European Stroke Journal最新文献

Aneurysmal subarachnoid haemorrhage (aSAH) results from the rupture of an intracranial aneurysm. The case-fatality after aSAH is approximately 40% and those who survive often have functional, cognitive or emotional sequelae. We prepared guidelines according to Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology, using data from meta-analyses, randomised trials, prospective observational and case-control studies, prospective registries with external validation and single-arm cohort studies with > 50 patients with aSAH. Based on high levels of evidence, we recommend oral administration of nimodipine and regular coiling over clipping if both aneurysm treatment options are equally suitable in patients who are in good clinical condition, and recommend against the routine use of antifibrinolytic drugs prior to aneurysm treatment and against the use of tirilazad, statins, magnesium sulphate or endothelin receptor antagonists. Because of lower levels of evidence, no evidence-based recommendations can be made for the prophylactic use of antiplatelet drugs or external lumbar drainage, hypertension induction, treatment of the ruptured aneurysm with endovascular devices other than coils or endovascular treatment of vasospasm. We formulated 37 expert-consensus statements, which include, among others, the suggestions to treat aSAH patients in a dedicated neuro-ICU or high care unit in a centre that treats at least 70 patients with aSAH per year or at least 35 patients with aSAH per year in geographically remote areas, and to treat the ruptured aneurysm within 24 h after ictus provided that the most dedicated team of experts is available. These guidelines present up-to-date recommendations and expert-consensus statements on key aspects in the management of aSAH patients.

Optimal blood pressure (BP) management in acute ischaemic stroke (AIS) and acute ICH remains uncertain. In light of new data published since the previous ESO guidelines, this update provides revised, evidence-based recommendations across 8 key clinical questions to support BP management in acute stroke. The guidelines were developed using the ESO standard operating procedure and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, including literature searches, systematic reviews and meta-analyses of relevant RCTs, assessment of evidence quality and formulation of specific recommendations. We advise against routine pre-hospital BP lowering in suspected stroke (moderate-certainty evidence). In AIS patients undergoing reperfusion therapy, we recommend maintaining BP < 185/110 mmHg before the bolus of intravenous thrombolysis and < 180/105 mmHg during and for 24 h after intravenous thrombolysis (low-certainty evidence) and/or mechanical thrombectomy (moderate-certainty evidence). We recommend against intensively lowering systolic BP < 140 mmHg in the first 24 h after successful mechanical thrombectomy (high-certainty evidence). Routine use of vasopressors to raise BP in AIS patients with neurological deterioration who are not treated with acute reperfusion therapies is discouraged (low-certainty evidence). In acute ICH, the net clinical benefit of intensive BP lowering remains uncertain; however, expert consensus supports early systolic BP reduction to < 140 mmHg in patients with small-to-moderate haematomas to limit haematoma expansion. Overall, the updated recommendations reaffirm the core principles of current clinical practice while providing more nuanced guidance for specific scenarios. However, the quality of evidence remains moderate to very low, limited by a lack of high-quality RCTs, methodological issues, inconsistent results and study heterogeneity. Consequently, most recommendations are weak and supported by expert consensus. These guidelines provide specific recommendations on BP thresholds and management strategies tailored to distinct acute stroke subgroups. They also highlight the ongoing uncertainty and emphasise the need for future RCTs to define optimal BP targets, timing, treatment strategies and ideal antihypertensive agents across different clinical contexts.

Stroke-associated pneumonia (SAP), which occurs in approximately 12%, is the most frequent infectious complication after acute stroke and a major contributor to morbidity and mortality. Despite its clinical importance, high-quality evidence to guide the diagnosis, prediction, prevention and treatment of SAP remains limited, underscoring the need for structured, consensus-based recommendations in stroke care. This guideline was developed following the standard methodology of the European Stroke Organisation (ESO): an interdisciplinary working group identified 15 clinically relevant questions, conducted systematic literature reviews and meta-analyses, appraised the quality of the available evidence and formulated evidence-based recommendations. Notably, only 3 of 15 questions were supported by predominantly low-quality evidence, and most guideline statements therefore rely on expert consensus rather than evidence-based recommendations. For clinical practice, standardised diagnostic criteria are recommended, while chest CT and plasma C-reactive protein may provide additional diagnostic value. Clinical prediction scores and biomarkers demonstrate moderate to good discriminative performance, However, their routine use will depend on the availability of effective preventive measures. Prevention strategies include positioning, early mobilisation and individualised nutritional approaches. Dysphagia screening and swallowing management are established components of post-stroke care for SAP prevention and are addressed in a separate ESO guideline. Adjunctive therapies are not part of standard care but may be considered in selected patients. Preventive antibiotic therapy is not recommended due to a lack of benefit on SAP incidence or clinical outcomes, whereas empirical antibiotic treatment should be initiated promptly after diagnosis and guided by local protocols targeting aspiration-associated pathogens. In addition, this guideline provides a framework for future randomised trials aimed at improving the evidence base for SAP management.

Introduction: The Colchicine for prevention of vascular inflammation in Non-CardioEmbolic stroke (CONVINCE) trial showed that recurrent events were significantly reduced among colchicine-adherent non-cardioembolic stroke patients in the on-treatment analysis. This study aimed to validate the SMART-REACH risk score in stroke patients, and to determine whether colchicine's efficacy varies by baseline atherosclerotic cardiovascular disease (ASCVD) risk.

Patients and methods: Patients with non-severe non-cardioembolic ischaemic stroke/transient ischaemic attack (TIA) were randomised to colchicine 0.5 mg plus usual care or usual care alone. Participants were stratified into moderate (10%-19%), high (20%-30%) and very high (≥30%) 10-year ASCVD risk categories using the SMART-REACH model. Model performance was assessed using the C-statistic and calibration plots. The primary endpoint (major adverse cardiovascular events [MACE]) was a composite of fatal or non-fatal recurrent ischaemic stroke, myocardial infarction, cardiac arrest or hospitalisation for unstable angina.

Results: Among 3144 patients, MACE incidence significantly increased with ASCVD risk levels: 7.2% (moderate), 8.8% (high) and 13.8% (very high) (P < .01). The C-statistic for 3-year risk of MACE was 0.59 (95% CI, 0.56-0.63). While no statistically significant treatment interaction was found (P = .88), absolute risk reductions (ARRs) were more pronounced in higher-risk groups: moderate risk 7.2% (colchicine) vs 7.2% (usual care) (hazard ratio [HR] 1.01; 95% CI, 0.55-1.83); high risk 7.7% vs 9.8% (ARR 2.1%; HR 0.79; 95% CI, 0.53-1.18); very high risk 12.5% vs 15.2% (ARR 2.7%; HR 0.85; 95% CI, 0.64-1.12).

Discussion and conclusion: We identified an association between very high baseline ASCVD risk (≥30%) assigned by the SMART-REACH score and increased recurrent MACE. Although no significant treatment interaction was observed, patients in higher risk categories may represent a more promising target population for secondary prevention with colchicine.

Trial registration: ClinicalTrials.gov Identifier: NCT02898610.

Background: Brain injury due to stroke is an important determinant of long-term disability. The acute lesion visible on MRI with DWI underestimates the total burden of the ischaemic injury. The objectives of this study are: (1) quantify the delayed secondary ischaemic injury volume by calculating the whole and regional brain volume loss at 90-days post-stroke and (2) determine whether brain volume loss independently predicted functional outcome at 90 days.

Methods: REPERFUSE-NA1 is a prospective, multisite MRI sub-study of the ESCAPE-NA1 trial (ClinicalTrialGov #NCT02930018), which randomised participants receiving endovascular therapy (EVT) to nerinetide versus placebo. MRI was acquired immediately after therapy (day 1, <5 hours post-EVT) and at 90-days. The primary outcome was change in whole-brain volume between day 1 and 90. Serial MR metrics were used to generate sample size calculations for future neuroprotectant trials.

Results: A total of 43 patients of mean age 65.1 years (SD = 14.9, 51.2% female, median NIHSS 15 [Q1-Q3 = 11-20]) were included. In the entire cohort, there was significant whole-brain volume loss (P < .001), ventricular enlargement (P < .001), and cortical grey matter (P = .001), subcortical white matter (P < .001), thalamic (P < .001), and hippocampal (P < .001) volume loss in the ipsilateral hemisphere. Baseline DWI volume and ipsilateral hemispheric brain atrophy were significant predictors of functional independence, with P-values of < .001. There was no significant association between nerinetide treatment and volume changes at 90-days. For a prospective 90-day neuroprotectant trial to demonstrate 50% reduction, 41 patients per group would be needed using ventricular volume change.

Conclusion: This study indicates that whole-brain volume loss is a feasible measurement of delayed secondary ischaemic injury. Future neuroprotectant clinical trials could utilise MR-based markers of delayed ischaemic injury.

Introduction: Endovascular thrombectomy is highly effective for large vessel occlusion strokes, yet timely access remains challenging in remote areas. The Flying Intervention Team study demonstrated that dispatching a neurointerventionist team to peripheral hospitals reduces time to treatment. This study evaluates 12-month functional outcomes of enrolled patients.

Patients and methods: This is a secondary analysis of a multicentre pseudo-randomised controlled intervention study comparing 2 systems of care in alternating weeks. The study was conducted in 13 nonurban primary stroke centres in Bavaria, Germany. Of 157 patients enrolled between February 2018 and October 2019, 146 had available 12-month follow-up information. Patients were treated either by the flying team or after interhospital transfer to a referral centre. Primary outcome was the modified Rankin Scale (mRS) score at 12 months in the intention-to-treat analysis. Secondary outcomes included quality of life, activities of daily living and mortality.

Results: Overall, 146 patients were included (median [IQR] age, 75 [66-80] years; 79 [54%] women), 70 in the flying team group and 76 in the transfer group. Median decision-to-puncture time was 89 min shorter in the flying team group. No significant differences were found in successful reperfusion and complication rates. mRS scores at 12 months favoured the flying team (3 [IQR 1-6] vs 4 [2-6]; adjusted common odds ratio, 2.03; 95% CI, 1.09-3.84). Surviving patients had significantly better quality of life (EQ-5D mean [SD] utility score, 0.79 [0.24] vs 0.68 [0.31]). No significant differences were observed in Barthel index or mortality.

Discussion and conclusion: In rural stroke patients, deployment of a flying team was associated with better functional outcomes at 12 months. These findings reinforce the potential for broader implementation of the model to increase equitable access to stroke care.

Introduction: Early care limitation (ECL) after ICH is increasingly recognised, but population-based data on time-dependent determinants remain scarce. We aimed to identify influencing factors of ECL within 72 h from admission and explore differences by sex, haematoma location and stroke-centre type.

Patients and methods: Prospective population-based study of consecutively recruited adults with spontaneous ICH and pre-stroke mRS 0-3, admitted within the first 24 h to any hospital of the Catalan Stroke Network (HIC-CAT registry, 2020-2022). Early care limitation was recorded at 24 h (ECL-24 h) and 72 h (ECL-72 h). Candidate predictors were selected using all-subsets modelling for each time window. Model performance was assessed overall and in predefined subgroups.

Results: Among 1821 patients, ECL-24 h was applied in 355 (19.5%) and an additional 102 had ECL by 72 h, yielding an overall ECL rate of 25.1%. Strongest predictors of ECL-24 h were age, prior anticoagulant use, baseline NIHSS, ICH volume and intraventricular haemorrhage (AUC 0.88). Predictors of ECL-72 h were age, prior anticoagulant use, pre-stroke mRS, baseline NIHSS and early neurological deterioration within 72 h (AUC 0.90). Across subgroups, AUCs ranged from 0.85 to 0.90, with lower performance in infratentorial ICH for ECL-72 h and in telestroke centres. Among ECL-24 h patients, 39 (11%) achieved 3-month favourable functional outcome, whereas no patients with ECL-72 h achieved this outcome.

Conclusion: Early care limitation after ICH is frequent and its determinants differ by timing. In our study, very early decisions rely mainly on the static severity at admission, whereas later decisions incorporate neurological deterioration and appear to better align with prognosis. These findings support deferring ECL decisions until clinical evolution can be observed.

Introduction: Patients with symptomatic carotid stenosis are at increased risk for recurrent ischaemic stroke. Plaque burden on MRI has been shown to independently predict (recurrent) ischaemic stroke. However, CT is usually preferred in acute stroke patients due to its availability and rapid scan time. We examined whether carotid plaque burden on CTA can also independently predict (recurrent) ipsilateral ischaemic cerebrovascular symptoms in patients with symptomatic carotid stenosis.

Patients and methods: In the Plaque At RISK (PARISK) study, recently symptomatic patients with < 70% carotid stenosis underwent a carotid CTA at baseline. Plaque burden was quantified as total plaque volume (μL) of the ipsilateral carotid artery using semiautomated segmentation. Cox proportional hazards models were used to assess whether plaque burden on CTA was associated with recurrent ipsilateral ischaemic events. Plaque burden was added to an existing prediction model (ECST score) to determine additional predictive value.

Results: During a median follow-up of 5.1 [IQR: 3.4-5.7] years, 26 of 199 patients experienced a (recurrent) ipsilateral TIA or stroke. A larger plaque burden increased the risk of recurrent ipsilateral stroke or TIA (HR = 1.07 [95% CI, 1.00-1.14] per 100 μL increase; P = .04). Performance of the ECST score increased from a C-statistic of 0.65-0.70 upon addition of plaque burden.

Discussion: The association between CTA-based plaque burden and recurrent ischaemic events aligns with previous MRI-based findings, suggesting that CTA can provide predictive value when MRI is unavailable.

Conclusions: Plaque burden on CTA is an independent predictor for recurrent ipsilateral stroke or TIA in symptomatic patients with a < 70% carotid stenosis.