : 2019-09-12
    Matthew W McDonald; Sandra E Black; David A Copland; Dale Corbett; Rick M Dijkhuizen; Tracy D Farr; Matthew S Jeffers; Rajesh N Kalaria; Frini Karayanidis; Alexander P Leff; Jess Nithianantharajah; Sarah Pendlebury; Terence J Quinn; Andrew N Clarkson; Michael J O’Sullivan

    The first Stroke Recovery and Rehabilitation Roundtable (SRRR I)1 focused primarily on motor recovery, as it was a more developed area in terms of mechanistic understanding and readiness for clinical trials. Cognitive function has since been identified as an area of unmet need requiring discussion. The definition of post-stroke cognitive impairment, adopted by the cognition working group in SRRR II, is a new cognitive deficit that develops in the first three months following stroke and persists for a minimum of six months, which is not explained by any other condition or disease.2 Such deficits occur in 30–40% of individuals,3 in one or more cognitive domains, including, language, executive function, visuospatial cognition, episodic and working memory.4 Furthermore, cognitive, affective and behavioral consequences of stroke are more strongly associated with poor quality of life (QoL) than measures of physical disability.5 The risk of dementia after stroke is high, with a post-event incidence of 34% one year after severe stroke (NIHSS>10), with lower rates after TIA and minor stroke.6 International guidelines highlight the lack of evidence on specific approaches for rehabilitation of cognitive function as a significant gap.7 Therefore, a major goal of SRRR II was to define current consensus and research priorities to advance our understanding and maximize research alignment in post-stroke cognition.

    更新日期:2019-10-29
  • Standardized measurement of quality of upper limb movement after stroke: Consensus-based core recommendations from the Second Stroke Recovery and Rehabilitation Roundtable
    Int. J. Stroke (IF 4.466) Pub Date : 2019-09-11
    G Kwakkel; EEH Van Wegen; JH Burridge; CJ Winstein; LEH van Dokkum; M Alt Murphy; MF Levin; JW Krakauer

    The worldwide prevalence of stroke in 2010 was 33 million, with 16.9 million people having a first stroke.1 Approximately two-thirds of patients have upper limb limitations, with only 5 to 20% demonstrating full recovery at six months post stroke.2 For individuals and society at large, this has important implications as reduced upper limb capacity is associated with dependence in activities of daily living (ADL) and poor quality of life for both patients and their carers.3

    更新日期:2019-10-29
  • A stroke recovery trial development framework: Consensus-based core recommendations from the Second Stroke Recovery and Rehabilitation Roundtable
    Int. J. Stroke (IF 4.466) Pub Date : 2019-10-29
    Julie Bernhardt; Kathryn S Hayward; Numa Dancause; Natasha A Lannin; Nick S Ward; Randolph J Nudo; Amanda Farrin; Leonid Churilov; Lara A Boyd; Theresa A Jones; S Thomas Carmichael; Dale Corbett; Steven C Cramer

    Stroke recovery treatments that set the field on a radical new path are critically needed.1 The number of neutral Phase III trials in stroke recovery and rehabilitation suggests that a new approach is required. Recent trials are methodologically rigorous, but often designed with little regard for key, underlying biological mechanisms. The SRRR II Next Trials working group aimed to address the challenge of how we develop the next generation of stroke recovery trials to be both rigorous and aspirational to produce game-changing stroke recovery treatments. The recommendations of this group comprise the current paper.

    更新日期:2019-10-29
  • How can the World Stroke Organization (WSO) optimize education in stroke medicine around the world? Report of the 2018 WSO Global Stroke Stakeholder Workshop
    Int. J. Stroke (IF 4.466) Pub Date : 2019-09-10
    Gord Gubitz; Monica Saini; Sarah Belson; Ramesh Sahathevan; Peter Sandercock

    Background Education in stroke is relevant to stroke survivors, clinicians, care providers, and healthcare system administrators and is of special importance in resource-limited settings. The World Stroke Organization Education Committee undertook a program of work, culminating in a focused workshop, to establish the key educational priorities, and work toward maximizing the WSOs impact on the global burden of stroke. Methods A facilitated workshop took place during the World Stroke Congress in Montreal, Canada in October 2018. The workshop was developed using opinions on priority topics for World Stroke Organization educational activities obtained from web-based surveys of World Stroke Organization Members, supplemented by interviews with international stroke support organizations. The workshop included over 50 international participants, selected to represent a balance of age, gender, geographical region, and different levels of health resources. Participants also included members of the World Stroke Organization Education Committee, the World Stroke Academy, stroke support organizations, and the International Journal of Stroke editorial board. The workshop focused on understanding more about educational needs (at all levels), with emphasis on resource-limited settings.  Three broad questions were posed: (1) What are the key educational needs: (a) in your region, (b) from your perspective (e.g. stroke support organization)? (2) Do the current educational activities offered by World Stroke Organization and WSA meet your needs? (3) What could World Stroke Organization/World Stroke Academy offer in your region that would meet your needs? The facilitated discussions were recorded, and the results transcribed and summarized by members of the World Stroke Organization Education Committee. Results Five key needs were identified: 1. Collaborative interdisciplinary, training in both stroke care and how to advocate for stroke. 2. Educational materials provided in a wider range of formats that could be adapted to local circumstances and clinical practices. 3. Educational activities for healthcare providers and stroke support organizations organized regionally, with the World Stroke Organization providing organizational support, and a pool of experts, therapists, nurses, etc. to deliver locally relevant materials. 4. Clear and authoritative online resources, where it is easy to find key policy and protocol guidance. 5. A range of online interactive education and training resources to help build knowledge and competence in stroke care. Conclusion The results of the workshop have been presented to the World Stroke Organization Board and will be used to help to guide the educational initiatives of the World Stroke Organization and World Stroke Academy going forward.

    更新日期:2019-10-29
  • Multi-level community interventions for primary stroke prevention: A conceptual approach by the World Stroke Organization
    Int. J. Stroke (IF 4.466) Pub Date : 2019-09-09
    Michael Brainin; Valery Feigin; Philip M Bath; Epifania Collantes; Sheila Martins; Jeyaraj Pandian; Ralph Sacco; Yvonne Teuschl

    The increasing burden of stroke and dementia emphasizes the need for new, well-tolerated and cost-effective primary prevention strategies that can reduce the risks of stroke and dementia worldwide, and specifically in low- and middle-income countries (LMICs).  This paper outlines conceptual frameworks of three primary stroke prevention strategies: (a) the “polypill” strategy; (b) a “population-wide” strategy; and (c) a “motivational population-wide” strategy.  (a) A polypill containing generic low-dose ingredients of blood pressure and lipid-lowering medications (e.g. candesartan 16 mg, amlodipine 2.5 mg, and rosuvastatin 10 mg) seems a safe and cost-effective approach for primary prevention of stroke and dementia.  (b) A population-wide strategy reducing cardiovascular risk factors in the whole population, regardless of the level of risk is the most effective primary prevention strategy. A motivational population-wide strategy for the modification of health behaviors (e.g. smoking, diet, physical activity) should be based on the principles of cognitive behavioral therapy. Mobile technologies, such as smartphones, offer an ideal interface for behavioral interventions (e.g. Stroke Riskometer app) even in LMICs.  (c) Community health workers can improve the maintenance of lifestyle changes as well as the adherence to medication, especially in resource poor areas. An adequate training of community health workers is a key point. Conclusion An effective primary stroke prevention strategy on a global scale should integrate pharmacological (polypill) and lifestyle modifications (motivational population-wide strategy) interventions. Side effects of such an integrative approach are expected to be minimal and the benefits among individuals at low-to-moderate risk of stroke could be significant. In the future, pragmatic field trials will provide more evidence.

    更新日期:2019-10-29
  • Sex differences in stroke metrics among Southeast Asian countries: Results from the Global Burden of Disease Study 2015
    Int. J. Stroke (IF 4.466) Pub Date : 2019-03-06
    Wen Yea Hwong; Michiel L Bots; Sharmini Selvarajah; Sheamini Sivasampu; Daniel D Reidpath; Wan Chung Law; Kamarul Imran Musa; Ilonca Vaartjes

    Background Sex differences in cardiovascular diseases generally disadvantage women, particularly within developing regions. Aims This study aims to examine sex-related differences in stroke metrics across Southeast Asia in 2015. Furthermore, relative changes between sexes are compared from 1990 to 2015. Methods Data were sourced from the Global Burden of Disease Study. Incidence and mortality from ischemic and hemorrhagic strokes were explored with the following statistics derived: (1) women-to-men incidence/mortality ratio and (2) relative percentage change in rate. Results Women had lower incidence and mortality from stroke compared to men. Notable findings include higher ischemic stroke incidence for women at 30–34 years in high-income countries (women-to-men ratio: 1.3, 95% CI: 0.1, 16.2 in Brunei and 1.3, 95% CI: 0.5, 3.2 in Singapore) and the largest difference between sexes for ischemic stroke mortality in Vietnam and Myanmar across most ages. Within the last 25 years, greater reductions for ischemic stroke metrics were observed among women compared to men. Nevertheless, women below 40 years in some countries showed an increase in ischemic stroke incidence between 0.5% and 11.4%, whereas in men, a decline from −4.2% to −44.2%. Indonesia reported the largest difference between sexes for ischemic stroke mortality; a reduction for women whereas an increase in men. For hemorrhagic stroke, findings were similar: higher incidence among young women in high-income countries and greater reductions for stroke metrics in women than men over the last 25 years. Conclusions Distinct sex-specific differences observed across Southeast Asia should be accounted in future stroke preventive guidelines.

    更新日期:2019-10-29
  • A national economic and clinical model for ischemic stroke care development in Saudi Arabia: A call for change
    Int. J. Stroke (IF 4.466) Pub Date : 2019-05-23
    Fahmi Al-Senani; Mohammed Al-Johani; Mohammad Salawati; Souda ElSheikh; Maha AlQahtani; Jamal Muthana; Saeed AlZahrani; Judith Shore; Matthew Taylor; Valeska S Ravest; Simon Eggington; Matthieu Cuche; Heather Davies; Kyriakos Lobotesis; Jeffrey L Saver

    Stroke is a major cause of morbidity and disability throughout the world.1 Across Saudi Arabia, stroke prevalence rates are estimated at 0.67%.2 Two decades ago, the rate of first stroke incidence was reported at 29.8 per 100,000 person-years, which when updated to the current demographic distribution leads to an estimated rate of 50.9/100,000.3 Similar rates were reported in a recent study in the Aseer region (57.64/100,000).4 The combination of an aging population and increased risk of stroke with age is expected to lead to a growing stroke burden from 16,900 first strokes up to 28,400 in the next 10 years.3

    更新日期:2019-10-29
  • Top 10 global educational topics in stroke: A survey by the World Stroke Organization
    Int. J. Stroke (IF 4.466) Pub Date : 2019-06-10
    Monica Saini; Sarah Belson; Carmen Lahiff-Jenkins; Peter Sandercock

    The World Stroke Organization (WSO) is recognized by the World Health Organization as the sole global non-governmental organization (NGO) for stroke. The WSO undertakes and supports various educational activities for health professionals and lay providers in best practice stroke care. This includes organizing the biennial World Stroke Congress, supporting regional conferences and teaching courses, and engaging with a network of Stroke Support Organizations (SSO).1

    更新日期:2019-10-29
  • Editorial Berlin Manifesto October
    Int. J. Stroke (IF 4.466) Pub Date : 2019-10-28
    Geoffrey A Donnan

    Driving change in preventing dementia

    更新日期:2019-10-28
  • Low-dose versus standard-dose alteplase in acute ischemic stroke in Asian stroke registries: an individual patient data pooling study
    Int. J. Stroke (IF 4.466) Pub Date : 2019-06-21
    Xia Wang; Jingwei Li; Tom J Moullaali; Keon-Joo Lee; Beom Joon Kim; Hee-Joon Bae; Anxin Wang; Yilong Wang; David Z Wang; Yongjun Wang; Masaya Kumamoto; Kazunori Toyoda; Masatoshi Koga; Shoichiro Sato; Sohei Yoshimura; Yi Sui; Bing Xu; Ying Xiao; Tsong-Hai Lee; Chia-Wei Liou; Jiann-Der Lee; Tsung-I Peng; Yen-Chu Huang; Prakash R Paliwal; Manasi Sharma; Cyrus Escabillas; Jose C Navarro; Mu-Chien Sun; Yi Dong; Qiang Dong; Craig S Anderson; Vijay K Sharma

    Objective To investigate the comparative efficacy and safety of the low-dose versus standard-dose alteplase using real-world acute stroke registry data from Asian countries. Methods Individual participant data were obtained from nine acute stroke registries from China, Japan, Philippines, Singapore, South Korea, and Taiwan between 2005 and 2018. Inverse probability of treatment weight was used to remove baseline imbalances between those receiving low-dose versus standard-dose alteplase. The primary outcome was death or disability defined by modified Rankin Scale scores of 2 to 6 at 90 days. Secondary outcomes were symptomatic intracerebral hemorrhage and death. Generalized linear mixed models with the individual registry as a random intercept were performed to determine associations of treatment with low-dose alteplase and outcomes. Results Of the 6250 patients (mean age 66 years, 36% women) included in these analyses, 1610 (24%) were treated with low-dose intravenous alteplase. Clinical outcomes for low-dose alteplase were not significantly different to those for standard-dose alteplase, adjusted odds ratios for death or disability: 1.00 (0.85–1.19) and symptomatic intracerebral hemorrhage 0.87 (0.63–1.19), except for lower death with borderline significance, 0.77 (0.59–1.01). Conclusions The present analyses of real-world Asian acute stroke registry data suggest that low-dose intravenous alteplase has overall comparable efficacy for functional recovery and greater potential safety in terms of reduced mortality, to standard-dose alteplase for the treatment of acute ischemic stroke.

    更新日期:2019-10-28
  • Applicability of ENCHANTED trial results to current acute ischemic stroke patients eligible for intravenous thrombolysis in England and Wales: Comparison with the Sentinel Stroke National Audit Programme registry
    Int. J. Stroke (IF 4.466) Pub Date : 2019-04-08
    Thompson G Robinson; Benjamin D Bray; Lizz Paley; Nikola Sprigg; Xia Wang; Hisatomi Arima; Philip M Bath; Joseph P Broderick; Alice C Durham; Jong S Kim; Pablo M Lavados; Tsong-Hai Lee; Sheila Martins; Thang H Nguyen; Jeyaraj D Pandian; Mark W Parsons; Octavio M Pontes-Neto; Stefano Ricci; Vijay K Sharma; Jiguang Wang; Mark Woodward; Anthony G Rudd; John Chalmers; Craig S Anderson; for the ENCHANTED Investigators and the SSNAP Collaboration

    Background Randomized controlled trials provide high-level evidence, but the necessity to include selected patients may limit the generalisability of their results. Methods Comparisons were made of baseline and outcome data between patients with acute ischemic stroke (AIS) recruited into the alteplase-dose arm of the international, multi-center, Enhanced Control of Hypertension and Thrombolysis Stroke study (ENCHANTED) in the United Kingdom (UK), and alteplase-treated AIS patients registered in the UK Sentinel Stroke National Audit Programme (SSNAP) registry, over the study period June 2012 to October 2015. Results There were 770 AIS patients (41.2% female; mean age 72 years) included in ENCHANTED at sites in England and Wales, which was 19.5% of alteplase-treated AIS patients registered in the SSNAP registry. Trial participants were significantly older, had lower baseline neurological severity, less likely Asian, and had more premorbid symptoms, hypertension and atrial fibrillation. Although ENCHANTED participants had higher rates of symptomatic intracerebral hemorrhage than those in SSNAP, there were no differences in onset-to-treatment time, levels of disability (assessed by the modified Rankin scale) at hospital discharge, and mortality over 90 days between groups. Conclusions Despite the high level of participation, equipoise over the dose of alteplase among UK clinician investigators favored the inclusion of older, frailer, milder AIS patients in the ENCHANTED trial. Clinical trial registration Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01422616

    更新日期:2019-10-28
  • Racial/ethnic disparities in hospital utilization in intracerebral hemorrhage
    Int. J. Stroke (IF 4.466) Pub Date : 2019-03-14
    Salvador Cruz-Flores; Gustavo J Rodriguez; Mohammad Rauf A Chaudhry; Ihtesham A Qureshi; Mohtashim A Qureshi; Paisith Piriyawat; Anantha R Vellipuram; Rakesh Khatri; Darine Kassar; Alberto Maud

    Background and purpose There is evidence that racial and ethnic differences among intracerebral hemorrhage (ICH) patients exist. We sought to establish the occurrence of disparities in hospital utilization in the United States. Methods We identified ICH patients from United States Nationwide Inpatient Sample database for years 2006–2014 using codes (DX1 = 431, 432.0) from the International Classification of Diseases, 9th edition. We compared five race/ethnic categories: White, Black, Hispanic, Asian or Pacific Islander, and Others ( Native American and other) with regard to demographics, comorbidities, disease severity, in-hospital complications, in-hospital procedures, length of stay (LOS), total hospital charges, in-hospital mortality, palliative care, (PC) and do not resuscitate (DNR). We categorized procedures as lifesaving (i.e. ventriculostomy, craniotomy, craniectomy, and ventriculoperitoneal (VP) shunt), life sustaining (i.e. mechanical ventilation, tracheostomy, transfusions, and gastrostomy). White race/ethnicity was set as the reference group. Results Out of 710,293 hospitalized patients with ICH 470,539 (66.2%), 114,821 (16.2%), 66,451 (9.3%), 30,297 (4.3%) and 28,185 (3.9%) were White, Black, Hispanic, Asian or Pacific Islander, and Others, respectively. Minorities (Black, Hispanic, Asian or Pacific Islander, and Others) had a higher rate of in-hospital complications, in-hospital procedures, mean LOS, and hospital charges compared to Whites. In contrast, Whites had a higher rate of in-hospital mortality, PC, and DNR. In multivariable analysis, all minorities had higher rate of MV, tracheostomy, transfusions, and gastrostomy compared to Whites, while Hispanics had higher rate of craniectomy and VP shunt; and Asian or Pacific Islander and Others had higher rate of craniectomy. Whites had a higher rate of in-hospital mortality, palliative care, and DNR compared to minorities. In mediation analysis, in-hospital mortality for whites remained high after adjusting with PC and DNR. Conclusion Minorities had greater utilization of lifesaving and life sustaining procedures, and longer LOS. Whites had greater utilization of palliative care, hospice, and higher in-hospital mortality. These results may reflect differences in culture or access to care and deserve further study.

    更新日期:2019-10-28
  • Factors, trends, and long-term outcomes for stroke patients returning to work: The South London Stroke Register
    Int. J. Stroke (IF 4.466) Pub Date : 2019-03-15
    Arup Sen; Alessandra Bisquera; Yanzhong Wang; Christopher J McKevitt; Anthony G Rudd; Charles D Wolfe; Ajay Bhalla

    Background and purpose There is limited information on factors, trends, and outcomes in return to work at different time-points post-stroke; this study aims to identify these in a multi-ethnic urban population. Methods Patterns of return to work were identified in individuals in paid work prior to first-ever stroke in the population-based South London Stroke Register (SLSR) between 1995 and 2014. Multivariable logistic regression examined associations between patient characteristics and return to work at 1 year (1 y), 5 years (5 y) and 10 years (10 y) post-stroke. Results Among 5609 patients, 940 (17%) were working prior to their stroke, of whom 177 (19%) were working 3 months post-stroke, declining to 172 (18%) at 1 y, 113 (12%) at 5 y, and 27 (3%) at 10 y. Factors associated with return to work within 1 y, after logistic regression, included functional independence (BI ≥ 19; p < 0.01) and shorter length of stay (p < 0.05). Younger age (p < 0.01) was associated with return to work at 5 y and 10 y post-stroke. Non-manual occupation (p < 0.05) was associated with return to work at 10 y post-stroke. Return to work within 1 y increased the likelihood of working at 5 y (OR: 13.68; 95% CI 5.03–37.24) and 10 y (9.07; 2.07–39.8). Of those who were independent at follow-up (BI ≥ 19), 48% were working at 1 y, 42% at 5 y, and 28% at 10 y. Lower rates of anxiety and depression and higher self-rated health were associated with return to work at 1 y (p < 0.01). Conclusion Although functionally independent stroke survivors are more likely to return to work long-term, a large proportion do not return to work despite functional independence. Return to work post-stroke is associated with improved long-term psychological outcomes and quality of life.

    更新日期:2019-10-28
  • Regional differences in ischemic stroke in India (north vs. south)
    Int. J. Stroke (IF 4.466) Pub Date : 2019-01-31
    Vishnu Y Venugopalan; Rohit Bhatia; Jeyaraj Pandian; Dheeraj Khurana; Subhash Kaul; P.N. Sylaja; Deepti Arora; Himani Khatter; M.V. Padma; Aneesh B. Singhal

    Background India is a large country with geographically diverse populations and varying risk factors. Identification of regional differences can improve healthcare policy decisions. Aim To study regional differences in stroke between North and South India. Methods We analyzed data from the Indo-US Collaborative Stroke Project, a National Institute of Health-funded multicentre prospective study conducted in five academic centers in India with a US-based coordinating center. Risk factors, severity, mechanisms, management, complications, and outcomes among ischemic stroke patients were compared between North and South Indian centers. Results Of the 2066 patients enrolled from North (n = 1060) and South India (n = 1006), North Indian patients were significantly older with fewer men and had lower rates of diabetes (32.8% vs. 38.7%, p < 0.01), dyslipidemia (3.5% vs. 25.7%, p < 0.01), tobacco use (27% vs. 38%, p < 0.001), and alcohol use (30.1% vs. 38.6%, p < 0.01). North Indian patients had higher median National Institute of Health stroke scale scores (10 vs. 9, p < 0.01), more frequent large-artery atherosclerosis mechanism (34% vs. 25.6%, p < 0.001), intravenous thrombolysis (14.0% vs. 6.1%, p < 0.001), and lower rates of pneumonia (10.5% vs. 15.1%, p = 0.02). The three-month outcome (modified Rankin Scale score 0–2, 45.8% vs. 50.3%, p = 0.08) did not differ; however, North Indian patients had higher 90-day mortality (23.5% vs. 13.5%, p < 0.0001). Conclusions The substantial regional differences in stroke risk factors and mechanisms may be partly explained by factors such as differing dietary habits and lifestyle, which can be addressed at a national level. Differences in acute and inpatient stroke care suggest a need for better adoption of national stroke management guidelines.

    更新日期:2019-10-28
  • Stroke in the Middle-East and North Africa: A 2-year prospective observational study of stroke characteristics in the region—Results from the Safe Implementation of Treatments in Stroke (SITS)–Middle-East and North African (MENA)
    Int. J. Stroke (IF 4.466) Pub Date : 2019-03-12
    Suhail Al Rukn; Michael V Mazya; Faycal Hentati; Samia Ben Sassi; Fatma Nabli; Zakharia Said; Belahsen Faouzi; Husnain Hashim; Foad Abd-Allah; Benhan Mansouri; Selma Kesraoui; Souheil Gebeily; Husen Abdulrahman; Naveed Akhtar; Niaz Ahmed; Nils Wahlgren; Hany Aref; Mohammed Almekhlafi; Tiago Moreira

    Background and methods Stroke incidence and mortality are reported to have increased in the Middle-East and North African (MENA) countries during the last decade. This was a prospective observational study to examine the baseline characteristics of stroke patients in the MENA region and to compare the MENA vs. the non-MENA stroke cohort in the Safe Implementation of Treatments in Stroke (SITS) International Registry. Results Of the 13,822 patients with ischemic and hemorrhagic stroke enrolled in the SITS-All Patients Protocol between June 2014 and May 2016, 5897 patients (43%) were recruited in MENA. The median onset-to-door time was 5 h (IQR: 2:20–13:00), National Institutes of Health Stroke Scale (NIHSS) score was 8 (4–13) and age was 65 years (56–76). Hypertension (66%) and diabetes (38%) were the prevailing risk factors; large artery stenosis > 50% (25.3%) and lacunar strokes (24.1%) were the most common ischemic stroke etiologies. In comparison, non-MENA countries displayed an onset-to-door time of 5:50 h (2:00–18:45), a median of NIHSS 6 (3–14), and a median age of 66 (56–76), with other large vessel disease and cardiac embolism as the main ischemic stroke etiologies. Hemorrhagic strokes (10%) were less common compared to non-MENA countries (13.9%). In MENA, only a low proportion of patients (21%) was admitted to stroke units. Conclusions MENA patients are slightly younger, have a higher prevalence of diabetes and slightly more severe ischemic strokes, commonly of atherosclerotic or microvascular etiology. Admission into stroke units and long-term follow-up need to be improved. It is suspected that cardiac embolism and atrial fibrillation are currently underdiagnosed in MENA countries.

    更新日期:2019-10-28
  • Cortical superficial siderosis and recurrent intracerebral hemorrhage risk in cerebral amyloid angiopathy: Large prospective cohort and preliminary meta-analysis
    Int. J. Stroke (IF 4.466) Pub Date : 2019-02-20
    Andreas Charidimou; Gregoire Boulouis; Duangnapa Roongpiboonsopit; Li Xiong; Marco Pasi; Kristin M Schwab; Jonathan Rosand; M Edip Gurol; Steven M Greenberg; Anand Viswanathan

    Background We aimed to investigate cortical superficial siderosis as an MRI predictor of lobar intracerebral hemorrhage (ICH) recurrence risk in cerebral amyloid angiopathy (CAA), in a large prospective MRI cohort and a systematic review. Methods We analyzed a single-center MRI prospective cohort of consecutive CAA-related ICH survivors. Using Kaplan–Meier and Cox regression analyses, we investigated cortical superficial siderosis and ICH risk, adjusting for known confounders. We pooled data with eligible published cohorts in a two-stage meta-analysis using random effects models. Covariate-adjusted hazard rations (adj-HR) from pre-specified multivariable Cox proportional hazard models were used. Results The cohort included 240 CAA-ICH survivors (cortical superficial siderosis prevalence: 36%). During a median follow-up of 2.6 years (IQR: 0.9–5.1 years) recurrent ICH occurred in 58 patients (24%). In prespecified multivariable Cox regression models, cortical superficial siderosis presence and disseminated cortical superficial siderosis were independent predictors of increased symptomatic ICH risk at follow-up (HR: 2.26; 95% CI: 1.31–3.87, p = 0.003 and HR: 3.59; 95% CI: 1.96–6.57, p < 0.0001, respectively). Three cohorts including 443 CAA-ICH patients in total were eligible for meta-analysis. During a mean follow-up of 2.5 years (range: 2–3 years) 92 patients experienced recurrent ICH (pooled risk ratio: 6.9% per year, 95% CI: 4.2%–9.7% per year). In adjusted pooled analysis, any cortical superficial siderosis and disseminated cortical superficial siderosis were the only independent predictors associated with increased lobar ICH recurrence risk (adj-HR: 2.4; 95% CI: 1.5–3.7; p < 0.0001, and adj-HR: 4.4; 95% CI: 2–9.9; p < 0.0001, respectively). Conclusions In CAA-ICH patients, cortical superficial siderosis presence and extent are the most important MRI prognostic risk factors for lobar ICH recurrence. These results can help guide clinical decision making in patients with CAA.

    更新日期:2019-10-28
  • Transfer to the Local Stroke Center versus Direct Transfer to Endovascular Center of Acute Stroke Patients with Suspected Large Vessel Occlusion in the Catalan Territory (RACECAT): Study protocol of a cluster randomized within a cohort trial
    Int. J. Stroke (IF 4.466) Pub Date : 2019-05-29
    Sònia Abilleira; Natalia Pérez de la Ossa; Xavier Jiménez; Pere Cardona; Dolores Cocho; Francisco Purroy; Joaquín Serena; Luis San Román; Xabier Urra; Marta Vilaró; Jordi Cortés; José Antonio González; Ángel Chamorro; Miquel Gallofré; Tudor Jovin; Carlos Molina; Erik Cobo; Antoni Dávalos; Marc Ribó

    Rationale Optimal pre-hospital delivery pathways for acute stroke patients suspected to harbor a large vessel occlusion have not been assessed in randomized trials. Aim To establish whether stroke subjects with rapid arterial occlusion evaluation scale based suspicion of large vessel occlusion evaluated by emergency medical services in the field have higher rates of favorable outcome when transferred directly to an endovascular center (endovascular treatment stroke center), as compared to the standard transfer to the closest local stroke center (local-SC). Design Multicenter, superiority, cluster randomized within a cohort trial with blinded endpoint assessment. Procedure Eligible patients must be 18 or older, have acute stroke symptoms and not have an immediate life threatening condition requiring emergent medical intervention. They must be suspected to have intracranial large vessel occlusion based on a pre-hospital rapid arterial occlusion evaluation scale of ≥5, be located in geographical areas where the default health authority assigned referral stroke center is a non-thrombectomy capable hospital, and estimated arrival at a thrombectomy capable stroke hospital in less than 7 h from time last seen well. Cluster randomization is performed according to a pre-established temporal sequence (temporal cluster design) with three strata: day/night, distance to the endovascular treatment stroke center, and week/week-end day. Study outcome The primary endpoint is the modified Rankin Scale score at 90 days. The primary safety outcome is mortality at 90 days. Analysis The primary endpoint based on the modified intention-to-treat population is the distribution of modified Rankin Scale scores at 90 days analyzed under a sequential triangular design. The maximum sample size is 1754 patients, with two planned interim analyses when 701 (40%) and 1227 patients have completed follow-up. Hypothesized common odds ratio is 1.35.

    更新日期:2019-10-28
  • The Acute Stroke or Transient Ischemic Attack Treated with Ticagrelor and Aspirin for Prevention of Stroke and Death (THALES) trial: Rationale and design
    Int. J. Stroke (IF 4.466) Pub Date : 2019-02-12
    S Claiborne Johnston; Pierre Amarenco; Hans Denison; Scott R Evans; Anders Himmelmann; Stefan James; Mikael Knutsson; Per Ladenvall; Carlos A Molina; Yongjun Wang; for the THALES Investigators

    Patients with acute cerebral ischemia are at high risk of recurrent ischemic events, particularly ischemic stroke1–6 and current international guidelines recommend antiplatelet therapy for secondary prevention in patients with acute stroke or transient ischemic attack (TIA) of non-cardioembolic origin. Aspirin is the only antiplatelet agent that has received a class 1A recommendation.7–9

    更新日期:2019-10-28
  • The randomized study of endovascular therapy with versus without intravenous tissue plasminogen activator in acute stroke with ICA and M1 occlusion (SKIP study)
    Int. J. Stroke (IF 4.466) Pub Date : 2019-03-29
    Kentaro Suzuki; Kazumi Kimura; Masataka Takeuchi; Masafumi Morimoto; Ryuzaburo Kanazawa; Yuki Kamiya; Keigo Shigeta; Norihiro Ishii; Yohei Takayama; Yorio Koguchi; Tomoji Takigawa; Mikito Hayakawa; Takahiro Ota; Seiji Okubo; Hiromichi Naito; Kazunori Akaji; Noriyuki Kato; Masato Inoue; Teruyuki Hirano; Kazunori Miki; Toshihiro Ueda; Yasuyuki Iguchi; Shigeru Fujimoto; Toshiaki Otsuka; Yuji Matsumaru

    Rationale Bridging therapy with endovascular therapy (EVT) and intravenous thrombolysis (IVT) has been reported to improve outcomes for acute stroke patients with large-vessel occlusion in the anterior circulation. While the IVT may increase the reperfusion rate, the risk of hemorrhagic complications increases. Whether EVT without IVT (direct EVT) is equally effective as bridging therapy in acute stroke remains unclear. Aim This randomized study of endovascular therapy with versus without intravenous tissue plasminogen activator for acute stroke with ICA and M1 occlusion aims to clarify the efficacy and safety of direct EVT compared with bridging therapy. Methods and design This is an investigator-initiated, multicenter, prospective, randomized, open-treatment, blinded-endpoint clinical trial. The target patient number is 200, comprising 100 patients receiving direct EVT and 100 receiving bridging therapy. Study outcome The primary efficacy endpoint is a modified Rankin Scale score of 0–2 at 90 days. Safety outcome measures are any intracranial hemorrhage at 24 h. Discussion This trial may help determine whether direct EVT should be recommended as a routine clinical strategy for ischemic stroke patients within 4.5 h from onset. Direct EVT would then become the choice of therapy in stroke centers with endovascular facilities. Trial registration UMIN000021488.

    更新日期:2019-10-28
  • Prehospital stroke care: The next big thing
    Int. J. Stroke (IF 4.466) Pub Date : 2019-07-29
    Stephen M Davis; Geoffrey A Donnan

    With the dramatic advances in acute stroke therapy made over the last few decades, one of the most important principles, which have become imbedded in the psyche of health care professionals working at the coalface, is that “time is brain.” This is explained by the diminishing frequency of salvageable brain tissue in the ischemic penumbra over time, although we now recognize substantial individual variations in growth of the ischemic core. Flowing from this developed the concept of the “golden hour,” a term borrowed from military field practice in the 1970s when it became clear that early evacuation and treatment of injuries vastly improved outcomes.

    更新日期:2019-10-19
  • Intracranial arterial wall imaging: Techniques, clinical applicability, and future perspectives
    Int. J. Stroke (IF 4.466) Pub Date : 2019-04-13
    Juan F Arenillas; Nikki Dieleman; Daniel Bos

    Purpose To review the current state of the art and future development of intracranial vessel wall imaging. Methods Recent literature review and expert opinion about intracranial arterial wall imaging. Results Intracranial large artery diseases represent an important cause of stroke and vascular cognitive impairment worldwide. Our traditional understanding of intracranial large artery diseases is based on the observation of luminal narrowing or occlusion with angiographic or ultrasound techniques. Recently, novel imaging techniques have made the intracranial artery wall accessible for noninvasive visualization. The main advantage of vessel-wall imaging as compared to conventional imaging techniques for visualization of intracranial arteries is the ability to detect vessel wall changes even before they get to cause any significant luminal stenosis. This diagnostic capacity is provoking a revolutionary change in the way we see the intracranial circulation. In this article, we will review the current state of magnetic resonance imaging and computed tomography-based intracranial arterial wall imaging, focusing on technical considerations and their clinical applicability. Moreover, we will provide the readers with our vision on the future development of vessel-wall imaging techniques. Conclusion Intracranial arterial wall imaging methods are gaining increasing potential to impact the diagnosis and treatment of patients with cerebrovascular diseases.

    更新日期:2019-10-19
  • NLRP3 inflammasome in ischemic stroke: As possible therapeutic target
    Int. J. Stroke (IF 4.466) Pub Date : 2019-04-02
    Masoumeh Alishahi; Maryam Farzaneh; Farhoodeh Ghaedrahmati; Armin Nejabatdoust; Alireza Sarkaki; Seyed Esmaeil Khoshnam

    Inflammation is a devastating pathophysiological process during stroke, a devastating disease that is the second most common cause of death worldwide. Activation of the NOD-like receptor protein (NLRP3)-infammasome has been proposed to mediate inflammatory responses during ischemic stroke. Briefly, NLRP3 inflammasome activates caspase-1, which cleaves both pro-IL-1 and pro-IL-18 into their active pro-inflammatory cytokines that are released into the extracellular environment. Several NLRP3 inflammasome inhibitors have been promoted, including small molecules, type I interferon, micro RNAs, nitric oxide, and nuclear factor erythroid-2 related factor 2 (Nrf2), some of which are potentially efficacious clinically. This review will describe the structure and cellular signaling pathways of the NLRP3 inflammasome during ischemic stroke, and current evidence for NLRP3 inflammasome inhibitors.

    更新日期:2019-10-19
  • Non-invasive sensor technology for prehospital stroke diagnosis: Current status and future directions
    Int. J. Stroke (IF 4.466) Pub Date : 2019-07-26
    Kyle B Walsh

    Stroke is severe neurological disease and a major cause of death. Ischemic stroke has a worldwide prevalence of 67.6 million (2.7 million annual deaths) and hemorrhagic stroke 15.3 million (2.8 million annual deaths).1 The current diagnostic paradigm for stroke typically involves recognition of the stroke-like symptoms as abnormal and concerning by the patient, family, or other bystanders, with subsequent transport of the patient, often by emergency medicine services (EMS), to an emergency department (ED). In the ED, further medical evaluation and emergent brain imaging is performed, most commonly a non-contrast CT (computed tomography) scan of the head and a CT angiogram of the head and neck. Through this diagnostic imaging, medical professionals are able to identify whether the patient has a brain hemorrhage (i.e. intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH)). Assuming there is no hemorrhage, and, thus, the patient's stroke symptoms are likely secondary to an ischemic stroke, the CT angiogram allows one to evaluate whether there is a large vessel occlusion (LVO).

    更新日期:2019-10-19
  • Factors influencing infarct growth including collateral status assessed using computed tomography in acute stroke patients with large artery occlusion
    Int. J. Stroke (IF 4.466) Pub Date : 2019-05-17
    Bin Jiang; Robyn L Ball; Patrik Michel; Ying Li; Guangming Zhu; Victoria Ding; Bochao Su; Zack Naqvi; Ashraf Eskandari; Manisha Desai; Max Wintermark

    In major ischemic stroke caused by a large artery occlusion, neuronal loss varies considerably across individuals without revascularization. This study aims to identify which patient characteristics are most highly associated with this variability. Demographic and clinical information were retrospectively collected on a registry of 878 patients. Imaging biomarkers including Alberta Stroke Program Early CT score, noncontrast head computed tomography infarct volume, perfusion computed tomography infarct core and penumbra, occlusion site, collateral score, and recanalization status were evaluated on the baseline and early follow-up computed tomography images. Infarct growth rates were calculated by dividing infarct volumes by the time elapsed between the computed tomography scan and the symptom onset. Collateral score was graded into four levels (0, 1, 2, and 3) in comparison with the normal side. Correlation of perfusion computed tomography and noncontrast head computed tomography infarct volumes and infarct growth rates were estimated with the nonparametric Spearman's rank correlation. Conditional inference trees were used to identify the clinical and imaging biomarkers that were most highly associated with the infarct growth rate and modified Rankin Scale at 90 days. Two hundred and thirty-two patients met the inclusion criteria for this study. The median infarct growth rates for perfusion computed tomography and noncontrast head computed tomography were 11.2 and 6.2 ml/log(min) in logarithmic model, and 18.9 and 10.4 ml/h in linear model, respectively. Noncontrast head computed tomography and perfusion computed tomography infarct volumes and infarct growth rates were significantly correlated (rho=0.53; P < 0.001). Collateral status was the strongest predictor for infarct growth rates. For collateral=0, the perfusion computed tomography and noncontrast head computed tomography infarct growth rate were 31.56 and 16.86 ml/log(min), respectively. Patients who had collateral >0 and penumbra volumes>92 ml had the lowest predicted perfusion computed tomography infarct growth rates (6.61 ml/log(min)). Collateral status was closely related to the diversity of infarct growth rates, poor collaterals were associated with a faster infarct growth rates and vice versa.

    更新日期:2019-10-19
  • Comparison of acute ischemic stroke evaluation and the etiologic subtypes between university and nonuniversity hospitals in Isfahan, Iran
    Int. J. Stroke (IF 4.466) Pub Date : 2019-03-12
    Fariborz Khorvash; Mabobeh Khalili; Roya Rezvani Habibabadi; Nizal Sarafzadegan; Mahshid Givi; Hamid Roohafza; Gahsem Yadgarfar; Leila Dehghani; Marzieh Taheri; Mohammad Saadatnia

    Background and purpose Performing a proper causative workup for ischemic stroke patients is essential as it guides the direction of primary and secondary preventions. We aim to investigate the etiological evaluation of these patients in university and nonuniversity hospitals. Method We enrolled subjects from the Persian Registry of Cardiovascular Disease–stroke. Stroke patients were categorized base on an etiological-based classification (Trial of Org 10172 in Acute Stroke Treatment or TOAST) into five groups. We also separated patients with ischemic stroke of undetermined etiology due to incomplete standard evaluation from ischemic stroke of undetermined etiology due to negative standard evaluation. The etiological subtypes and diagnostic evaluations were compared between the two hospital groups. Result Ischemic stroke of undetermined etiology was the most common subtype overall (43%). The prevalence of ischemic stroke of undetermined etiology (incomplete standard evaluation) was significantly higher in patients evaluated in nonuniversity hospitals versus university hospital (46.2% vs. 22.3%). Patients with ischemic stroke of undetermined etiology (negative standard evaluation) and large-artery atherosclerosis were significantly more prevalent in university hospitals (10.3% vs. 4.6% and 13.9% vs. 4.4%, respectively). All diagnostic workups were performed more significantly for university hospital patients. Patients with Ischemic stroke of undetermined etiology (negative standard evaluation). Patients were significantly younger (64.91 ± 14.44 vs. 71.42 ± 12.93) and had lower prevalence of risk factors such as hypertension (48.5% vs. 65.4%) and diabetes (19.4% vs. 33.1%) than patients in ischemic stroke of undetermined etiology (incomplete standard evaluation) subgroup. University hospital patients had better clinical outcomes in terms of mortality and degree of disability during one-year follow-up. Conclusion The high clinical burden of ischemic stroke of undetermined etiology especially in nonuniversity hospitals shows the rational for promoting ischemic stroke evaluation and providing specialized stroke centers for these hospitals in a developing country like Iran.

    更新日期:2019-10-19
  • 4G versus 3G-enabled telemedicine in prehospital acute stroke care
    Int. J. Stroke (IF 4.466) Pub Date : 2019-03-15
    B Winter; M Wendt; C Waldschmidt; M Rozanski; A Kunz; F Geisler; U Grittner; S Kaczmarek; M Ebinger; HJ Audebert; for the Stroke Emergency Mobile (STEMO) Consortium

    Background Time to reperfusion treatment is closely related to outcome in ischemic stroke. Prehospital stroke work-up in CT-equipped mobile stroke units is effective in reducing time to thrombolytic treatment. Current evidence predominantly comes from mobile stroke units staffed with neurologists but telemedicine-guided management may be acceptable for providing neurological expertise in ambulances. With unsatisfactory experiences in third-generation (3G)-based approaches, fourth-generation (4G) networks may provide adequate audio-visual quality but systematic comparisons of technological parameters and decision-making are lacking. Methods Trained actors presented stroke symptoms and paramedics assisted the remotely guided extended National Institutes of Health Stroke Scale (eNIHSS) assessment on the mobile stroke unit in Berlin, Germany. We compared technical parameters of 4G and 3G connections, assessed audio-visual quality of examination, and analyzed reliability of neurological assessment and treatment decisions made by the remote neurologist versus the mobile stroke unit neurologist. Results 4G and 3G connections were evaluated in 40 scenarios each. Connectivity was not available in 17% of 4G- and 15% of 3G-attempts with 6% simultaneous unavailability of both networks. The remote examiners graded audio and video quality in 4G better than in 3G with slightly shorter assessment duration in 4G (mean: 9 (SD:5) vs. mean 11 (SD:3) min, p = 0.10). Reliability of the eNIHSS sum scores was high with intraclass correlation coefficients of 0.99 (95% CI: 0.987–1.00) for 4G and 0.98 (95% CI: 0.96–0.99) for 3G. None of the remote treatment decisions differed from onsite decisions. Conclusions 4G mobile communications provided higher quality of video-examination and allowed reliable remote assessment of stroke symptoms but coverage was still incomplete in both networks.

    更新日期:2019-10-19
  • Phone-based intervention for blood pressure control among Ghanaian stroke survivors: A pilot randomized controlled trial
    Int. J. Stroke (IF 4.466) Pub Date : 2018-11-22
    Fred Stephen Sarfo; Frank Treiber; Mulugeta Gebregziabher; Sheila Adamu; Michelle Nichols; Arti Singh; Vida Obese; Osei Sarfo-Kantanka; Asumadu Sakyi; Nyantakyi Adu-Darko; Raelle Tagge; Marian Agyei-Frimpong; Naomi Kwarteng; Elizabeth Badu; Nathaniel Mensah; Michael Ampofo; Carolyn Jenkins; Bruce Ovbiagele; on behalf of PINGS Team

    Background The potential of mobile-health (mHealth) technology for the management of hypertension among stroke survivors in Africa remains unexplored. We assessed whether an mHealth technology-enabled, nurse-guided intervention initiated among stroke patients within one month of symptom onset is effective in improving their blood pressure (BP) control. Methods A two-arm pilot cluster randomized controlled trial involving 60 stroke survivors, ≥18 years, with BP ≥140/90 mmHg at screening/enrollment visit at a medical center in Ghana. Participants in the intervention arm (n = 30) received a Blue-toothed BP device and smartphone with an App for monitoring BP measurements and medication intake under nurse guidance for three months after which intervention was withdrawn. Control arm (n = 30) received usual care. Primary outcome measure was proportion with clinic BP < 140/90 mmHg at month 9; secondary outcomes included medication adherence. Findings Mean ± SD age was 55 ± 13 years, 65% males. Two participants on intervention and three in control group were lost to follow-up. At month 9, proportion on the intervention versus controls with BP < 140/90 mmHg was 14/30 (46.7%) versus 12/30 (40.0%), p = 0.79 by intention-to-treat; systolic BP < 140 mmHg was 22/30 (73.3%) versus 13/30 (43.3%), p = 0.035. Mean ± SD medication possession ratio was 0.95 ± 0.16 on intervention versus 0.98 ± 0.24 in the control arm, p = 0.56. Interpretation We demonstrate feasibility and signal of improvement in BP control among stroke survivors in a resource-limited setting via an mHealth intervention. Larger scale studies are warranted. Trial registration NCT02568137. Registered on 13 July 2015 at ClinicalTrials.gov.

    更新日期:2019-10-19
  • Metabolic syndrome identifies normal weight insulin-resistant stroke patients at risk for recurrent vascular disease
    Int. J. Stroke (IF 4.466) Pub Date : 2018-12-03
    Jennifer L Dearborn; Catherine M Viscoli; Silvio E Inzucchi; Lawrence H Young; Walter N Kernan

    Over 65% of the U.S. population is overweight or obese.1 Excess weight, as most commonly measured by body mass index (BMI) or waist circumference (WC), is associated with increased risk for stroke and myocardial infarction (MI).2 The adverse effect of increased weight on cardiovascular outcomes is thought to result primarily from the consequences of metabolic impairment, such as hypertension, dyslipidemia, vascular inflammation, insulin resistance, hyperglycemia, and abnormal vascular reactivity.3

    更新日期:2019-10-19
  • Impact of prehospital stroke code in a public center in Paraguay: A pilot study
    Int. J. Stroke (IF 4.466) Pub Date : 2019-02-01
    Alan Flores; Laia Seró; Christian Otto; Ricardo Mernes; Silvia Gonzalez; Luis Diaz-Escobar; Romina Gonzalez

    Prehospital stroke code activation results in reduced pre- and in-hospital delays and triage and transport of stroke patients to the right centers. In Paraguay, data about acute reper fusion treatment are not available. Recently, a pilot prehospital stroke code program was implemented in the country in November 2016. In an observational, single-center cohort study with a before–after design, from April 2015 to July 2018, we found that 193/832 (23.1%) of stroke patients were stroke code activated, and from these, 54 (6.5%) were brought to hospital under the prehospital stroke code protocol. Fifty-eight patients (58 alteplase and 2 additional endovascular treatment) received reperfusion therapy. Prehospital stroke code patients had a lower mean door-to-CT time (24 vs. 33 min, p = 0.021) and lower mean door-to-needle time (35.3 vs.76.3 min, p < 0.001) compared to in-hospital stroke code patients. Prehospital stroke code is feasible in Paraguay and has a positive impact on in-hospital acute stroke management, reducing delays and increasing the rates of reperfusion treatments.

    更新日期:2019-10-19
  • The effect of cerebellar transcranial direct current stimulation to improve standing balance performance early post-stroke, study protocol of a randomized controlled trial
    Int. J. Stroke (IF 4.466) Pub Date : 2019-02-13
    Sarah B Zandvliet; Carel GM Meskers; Rinske HM Nijland; Andreas Daffertshofer; Gert Kwakkel; Erwin EH van Wegen

    Impaired standing balance after stroke is common and has a significant impact on fall events, independence in activities of daily living and perceived disability.1,2 Prospective cohort studies suggest that most improvements in standing balance and walking ability occur within the first five to eight weeks post-stroke.3,4 There is strong evidence of enhanced homeostatic forms of neuroplasticity during this time window, including upregulation of gene expression of growth promoting factors, such as brain derived nerve growth factors (BDNF) followed by growth inhibiting factors.5 Human motor learning in this critical time window may be facilitated by transcranial direct current stimulation (tDCS) which is believed to specifically target synapse-based learning by enhancing the turnover of the secretion of BDNF.6 tDCS is thought to induce polarity-driven alterations of membrane potentials and efficacy modulations of specific neuronal receptors in the underlying brain tissue.6 These dynamic neural modulations are evident not only in motor performance,7–9 but also in intrinsic functional network connectivity that manifest in neurophysiological recordings of cortical brain activity.10 Neural changes while performing balance tasks are mostly reflected by a change in theta (4–7 Hz), and alpha power (7.5–12.5 Hz).11,12 A higher alpha power reflects increased learning speed and an optimal concentration level.13 Decreased alpha activity is also generally seen in patients after stroke.14 Theta power activity is associated with an emerging state of concentration and optimal error control and found to increase with increasing complexity of balance tasks.11,15 Although a general deceleration of EEG signals is associated with poor functional outcome after stroke, conflicting results regarding a correlation of increased theta power activity with post-stroke function are found.16–18 Next to an alteration in power spectral density, asymmetry between the hemispheres (low Brain Symmetry Index) has been associated with poor clinical function and disability six months post-stroke and is believed to reflect the clinical neurological condition of acute stroke patients.19,20 To study these changes in cortical activation patterns in post-stroke recovery, and the potential influence tDCS may have on these processes, repetitive EEG measurements in both a resting state and during postural balance tasks are required.21–23

    更新日期:2019-10-19
  • Antiplatelet vs. R-tPA for acute mild ischemic stroke: A prospective, random, and open label multi-center study
    Int. J. Stroke (IF 4.466) Pub Date : 2019-03-25
    Xin-Hong Wang; Lin Tao; Zhong-He Zhou; Xiao-Qiu Li; Hui-Sheng Chen

    Rationale The evidence of intravenous thrombolysis in patients with not clearly disabling minor stroke (low National Institutes of Health Stroke Scale of 0–5) is still insufficient. Recent early terminated PRISMS trial could not provide definitive conclusion, although suggesting the similar functional outcome between alteplase and aspirin groups. Recent two clinical trials provide a definitive evidence for the superiority of dual antiplatelet to mono-antiplatelet in minor stroke. However, the efficacy and safety of dual antiplatelet vs. alteplase in the treatment of acute minor stroke are not known. Aim To explore the efficacy and safety of dual antiplatelet with aspirin and clopidogrel vs. alteplase in the treatment of acute minor stroke. Sample size estimates A maximum of 760 subjects are required to test the non-inferiority hypothesis with 80% power according to a one-sided 0.025 level of significance, stratified by age, diabetes, time from onset to treatment, stroke etiology, degree of vascular stenosis, location of index vessel. Methods and design ARAMIS is a prospective, randomized, open label, blinded assessment of endpoints (PROBE) and multicenter clinical trial in China. The subjects are randomized to the control arm (intravenous alteplase with standard dose of 0.9 mg/kg, followed by guideline-based treatment 24 h after thrombolysis) or the experiment arm (clopidogrel: loading dose of 300 mg on the first day, followed by 75 mg daily for 10–14 days; aspirin: 100 mg on the first day, followed by 100 mg daily for 10–14 days; after the combination, antiplatelet will be given based on guideline till 90 days). Study outcome The primary efficacy endpoint is favorable functional outcome, defined as a mRS 0–1 assessed at 90-day post-randomization.

    更新日期:2019-10-19
  • Corrigendum
    Int. J. Stroke (IF 4.466) Pub Date : 2019-07-17

    Lundervik, M, Fromm A, Haaland ØA, Waje-Andreassen U, Svendsen F, Thomassen L and Helland CA. Carotid intima-media thickness – a potential predictor for rupture risk of intracranial aneurysms. Int J Stroke 2014; 9(7): 866–972.

    更新日期:2019-10-19
  • A systematic review and meta‐analysis of randomized controlled trials of endovascular thrombectomy compared with best medical treatment for acute ischemic stroke
    Int. J. Stroke (IF 4.466) Pub Date : 2015-08-26
    Joyce S. Balami, Brad A. Sutherland, Laurel D. Edmunds, Iris Q. Grunwald, Ain A. Neuhaus, Gina Hadley, Hasneen Karbalai, Kneale A. Metcalf, Gabriele C. DeLuca, Alastair M. Buchan

    Acute ischemic strokes involving occlusion of large vessels usually recanalize poorly following treatment with intravenous thrombolysis. Recent studies have shown higher recanalization and higher good outcome rates with endovascular therapy compared with best medical management alone. A systematic review and meta‐analysis investigating the benefits of all randomized controlled trials of endovascular thrombectomy where at least 25% of patients were treated with a thrombectomy device for the treatment of acute ischemic stroke compared with best medical treatment have yet to be performed.

    更新日期:2019-07-05
  • The iScore predicts total healthcare costs early after hospitalization for an acute ischemic stroke
    Int. J. Stroke (IF 4.466) Pub Date : 2015-10-26
    Emmanuel M. Ewara, Wanrudee Isaranuwatchai, Dawn M. Bravata, Linda S. Williams, Jiming Fang, Jeffrey S. Hoch, Gustavo Saposnik,

    The ischemic Stroke risk score is a validated prognostic score which can be used by clinicians to estimate patient outcomes after the occurrence of an acute ischemic stroke.

    更新日期:2019-07-05
  • High rate of microbleed formation following primary intracerebral hemorrhage
    Int. J. Stroke (IF 4.466) Pub Date : 2015-08-26
    Jason Mackey, Jeffrey J. Wing, Gina Norato, Ian Sobotka, Ravi S. Menon, Richard E. Burgess, M. Chris Gibbons, Nawar M. Shara, Stephen Fernandez, Annapurni Jayam‐Trouth, Laura Russell, Dorothy F. Edwards, Chelsea S. Kidwell

    We sought to investigate the frequency of microbleed development following intracerebral hemorrhage in a predominantly African‐American population and to identify predictors of new microbleed formation.

    更新日期:2019-07-05
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