Stroke最新文献

{"title":"Spot Sign in Intracerebral Hemorrhage: Critical Reappraisal and Future Clinical Implications.","authors":"Umberto Pensato, Dar Dowlatshahi, David Rodriguez-Luna, Johanna M Ospel, Andrea Morotti, Koji Tanaka, Vignan Yogendrakumar, Javier M Romero, H Bart Brouwers, Stephen M Davis, Nawaf Yassi, Matthew L Flaherty, David J Gladstone, Richard I Aviv, Joshua N Goldstein, Andrew M Demchuk","doi":"10.1161/STROKEAHA.125.050637","DOIUrl":"https://doi.org/10.1161/STROKEAHA.125.050637","url":null,"abstract":"<p><p>Hematoma expansion (HE) is a common occurrence affecting around 10% to 30% of patients with acute intracerebral hemorrhage within the initial hours from symptom onset and is the only modifiable factor associated with poor clinical outcomes. The detection of contrast extravasation on computed tomography (CT) angiography, known as the spot sign, was initially embraced as a promising radiological marker for predicting HE that could aid patient selection for acute interventions aimed at minimizing HE. However, the initial enthusiasm waned as clinical studies failed to show clear clinical benefits of hemostatic treatments when patients were selected based on the presence of this imaging marker. In this narrative review, we provide a comprehensive summary of the pathophysiology, definitions, imaging protocols, and predictive performance of the CT angiography spot sign, along with the clinical studies that have selected and treated patients based on its presence. Finally, we delve into some nuances of the spot sign that can enhance its predictive performance and help stratify HE risk with greater precision. These features include static findings observed on single-phase CT angiography (ie, number, volume, CT density, and colocalization with hypodensities), as well as dynamic findings identified on multiphase/dynamic CT angiography (ie, timing of appearance, volume increase, volume decrease for tissue dispersion, and CT density changes). In this reappraisal of the spot sign, we aim to reinvigorate research on advanced neuroimaging in intracerebral hemorrhage that could lead to a more accurate HE prediction. This could facilitate better selection for therapies aimed at preventing HE or surgical approaches to address the bleeding source.</p>","PeriodicalId":21989,"journal":{"name":"Stroke","volume":" ","pages":""},"PeriodicalIF":7.8,"publicationDate":"2025-04-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143804394","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"New Animated Training and Certification Application for NIHSS.","authors":"Ariana Anderson, Brian White, Marianne Bourgeois, Chase Champagne, Elizabeth Rothermel, John Klein, Joseph Aucoin, Patrick Lyden","doi":"10.1161/STROKEAHA.124.048924","DOIUrl":"https://doi.org/10.1161/STROKEAHA.124.048924","url":null,"abstract":"<p><strong>Background: </strong>The National Institutes of Health Stroke Scale is used globally to rate neurological deficits in patients with acute stroke. Originally designed for research use, the scale uses idiosyncratic scoring rules and requires thorough training for proper use. Currently available training and certification systems are timeworn and limited in the range of demonstrated neurological findings. We aimed to develop a new training and certification method to address the limitations of the prior system.</p><p><strong>Methods: </strong>We describe a new animated system that uses state-of-the-art digital motion capture, avatar rendering, and digital animation that enables illustration of all possible scale item responses within a training module. For certification, we created 20 unique case vignettes, which can be viewed from many angles allowing better scoring scenario presentation. Training to use the scale via telemedicine was added. Alpha and beta testing was completed to enhance iterative development. From a penultimate version, we measured interrater agreement among 42 pilot users who each viewed 6 cases. After further improvement, we finalized the application and confirmed interrater agreement in a second sample of 365 consecutive, unselected users viewing 3 cases. Clinometric analysis methods followed our prior studies of the scale.</p><p><strong>Results: </strong>Users agreed the new, animated training module is more engaging and informative than legacy training videos. We compared the new system to the legacy live-video certification system for clinometric reliability. In the confirmatory sample, the intraclass correlation coefficient was 0.979 (97.5% CI, 0.919-0.99). Kappa scores ranged from 0.25 to 0.90 across all 15 scale items. These results are comparable to previous studies.</p><p><strong>Conclusions: </strong>A new, animated training and certification system showed equivalent clinometric properties to legacy systems, providing a reliable method for National Institutes of Health Stroke Scale training and certification. The new system allows modification and reconfiguration if needed to maintain user interest and case novelty.</p>","PeriodicalId":21989,"journal":{"name":"Stroke","volume":" ","pages":""},"PeriodicalIF":7.8,"publicationDate":"2025-04-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143804297","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Hemorrhagic Infarction Does Not Worsen Functional Outcomes in Noncardioembolic Ischemic Stroke-Secondary Analysis From PACIFIC-STROKE.","authors":"Chih-Hao Chen, Ashkan Shoamanesh, Pablo Colorado, Feryal Saad, Robin Lemmens, Gian Marco De Marchis, Valeria Caso, Lizhen Xu, Laura Heenan, Jaime Masjuan, Hanne Christensen, Pooja Khatri, Hardi Mundl, Robert G Hart, Eric E Smith","doi":"10.1161/STROKEAHA.124.049188","DOIUrl":"https://doi.org/10.1161/STROKEAHA.124.049188","url":null,"abstract":"<p><strong>Background: </strong>Hemorrhagic infarction (HI) of acute ischemic stroke is frequent. Whether radiologically detected HI affects stroke outcomes has been less explored.</p><p><strong>Methods: </strong>This was a secondary analysis of the PACIFIC-STROKE trial (Proper Dosing and Safety of the Oral FXIa Inhibitor BAY 2433334 in Patients Following Acute Noncardioembolic Stroke), which enrolled patients with acute noncardioembolic ischemic stroke receiving either asundexian or placebo in addition to guideline-based antiplatelet therapy. All patients received brain magnetic resonance imaging within 120 hours after stroke onset. Patients with hemorrhagic transformation detected on iron-sensitive sequences and classified as HI (H1 and H2) by the Heidelberg Bleeding Classification were included in the analysis. Primary outcome was poor functional outcome, defined by a modified Rankin Scale score of 2 to 6 at 90 days after stroke.</p><p><strong>Results: </strong>From 1745 patients with adequate baseline brain magnetic resonance imaging (median, 47.8 hours; interquartile range, 28.2-69.4 hours after symptom onset), 10 with parenchymal hemorrhage and 191 without modified Rankin Scale score were excluded. Of the 1544 patients (mean age, 67 years; 67% male), 248 (16.1%) had HI type 1, and 189 (12.2%) had HI type 2. The proportion of patients with poor functional outcome was 27.4% (68/248) in HI type 1, 25.9% (49/189) in HI type 2, and 23.0% (255/1107) in no HI groups. In the multivariable logistic regression model adjusting for stroke severity, infarct size, type of iron-sensitive sequences used, and other covariates, the presence of HI type 1 (adjusted odds ratio, 1.05 [95% CI, 0.74-1.51]) or HI type 2 (adjusted odds ratio, 0.88 [95% CI, 0.57-1.34]) were not associated with poor functional outcome. Of note, the type of iron-sensitive sequences did not modify the results.</p><p><strong>Conclusions: </strong>The presence of HI did not lead to poor functional outcome on the modified Rankin Scale in patients with acute noncardioembolic ischemic stroke.</p>","PeriodicalId":21989,"journal":{"name":"Stroke","volume":" ","pages":""},"PeriodicalIF":7.8,"publicationDate":"2025-04-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143804283","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Does the Burden of CSVD Modify the Efficacy of Dual Antiplatelet Therapy? A Post Hoc Analysis of the INSPIRES Trial.","authors":"Hang Li, Min Cheng, Ying Gao, Hongyi Yan, Yicong Wang, S Claiborne Johnston, Philip M Bath, Pierre Amarenco, Yingying Yang, Weiqi Chen, Yongjun Wang, Yuesong Pan, Yilong Wang","doi":"10.1161/STROKEAHA.124.049826","DOIUrl":"https://doi.org/10.1161/STROKEAHA.124.049826","url":null,"abstract":"<p><strong>Background: </strong>The prevalence of cerebral small vessel disease (CSVD) imaging markers is high, yet their influence on stroke prognosis remains unclear. This study aimed to estimate the effects of CSVD on the efficacy and safety of clopidogrel+aspirin versus aspirin among patients with minor stroke or high-risk transient ischemic attack.</p><p><strong>Methods: </strong>This was a post hoc subgroup analysis of the INSPIRES trial (Intensive Statin and Antiplatelet Therapy for Acute High-Risk Intracranial or Extracranial Atherosclerosis), which was a double-blind, placebo-controlled, 2×2 factorial, and randomized clinical trial conducted at 222 centers in China from September 2018 to October 2022. Patients were classified into CSVD score 0 to 2 and CSVD score ≥3 groups based on a modified CSVD burden score without microbleeds. The primary efficacy and safety outcomes were stroke recurrence and moderate-to-severe bleeding risk within 90-day follow-up. We used Cox proportional hazards models to test the treatment-by-CSVD group interaction for stroke and bleeding risk.</p><p><strong>Results: </strong>A total of 5126 patients (median age, 65 [57-71] years; 3915 [64.2%] males) were enrolled and 2131 (41.57%) had a modified CSVD score ≥3. Patients with CSVD score ≥3 had numerically higher stroke recurrence rate (9.10% versus 8.05%) and lower risk of moderate-to-severe bleeding (0.56% versus 0.80%) than those with CSVD score 0 to 2 within 90 days. Clopidogrel+aspirin versus aspirin reduced stroke recurrence to a similar relative degree in both CSVD score 0 to 2 (adjusted hazard ratio, 0.78 [95% CI, 0.61-1.01]; <i>P</i>=0.06) and CSVD score ≥3 groups (adjusted hazard ratio, 0.82 [95% CI, 0.62-1.09]; <i>P</i>=0.12) with no evidence of statistical interaction (<i>P</i>=0.84). Clopidogrel+aspirin versus aspirin increased bleeding risk to a similar relative degree in both CSVD score 0 to 2 (adjusted hazard ratio, 2.83 [95% CI, 1.52-5.27]; <i>P</i>=0.03) and CSVD score ≥3 groups (adjusted hazard ratio, 2.13 [95% CI, 1.08-4.19]; <i>P</i>=0.22) with no statistical interaction (<i>P</i>=0.68).</p><p><strong>Conclusions: </strong>In this post hoc subgroup analysis, no significant interaction effect was observed between the antiplatelet treatment and the modified CSVD score, suggesting that clopidogrel+aspirin may not provide a significantly different benefit-risk profile across patients with CSVD score 0 to 2 versus CSVD score ≥3.</p><p><strong>Registration: </strong>URL: https://www.clinicaltrials.gov; Unique identifier: NCT03635749.</p>","PeriodicalId":21989,"journal":{"name":"Stroke","volume":" ","pages":""},"PeriodicalIF":7.8,"publicationDate":"2025-04-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143796517","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Incidence of Visuospatial Neglect in Acute Stroke: Assessment and Stroke Characteristics in an Unselected 1-Year Cohort.","authors":"Dario Cazzoli, Brigitte C Kaufmann, Henrik Rühe, Nora Geiser, Thomas Nyffeler","doi":"10.1161/STROKEAHA.124.048907","DOIUrl":"https://doi.org/10.1161/STROKEAHA.124.048907","url":null,"abstract":"<p><strong>Background: </strong>The true incidence of visuospatial neglect, impaired attention toward contralesional space, remains unclear. Common variability sources are sensitivity differences of conventional assessments and the exclusion of patients with language, motor, and other cognitive impairments. We aimed to determine the incidence of visuospatial neglect in an unselected cohort of patients with acute stroke using video oculography during free visual exploration, a newly established assessment overcoming the aforementioned biases.</p><p><strong>Methods: </strong>Single-center, prospective, observational cohort study. We screened every patient admitted to a representative Swiss stroke center over 1 year (n=626). Two hundred eighty-five patients were eligible (first-ever stroke within 72 hours), and 221 were included. The incidence of visuospatial neglect was determined with conventional paper-pencil assessments and video oculography during free visual exploration. Demographic, risk, and stroke-related factors, as well as stroke localization, were also considered. Feasibility and ability to detect visuospatial neglect of the assessments were evaluated.</p><p><strong>Results: </strong>The overall incidence of visuospatial neglect was ≈38%: widely varying location-specifically: ≈61% and ≈22% for stroke in the right and left cerebral hemispheres, respectively, and ≈14% to ≈37% for some less commonly affected infratentorial areas or multifocal stroke. In hemispheric stroke, visuospatial neglect was most common when the middle (≈64% right and ≈21% left) and posterior (≈53% right and ≈25% left) cerebral artery territories were affected. Neglect patients had higher National Institutes of Health Stroke Scale scores, more commonly atrial fibrillation and thrombectomy, and less commonly an undetermined stroke cause. They were older, with ≈4% yearly increase in the odds of having visuospatial neglect. Video oculography during free visual exploration was administrable and detected visuospatial neglect more often than conventional paper-pencil assessments.</p><p><strong>Conclusions: </strong>The incidence of visuospatial neglect in an unselected cohort, using a highly sensitive assessment, is considerably higher than previously assumed and can also occur after less typically localized strokes. These results can enhance the awareness of visuospatial neglect in the acute setting, potentially facilitating earlier identification and therapy of this disabling disorder.</p>","PeriodicalId":21989,"journal":{"name":"Stroke","volume":" ","pages":""},"PeriodicalIF":7.8,"publicationDate":"2025-04-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143796519","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Application of Human Genetics to Prioritize Coagulation Cascade Protein Targets for Ischemic Stroke Prevention.","authors":"Iyas Daghlas, Ville Karhunen, Anthony S Kim, Dipender Gill","doi":"10.1161/STROKEAHA.124.049808","DOIUrl":"https://doi.org/10.1161/STROKEAHA.124.049808","url":null,"abstract":"<p><strong>Background: </strong>While interindividual variations in concentration and function of coagulation cascade proteins are established risk factors for venous thromboembolism (VTE), their associations with arterial ischemic stroke are less well defined.</p><p><strong>Methods: </strong>We identified and validated genetic proxies for lifelong, randomized perturbations of coagulation cascade proteins in genome-wide association studies of circulating protein levels (deCODE, n=35 559; UK Biobank, n=46 218) and of VTE risk (81 190 cases and 1 419 671 controls). Study participants were all of European ancestry. We performed 2-sample Mendelian randomization and colocalization analyses to test associations of these genetic proxies with risk of ischemic stroke (62 100 cases and 1 234 808 controls from the GIGASTROKE consortium) and ischemic stroke subtypes, and further contextualized associations with VTE and secondary efficacy and safety outcomes.</p><p><strong>Results: </strong>We identified genetic proxies for 30 coagulation factors, with cross-trait associations recapitulating canonical coagulation biology. Mendelian randomization and colocalization analyses supported causal associations of genetically proxied levels of 5 proteins with risk of ischemic stroke, with all proteins associating with the cardioembolic stroke subtype: factor XI (odds ratio [OR] of cardioembolic stroke per 1-SD increase, 1.31 [95% CI, 1.19-1.44]; <i>P</i>=3.30×10^-8), high-molecular-weight kininogen (OR, 1.19 [95% CI, 1.09-1.30]; <i>P</i>=7.79×10^-5), prothrombin (OR, 1.83 [95% CI, 1.31-2.57]; <i>P</i>=4.20×10^-4), soluble PROCR (protein C receptor; OR, 0.88 [95% CI, 0.82-0.95]; <i>P</i>=6.19×10^-4), and γ' fibrinogen (OR per doubling in VTE risk due to lower γ' fibrinogen levels, 1.44 [95% CI, 1.25-1.66]; <i>P</i>=3.96×10^-7). γ' Fibrinogen and prothrombin also associated with large artery atherosclerotic stroke, and no proteins were associated with small vessel stroke risk. By contrast, genetic proxies for several coagulation factors (including proteins C and S and factors V and VII) showed selective associations with VTE.</p><p><strong>Conclusions: </strong>These data highlight specific coagulation cascade components implicated in ischemic stroke pathogenesis, while identifying proteins with distinct roles in VTE. These findings may inform development of novel anticoagulants and optimize their use in targeted populations with stroke.</p>","PeriodicalId":21989,"journal":{"name":"Stroke","volume":" ","pages":""},"PeriodicalIF":7.8,"publicationDate":"2025-04-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143796422","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of White Matter Hyperintensities on Nonverbal Cognition Through Structural Disconnections in Poststroke Aphasia.","authors":"Ida Rangus, Natalie Busby, Alex Teghipco, Rebecca W Roth, Janina Wilmskoetter, Chris Rorden, Argye E Hillis, Dirk B den Ouden, Roger Newman-Norlund, Julius Fridriksson, Leonardo Bonilha","doi":"10.1161/STROKEAHA.124.049058","DOIUrl":"https://doi.org/10.1161/STROKEAHA.124.049058","url":null,"abstract":"<p><strong>Background: </strong>Nonverbal cognitive deficits in poststroke aphasia remain poorly understood. They may result from direct stroke damage or disconnections of preserved cortical regions due to white matter injury, which may be worsened by white matter hyperintensities (WMH). Here, we examined the prevalence of nonverbal cognitive deficits in chronic poststroke aphasia and whether WMH-related disconnections contribute to these deficits beyond those caused by stroke lesions.</p><p><strong>Methods: </strong>Individuals with chronic left hemisphere ischemic or hemorrhagic stroke were enrolled between 2012 and 2021. Nonverbal cognition was assessed using the Matrix Subtest of the Wechsler Adult Intelligence Scale Version IV, the Pyramids and Palm Trees Test, and the Kissing and Dancing Test. Stroke lesions and WMH masks were derived from structural magnetic resonance imaging scans. Disconnection severity from stroke lesions and WMH was quantified across association, commissural, and projection fibers using the Lesion Quantification Toolbox. Hierarchical regression models examined whether WMH-related disconnections explained additional variance in nonverbal cognitive deficits.</p><p><strong>Results: </strong>Among 73 participants (mean age, 59.1±11.9 years; 61.6% male; mean time poststroke, 47.3±52.4 months), nonverbal cognitive deficits were common (Wechsler Adult Intelligence Scale, 27/58 [46.6%]; Pyramids and Palm Trees Test, 44/73 [60.3%]; Kissing and Dancing Test, 32/61 [52.5%]). Lesion-related commissural disconnections were associated with worse Kissing and Dancing Test performance (<i>r</i>[61]=-0.378; <i>P</i>=0.004), whereas WMH-related disconnections across all fiber types were linked to lower Pyramids and Palm Trees Test scores (<i>r</i>[73]=-0.392 to -0.462; <i>P</i><0.001). Interestingly, disconnection severity from stroke lesions was a weak predictor of nonverbal cognitive deficits, but adding disconnection severity from WMH significantly improved the prediction of nonverbal semantic memory as measured by the Pyramids and Palm Trees Test (<i>R</i>² increase from 0.111 to 0.338; <i>P</i><0.001).</p><p><strong>Conclusions: </strong>Disconnections from WMH contribute to nonverbal cognitive deficits, particularly in semantic memory, among individuals with poststroke aphasia. Considering WMH in poststroke aphasia research and rehabilitation may improve the understanding and treatment of cognitive impairments in this population.</p>","PeriodicalId":21989,"journal":{"name":"Stroke","volume":" ","pages":""},"PeriodicalIF":7.8,"publicationDate":"2025-04-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143773177","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Outcomes Following Minimally Invasive Surgery for Intracerebral Hemorrhage in the AHA Get With The Guidelines Registry.","authors":"Santosh B Murthy, Cenai Zhang, Andrew L A Garton, Brian Mac Grory, Shreyansh Shah, Gregg C Fonarow, Lee H Schwamm, Deepak L Bhatt, Eric E Smith, Guido J Falcone, Seyedmehdi Payabvash, Wendy C Ziai, Jared Knopman, Charles C Matouk, J Mocco, Hooman Kamel, Kevin N Sheth","doi":"10.1161/STROKEAHA.124.048650","DOIUrl":"https://doi.org/10.1161/STROKEAHA.124.048650","url":null,"abstract":"<p><strong>Background: </strong>The efficacy of minimally invasive surgery (MIS) in improving outcomes after nontraumatic intracerebral hemorrhage (ICH) remains uncertain, with inconsistent findings from randomized clinical trials. Our objective was to evaluate the real-world impact of MIS on ICH outcomes using a nationally representative cohort.</p><p><strong>Methods: </strong>We performed a retrospective cohort study of patients with a nontraumatic ICH enrolled in the American Heart Association Get With The Guidelines-Stroke Registry between January 1, 2011, and December 31, 2021. We excluded patients with a diagnosis of ischemic stroke or other intracranial hemorrhage subtypes, those who underwent open craniotomy or craniectomy, and patients transferred to another hospital. The exposure was MIS, defined as a composite of stereotactic surgical evacuation and endoscopic surgical evacuation. The primary outcome was in-hospital mortality, while secondary outcomes included functional outcomes at discharge (discharge disposition, ambulatory status, and modified Rankin Scale score). We matched patients who underwent MIS with nonsurgical patients using overlap propensity matching and used multiple logistic regression to study the association between MIS and outcomes.</p><p><strong>Results: </strong>Among 684 467 patients with ICH, 555 964 were included; the mean age was 68 (SD, 15.3) years, and 262 999 (47.3%) were female. MIS was performed in 703 patients of whom 312 had stereotactic surgery and 391 had endoscopic surgery. In the matched cohort, in-hospital deaths occurred in 60 of 446 (13.5%) with MIS and 8321 of 35 361 patients (23.5%) without surgery. In regression analyses, MIS was associated with lower in-hospital mortality (adjusted odds ratio, 0.50 [95% CI, 0.39-0.65]) and favorable discharge disposition (adjusted odds ratio, 1.93 [95% CI, 1.61-2.32]) but not with ambulatory status or functional outcomes. In additional analyses, stereotactic surgery and endoscopic surgery were independently associated with lower mortality.</p><p><strong>Conclusions: </strong>In a large diverse cohort of patients with ICH, MIS was associated with lower in-hospital mortality and favorable discharge disposition. These findings support efforts to understand the durable impact of MIS in patients with ICH.</p>","PeriodicalId":21989,"journal":{"name":"Stroke","volume":" ","pages":""},"PeriodicalIF":7.8,"publicationDate":"2025-04-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143773178","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effects of Intensive Blood Pressure Lowering on Brain Swelling in Thrombolyzed Acute Ischemic Stroke: The ENCHANTED Results.","authors":"Guobin Zhang, Chen Chen, Xinwen Ren, Yang Zhao, Menglu Ouyang, Laurent Billot, Qiang Li, Xia Wang, Luyun Zhang, Sheila Ong, Leibo Liu, Shoujiang You, Richard I Lindley, Thompson G Robinson, Gang Li, Xiaoying Chen, Yi Sui, Craig S Anderson, Lili Song","doi":"10.1161/STROKEAHA.124.049938","DOIUrl":"https://doi.org/10.1161/STROKEAHA.124.049938","url":null,"abstract":"<p><strong>Background: </strong>Cerebral swelling in relation to cytotoxic edema is a predictor of poor outcome in acute ischemic stroke (AIS) and elevated blood pressure (BP) promotes its development. Whether intensive BP-lowering treatment reduces cerebral swelling is uncertain. We aimed to determine whether intensive BP lowering reduces the severity of cerebral swelling after thrombolysis for AIS.</p><p><strong>Methods: </strong>A secondary analysis of the ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study), a partial factorial, international, multicenter, open-label, blinded end point, randomized controlled trial of alteplase dose and levels of BP control in thrombolyzed patients with AIS. Participants were randomly assigned to intensive (systolic target 130-140 mm Hg within 1 hour; maintained for 72 hours) or guideline-recommended (systolic target <180 mm Hg) BP management. Available serial brain images (baseline and follow-up, computed tomography, or magnetic resonance imaging) were centrally analyzed with standardized techniques (Apollo MIStar software) by expert readers blind to clinical details to rate swelling severity (from 0 no to 6 most severe swelling [midline shift and effacement of basal cisterns]) and other abnormalities. Primary outcome was any cerebral swelling (score, 1-6) in logistic regression models.</p><p><strong>Results: </strong>Of 1477/2196 (67.3%) patients (mean age, 67.7 years; female, 39.6%) with sequential scans, the between-group mean systolic BP difference was 6.6 mm Hg over 24 hours. No significant difference was found in the treatment effect on any cerebral swelling between intensive and guideline-recommended BP management (22.12% versus 22.39%, adjusted odds ratio, 1.05 [95% CI, 0.81-1.36]; <i>P</i>=0.71). Results were consistent across different groups of swelling severity (swelling score 2-6, 3-6, and 4-6; and ordinal shift on swelling score).</p><p><strong>Conclusions: </strong>Modest early intensive BP lowering does not seem to alter cerebral swelling in thrombolyzed patients with AIS. Further research is needed to quantify brain edema to allow a better understanding of the complex relations of BP and outcomes from AIS.</p>","PeriodicalId":21989,"journal":{"name":"Stroke","volume":" ","pages":""},"PeriodicalIF":7.8,"publicationDate":"2025-04-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143773170","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Standalone Middle Meningeal Artery Embolization Versus Conservative Management for Nontraumatic Subdural Hematoma.","authors":"Huanwen Chen, Mihir Khunte, Marco Colasurdo, Ajay Malhotra, Dheeraj Gandhi","doi":"10.1161/STROKEAHA.124.050190","DOIUrl":"https://doi.org/10.1161/STROKEAHA.124.050190","url":null,"abstract":"<p><strong>Background: </strong>Recent randomized control trials have demonstrated the efficacy and safety of middle meningeal artery embolization (MMAE) as an adjunct to conventional management for patients with nonacute subdural hematoma (SDH); however, a large majority of trial participants received surgical evacuation as part of the standard of care. Thus, the efficacy and safety of standalone MMAE compared with conservative management (CM) for patients with nonsurgical SDH are unclear.</p><p><strong>Methods: </strong>This was a retrospective cohort study of the 2019 to 2021 Nationwide Readmissions Database in the United States. Patients with nonsurgical nontraumatic SDH were identified, and MMAE patients were matched with similar CM patients using propensity score matching calculated from demographics, comorbidities, and initial hospitalization outcomes. Patients were followed up to 300 days. The primary end point was composite surgical rescue or death, and secondary end points included surgical rescue and all-cause mortality by 180 days.</p><p><strong>Results: </strong>24 465 patients with nonsurgical nontraumatic SDH were identified; 2228 (9.1%) underwent MMAE. After propensity score matching, 6675 patients remained in the CM group and 2217 in the MMAE group. At 180 days, MMAE patients had a significantly lower risk of surgery or death compared with CM (8.2% versus 10.9%; relative risk, 0.75 [95% CI, 0.59-0.96]; <i>P</i>=0.022) and lower risk of death (1.1% versus 3.0%; relative risk, 0.38 [95% CI, 0.17-0.86]; <i>P</i>=0.020). Rates of surgical rescue among MMAE and CM patients at 180 days were similar (7.1% versus 8.4%; relative risk, 0.85 [95% CI, 0.63-1.14]; <i>P</i>=0.27). Time-to-event analyses for the entire 300-day study follow-up period confirmed that while MMAE was associated with a lower cumulative risk of all-cause mortality (hazard ratio, 0.55 [95% CI, 0.35-0.87]; <i>P</i>=0.010), it was not associated with a different risk of surgical rescue (hazard ratio, 1.00 [95% CI, 0.76-1.31]; <i>P</i>=1.00).</p><p><strong>Conclusions: </strong>Standalone MMAE may be beneficial for patients with nonsurgical nontraumatic SDH by reducing the long-term risk of all-cause mortality.</p>","PeriodicalId":21989,"journal":{"name":"Stroke","volume":" ","pages":""},"PeriodicalIF":7.8,"publicationDate":"2025-04-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143773179","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}