International Journal Of Stroke[JOURNAL]
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200 papers
Prehospital stroke care in low- and middle-income countries: A World Stroke Organization (WSO) scientific statement.
Bosch J, Lotlikar R, Melifonwu R … +16 more , Roushdy T, Sebastian I, Abraham SV, Benjamin L, Li D, Ford G, Heldner M, Langhorne P, Liu R, Malewezi E, Olaleye OA, Pandian J, Urimubenshi G, Waters D, Zhao J, Rudd A
Int J Stroke · 2025 Oct · PMID 40495741 · Full text
Evidence-based prehospital stroke care is effective in reducing stroke-related mortality and morbidity. The crucial period from symptom awareness to presentation at the hospital, the first step in the World Stroke Organi...
Evidence-based prehospital stroke care is effective in reducing stroke-related mortality and morbidity. The crucial period from symptom awareness to presentation at the hospital, the first step in the World Stroke Organization Road Map to Quality Care, is under-resourced in the majority of low- and middle-income countries (LMICs). Key challenges focus on a lack of stroke action awareness as well as human resources trained in stroke care. We aimed to identify prehospital stroke practices in LMICs and identify where innovation may address service gaps. We conducted scoping reviews focused on key domains of prehospital stroke care in LMICs that include organization of services, stroke action awareness in the community, educating primary care physicians and traditional/faith healers, diagnostic tools for prehospital stroke detection, and emergency medical service (EMS) provision. We sought to determine current practices and gaps in LMICs and evidence on effective interventions to address gaps in each domain. Recommendations are provided identifying priority considerations in each domain, based on evidence, and where lacking, expert opinion. Key recommendations include the need for adequately funded national-level strategies for prehospital stroke care; stroke action awareness education for the public, primary care physicians, community health workers, EMSs, and traditional and faith healers; affordable imaging solutions; and approaches to create or improve prehospital EMS (e.g., protocols). We found that efforts, although few, have been made to address gaps in LMICs; however, they have rarely been evaluated, and it is unclear if they are sustained. The required elements necessary to improve prehospital services and stroke outcomes are known. Creativity is and perseverance are required for implementation to ensure sustainability. This scientific statement has been reviewed and approved by the World Stroke Organization Executive.
Statin use is associated with reduced risk of incident intracerebral hemorrhage: A prospective population-based cohort study.
Hu X, Wang Z, Liu J … +5 more , Liu X, Luo J, Meng Z, Yang T, Li Q
Int J Stroke · 2025 Dec · PMID 40492652 · Publisher ↗
BACKGROUND: The association between statin use and the risk of incident intracerebral hemorrhage (ICH) remains controversial, with concerns about a potential increased risk of ICH among statin users. AIMS: This study aim...
BACKGROUND: The association between statin use and the risk of incident intracerebral hemorrhage (ICH) remains controversial, with concerns about a potential increased risk of ICH among statin users. AIMS: This study aimed to investigate the association between statin use and incident ICH in the general population. METHODS: This prospective cohort study utilized data from UK Biobank. Cox proportional regression models were employed to estimate hazard ratios (HRs) for the association between statin use and incident ICH in both unmatched and propensity score-matched (PSM) cohorts, adjusting for sociodemographic characteristics, lifestyle factors, comorbidities, and concurrent medication use. RESULTS: A total of 421,444 participants were included in the final analysis, with a median age of 58.0 years (interquartile range [IQR]: 50.0-63.0), and 53.9% were female. At baseline, 69,272 individuals reported regular statin use. Over a median follow-up period of 12.75 years (IQR: 11.30-14.21), 1533 participants (0.4%) experienced incident ICH. Multivariate Cox regression analyses showed that statin use was significantly associated with a reduced risk of ICH in the fully adjusted model (aHR 0.77; 95% CI 0.66-0.90). This association was significant among individuals without a history of coronary artery disease, stroke or transient ischemic attack (aHR 0.75; 95% CI 0.63-0.89). Potential interaction effects were identified between statin use and age ( for interaction = 0.027 in the total cohort), waist-to-hip ratio, and low-density lipoprotein cholesterol levels ( for interaction = 0.025 and 0.062, respectively, in the PSM cohort) in relation to ICH risk. CONCLUSION: In this large population-based study, statin use was associated with a reduced risk of incident ICH, providing further evidence for the long-term safety of statin therapy with respect to ICH risk in the general population and across diverse subgroups.Data access statement:UK Biobank database is available on application by approved researchers.
Sex-specific risk prediction models for aneurysmal subarachnoid hemorrhage-A UK Biobank study.
Rissanen I, Klieverik VM, Kanning JP … +2 more , Geerlings MI, Ruigrok YM
Int J Stroke · 2025 Dec · PMID 40481738 · Full text
BACKGROUND: We recently developed and validated the SMASHERS risk prediction model for aneurysmal subarachnoid hemorrhage (ASAH) in the general population (c-statistic 0.62; 95% confidence interval [CI] 0.60-0.64). Given...
BACKGROUND: We recently developed and validated the SMASHERS risk prediction model for aneurysmal subarachnoid hemorrhage (ASAH) in the general population (c-statistic 0.62; 95% confidence interval [CI] 0.60-0.64). Given that women have higher ASAH incidence than men, and that predictors for ASAH have different effect sizes between sexes, we developed sex-specific risk prediction models. METHODS: Data from the prospective UK Biobank Study were used for model development. Participants with ASAH (per hospital-based ICD codes) before baseline or with missing predictor data were excluded. We developed multivariable Cox proportional hazards models for women and men separately to study the association between earlier recognized SMASHERS predictors and incident ASAH. Predictive performances were assessed with c-statistics and calibration plots and corrected for overfitting using bootstrapping. RESULTS: A total of 246,771 women and 210,085 men were included with median follow-up of 12 years. ASAH incidence rate per 100 000 person years was 16.1 in women, and 10.7 in men. The women-specific model had a c-statistic of 0.63 (95% CI 0.60-0.65) and the mean predicted absolute 10-year ASAH risk was 0.15%. Independent predictors for women were higher age, family history of stroke, former and current smoking, alcohol consumption, and intermediate education. The men-specific model c-statistic was 0.57 (95% CI 0.53-0.60) and the mean 10-year risk 0.10%. Independent predictors for men were higher age, hypertension, and smoking status. CONCLUSION: The sex-specific models did not perform better than the general SMASHERS model in women or in men. Further validation studies are needed before clinical use can be recommended.
Ayurvedic treatment in the rehabilitation of ischemic stroke patients in India: A randomized controlled trial (RESTORE).
Sylaja PN, Nambiar V, Narayan S … +14 more , Pr J, Kumar CS, Nk P, Menon MM, Berieau VB, Nair D, Dhasan A, Arora D, Verma SJ, Sharma M, Dhaliwal RS, Sarma PS, Pandian JD, RESTORE trial collaborators
Int J Stroke · 2025 Dec · PMID 40476511 · Publisher ↗
BACKGROUND: The effect of Ayurvedic Rehabilitation therapy (ART) in improving the sensorimotor recovery of patients with ischemic stroke is unclear irrespective of the fact that ayurveda is a commonly practiced alternate...
BACKGROUND: The effect of Ayurvedic Rehabilitation therapy (ART) in improving the sensorimotor recovery of patients with ischemic stroke is unclear irrespective of the fact that ayurveda is a commonly practiced alternate system of medicine in India and south Asia. The trial hypothesized that ayurvedic treatment is superior to physiotherapy (PT) in recovery of ischemic stroke patients. METHODS: We performed investigator-initiated, multi-center prospective, parallel arm randomized controlled trial (RCT) with blinded outcome assessment across four comprehensive stroke centers in India. Participants were randomly assigned in a 1:1 ratio to the ART arm (intervention group) or on to the PT arm (control group). The primary outcome was sensory motor recovery of upper extremity assessed using Fugl Meyer Assessment-upper extremity (FMA-UE) and secondary outcome, a composite of functional disability, activities of daily living, postural balance and quality of life at 1- and 3-month follow-up. The safety outcomes were serious adverse events during the study duration. RESULTS: Of 403 participants screened, 140 patients were enrolled, 70 in intervention (ART) and 70 in control (PT) group. At 3 months, compared with ayurveda group, the sensory motor impairment (FMA-UE) score was significantly better in the PT group (71.97 ± 23.88 vs. 81.97 ± 24.57, p = 0.023) but after adjusting for age, stroke severity, baseline FMA-UE scale and risk factors, the group differences were not significant (p = 0.057). None of the secondary outcomes were significantly better in the ayurveda group. During the trial, no major serious adverse events were reported. CONCLUSION: This pragmatic first-ever RCT of ayurveda in stroke looked into the benefit of ayurveda treatment in first ever stroke survivors. The current intervention protocol of ART was not superior to PT in improving the sensorimotor recovery of patients with ischemic stroke. This is the first RCT of its kind.
Low vegetable consumption doubles the odds of stroke among people with hypertension: Findings from the SIREN Study in West Africa.
Asowata OJ, Bodunde I, Okekunle AP … +47 more , Akpa OM, Danladi DK, Fakunle AG, Komolafe MA, Obiako R, Wahab K, Akinyemi J, Akpalu A, Adebajo O, Uwanuruochi K, Olowookere S, Arulogun O, Singh A, Olowoyo P, Olalusi O, Ogbole GI, Amusa GA, Adeniyi S, Chukwuonye II, Ogah O, Isah SY, Ibinaiye PO, Oguntade A, Olabinri E, Adeyemo A, Balogun O, Calys-Tagoe B, Adebayo P, Appiah L, Ajose A, Ogunmodede A, Adeoye A, Shindali V, Bello AH, Agunloye AM, Onyenonoro U, Olunuga T, Efidi RC, Adebayo O, Rabiu M, Adesina J, Oguike W, Owolabi A, Sarfo FS, Akinyemi R, Ovbiagele B, Owolabi M
Int J Stroke · 2025 Oct · PMID 40476509 · Publisher ↗
BACKGROUND: While hypertension is a primary risk factor for higher stroke risk, adequate vegetable consumption has been linked with a lower odds of stroke. However, it is unclear whether low/inadequate vegetable consumpt...
BACKGROUND: While hypertension is a primary risk factor for higher stroke risk, adequate vegetable consumption has been linked with a lower odds of stroke. However, it is unclear whether low/inadequate vegetable consumption could aggravate the odds of stroke among people with hypertension. This study assessed the interaction of low vegetable consumption and hypertension with stroke among West Africans. METHODS: In this case-control study, 3684 stroke cases (aged ⩾ 18 years) matched for age ±5 years, sex, and ethnicity, with 3684 healthy controls were recruited across multiple sites in Nigeria and Ghana. Hypertension was defined using standard guidelines, and vegetable consumption was assessed with a food frequency questionnaire. Multivariable-adjusted conditional logistic regression and interaction models were used to estimate the odds ratios (OR) with a 95% confidence interval (CI) of stroke and the synergistic interaction of both low vegetable consumption (< 6 servings per week) and hypertension. The attributable proportion (AP), relative excess risk due to interaction (RERI), and synergy index (SI) were estimated at a two-sided < 0.05. RESULTS: Overall, the mean age was 59.0 ± 14.9 years, and 45.8% (3376) were female. Among stroke cases, the prevalence of low vegetable consumption and hypertension was 68.1% (2508) and 95.9% (3480), respectively. The multivariable-adjusted odds of stroke, given low vegetable consumption with hypertension, were OR = 25.66 (95% CI = 16.65, 39.54) with an RERI of 13.40 (95% CI = 7.21, 19.59), AP of 0.52 (95% CI = 0.44, 0.60), SI of 2.19 (95% CI = 1.82, 2.63), and a multiplicative interaction of about 50%; 1.51 (95% CI = 0.91, 2.49). CONCLUSION: The odds of stroke double with low vegetable consumption among people with hypertension in this population.
Characteristics and outcomes in patients with in-hospital stroke: Japan stroke data bank.
Usui K, Yoshimura S, Wada S … +14 more , Toyoda K, Miwa K, Koge J, Ishigami A, Shiozawa M, Miyamoto Y, Yazawa Y, Kobayashi T, Handa A, Wada N, Mizoue T, Nishiyama K, Minematsu K, Koga M
Int J Stroke · 2025 Dec · PMID 40476508 · Publisher ↗
PURPOSE: We aimed to clarify the clinical characteristics and outcomes of patients with in-hospital onset ischemic stroke (IOS) compared with those in patients with community-onset ischemic stroke (COS). METHODS: Patient...
PURPOSE: We aimed to clarify the clinical characteristics and outcomes of patients with in-hospital onset ischemic stroke (IOS) compared with those in patients with community-onset ischemic stroke (COS). METHODS: Patients from the Japan Stroke Data Bank, a hospital-based multicenter prospective registry, who were diagnosed with acute ischemic stroke (AIS) within 24 h of onset between January 2001 and December 2020 were included in this study. We assessed favorable outcomes at discharge corresponding to a modified Rankin Scale (mRS) score of 0-2, unfavorable outcomes corresponding to an mRS score of 5-6, and mortality. We also examined trends in these outcomes at 4-year intervals over a period of 20 years. RESULTS: Of the 100,865 patients analyzed, 2979 had IOS (1416 women, mean age 77 ± 12 years) and were older than those with COS (n = 97,886; 39,110 women, mean age 74 ± 12 years). Multivariate analysis revealed that younger age, higher premorbid mRS score, absence of stroke history, normotension, congestive heart failure, coronary artery disease, chronic kidney disease, liver disease, malignancy, tendency to bleed, and cardioembolic stroke were positively associated with IOS. Compared with COS, IOS was inversely associated with a favorable outcome (42.1% vs 64.8%, adjusted odds ratio [aOR] 0.72 [95% confidence interval (CI) 0.63-0.82]), positively associated with an unfavorable outcome (mRS 5-6 at discharge; 34.3% vs 15.5%, aOR 1.31 [95% CI 1.16-1.48]), and mortality (11.8% vs 4.6%, aOR 1.59 [95% CI 1.37-1.84]). Over 20 years, the mortality rate significantly decreased in both patients with IOS and COS ( < 0.01 both). CONCLUSION: IOS is associated with unfavorable outcomes and higher mortality rates during acute hospitalization. The mortality rates in patients with IOS decreased over time, similar to those observed in patients with COS.
Early neurological improvement with deferoxamine after intracerebral hemorrhage: A post hoc analysis of the i-DEF trial.
Polymeris AA, Lioutas VA, Foster LD … +9 more , Incontri D, Heistand EC, Marchal J, Lazar A, Fischer U, Engelter ST, Seiffge DJ, Yeatts SD, Selim MH
Int J Stroke · 2025 Dec · PMID 40418029 · Full text
BACKGROUND: Little is known about early major neurological improvement (EMNI) after intracerebral hemorrhage (ICH). AIMS: We performed a post hoc analysis of the Intracerebral Hemorrhage-Deferoxamine trial (i-DEF; NCT021...
BACKGROUND: Little is known about early major neurological improvement (EMNI) after intracerebral hemorrhage (ICH). AIMS: We performed a post hoc analysis of the Intracerebral Hemorrhage-Deferoxamine trial (i-DEF; NCT02175225) to comprehensively evaluate EMNI and assess whether deferoxamine treatment affects it. METHODS: Comparing repeated assessments of National Institutes of Health Stroke Scale (NIHSS) on days 2, 3, 4, and 7 (or discharge, if it was earlier) versus NIHSS score at presentation, and defining EMNI as an NIHSS score decrement of an absolute ⩾4 points from presentation, we determined its presence or absence on day 2, day 3, day 4, and day 7(/discharge). Using adjusted generalized linear mixed-effects or logistic models as appropriate, we examined the association of deferoxamine with EMNI as repeated measure, as well as EMNI's overall frequency, time course, determinants, and association with favorable long-term outcome (modified Rankin Scale 0-2). RESULTS: Among 291 i-DEF participants in the modified intention-to-treat population (median age 61 years, 38.5% female, median NIHSS score 13, 144 randomized to deferoxamine and 147 to placebo), the proportion of participants with EMNI continuously increased from 20% on day 2 to 36% on day 7(/discharge). Deferoxamine was associated with an average twofold higher odds of EMNI (odds ratio (OR): 2.30, 95% confidence interval (CI): 1.07 to 4.95, p = 0.033 after adjustment for the prespecified trial covariates onset-to-treatment time, baseline ICH volume, and presenting NIHSS score), without clear evidence for treatment-by-time interaction (p = 0.092). Secondary and sensitivity analyses using alternative EMNI definitions (as relative ⩾20% or ⩾30% NIHSS score decrement) and additional covariate adjustment yielded consistent findings. Race, ICH volume and location were also associated with EMNI. EMNI was independently associated with twofold to sixfold higher odds of favorable 90-day and 180-day outcome, regardless of assessment timepoint. CONCLUSION: In a post hoc analysis of the i-DEF trial, the likelihood of EMNI over the first week following ICH was higher with deferoxamine. EMNI showed a continuous upward trajectory and strong association with favorable long-term functional outcome.
The long-term risk of atrial fibrillation after ischemic stroke: A propensity score matching analysis.
Kang J, Yoo JE, Ko TY … +6 more , Kim Y, Kim B, Chang WH, Park YM, Han K, Shin DW
Int J Stroke · 2025 Dec · PMID 40418027 · Publisher ↗
BACKGROUND: Although atrial fibrillation (AF) is a known risk factor for ischemic stroke (IS), few studies have evaluated the risk of AF after IS. AIM: We evaluated associations between IS and subsequent AF risk in the K...
BACKGROUND: Although atrial fibrillation (AF) is a known risk factor for ischemic stroke (IS), few studies have evaluated the risk of AF after IS. AIM: We evaluated associations between IS and subsequent AF risk in the Korean population. METHODS: We identified 98,076 participants newly diagnosed with IS between 2010 and 2018 who underwent health screening within the 2 years prior to IS diagnosis, and 98,076 propensity score matched controls were included. The risk of AF was estimated using a Fine and Gray model, with death as a competing event. RESULTS: During the mean follow-up period of 4.7 years, 9611 participants developed AF (6728 with IS and 2883 controls). The IS patients had a greater risk of AF (sub-distribution hazard ratio [sHR] 2.32, 95% confidence interval [CI] 2.22-2.42) than the controls, and this association was more prominent during the first year after IS (sHR 7.32, 95% CI 6.59-8.13). After 1 year, the increased risk of AF was attenuated but remained elevated (sHR 1.64, 95% CI 1.56-1.73). While IS patients with severe disability had the greatest risk of AF during the first year after IS (sHR 8.92, 95% CI 7.23-11.01), this finding was not evident after more than 1 year. CONCLUSIONS: The IS patients were at significantly greater risk of AF during the first year following IS diagnosis. Although the risk was attenuated after 1 year, it remained elevated. Physicians should be aware of the elevated risk of AF in IS patients and take appropriate measures to identify and treat AF.
Stroke care in indigenous populations: A World Stroke Organization (WSO) scientific statement.
Ranta A, Hart M, Dos Santos A … +10 more , Balabanski AH, Siri SRA, Zavaleta-Cortijo C, Duncan S, Yu AY, Thresia CU, Stewart T, Kelliher A, Warne D, Jones B
Int J Stroke · 2025 Oct · PMID 40415682 · Full text
BACKGROUND: Indigenous Peoples have been reported to experience higher rates of stroke, poorer access to high-quality acute and rehabilitation stroke services, and worse post-stroke outcomes compared to dominant cultures...
BACKGROUND: Indigenous Peoples have been reported to experience higher rates of stroke, poorer access to high-quality acute and rehabilitation stroke services, and worse post-stroke outcomes compared to dominant cultures residing in the same countries. The aim of this statement is to summarize available evidence on access barriers contributing to these inequities, effective solutions that have been deployed and tested, and present key recommendations to advance the field. METHODS: We conducted a scoping review searching Medline, Embase, CINHAL, PubMed, Scopus, and Informit Indigenous Collection using the broad search terms "stroke" and "Indigenous" without date restriction until 1 August 2024. We screened 673 unique titles, 96 abstracts, and 80 full-text papers of which we retained 41. We added 10 additional key references known to authors. Articles were analyzed to identify key cross-cutting themes. RESULTS: We identified five key themes: (1) Historical context, colonization and racism; (2) wholistic strength-based approaches to health, well-being, and recovery; (3) communication, health literacy, and cultural safety; (4) Indigenous knowledge systems, research principles, and community-led action; (5) achieving local acceptance versus wide generalizability. RECOMMENDATIONS: Key priority areas, detailed in the form of 11 specific recommendations and based on six core values, include improving stroke service responsiveness, Indigenous Peoples empowerment, and Indigenous research support to better meet the needs of Indigenous Populations globally. The statement has been reviewed and approved by the WSO Executive Committee.
Moya-Moya angiopathy, falls after stroke, post-stroke dementia, and infection as a trigger for stroke.
Markus HS
Int J Stroke · 2025 Jun · PMID 40391717 · Publisher ↗
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Incidence, characteristics, and consequences of fractures after acute ischemic stroke and TIA-A prospective cohort study.
Karisik A, Dejakum B, Moelgg K … +24 more , Granna J, Felicetti S, Pechlaner R, Mayer-Suess L, Toell T, Buergi L, Scherer L, Willeit K, Heidinger M, Lang C, Ferrari J, Krebs S, Kleyhons R, Resch H, Willeit J, Seekircher L, Tschiderer L, Willeit P, Sykora M, Schett G, Lang W, Knoflach M, Kiechl S, Boehme C
Int J Stroke · 2025 Oct · PMID 40391684 · Full text
BACKGROUND: Recent advances in acute stroke therapy improved short-term outcome, but some of this benefit may be lost due to post-stroke complications, including fractures. AIMS: We assessed the incidence of fractures be...
BACKGROUND: Recent advances in acute stroke therapy improved short-term outcome, but some of this benefit may be lost due to post-stroke complications, including fractures. AIMS: We assessed the incidence of fractures before and after stroke and transient ischemic attack (TIA), the risk factors for fractures, and the consequences for mortality, functional outcome, and quality of life. METHODS: Consecutive patients with acute ischemic stroke or TIA from the prospective STROKE-CARD Registry and the randomized controlled STROKE-CARD trial and its long-term follow-up were analyzed. We prospectively assessed all fractures using self-report and documentation, records of hospitals and general practitioners, and electronic health records with all radiographs. RESULTS: A total of 2513 patients were included (median age = 72 years (interquartile range, IQR = 61-79), 39.2% female). In the first year after the event, 145 individuals (5.8%, 95% confidence interval (CI) = 4.9%-6.7%) experienced 152 fractures corresponding to an incidence rate of 61.87 (95% CI = 52.04-71.71) per 1000 person-years. Rates were similar after stroke and TIA (60.84 and 72.28 per 1000 person-years). The incidence of fractures was more than five times higher compared to the general population (age- and sex-adjusted hazard ratio (HR) for first fracture 5.36, 95% CI = 2.49-11.52). The risk of fractures 1 year before stroke/TIA was also increased (HR = 2.99, 95% CI = 1.39-6.42). Stroke/TIA further increased the risk of fractures as documented by a comparison between fractures 1 year before and 1 year after the event (age- and sex-adjusted risk ratio = 1.69, 95% CI = 1.10-2.58). The main risk factors for fractures were falls and osteoporosis. Fracture after stroke/TIA was associated with death (adjusted odds ratio (aOR) = 2.16, 95% CI = 1.20-3.89), inability to walk (aOR = 2.06, 95% CI = 1.08-3.93), and poor quality of life. CONCLUSIONS: Patients with ischemic stroke and TIA are at high risk for future fractures. Fracture after stroke/TIA is strongly associated with death, poor functional outcome, and reduced health-related quality of life. Therefore, there is a need to incorporate fracture prevention into post-stroke care to improve patient outcomes. TRIAL REGISTRATION: STROKE-CARD Registry (NCT04582825, https://clinicaltrials.gov/study/NCT04582825); STROKE-CARD trial (NCT02156778, https://clinicaltrials.gov/study/NCT02156778); STROKE-CARD long-term follow-up (NCT04205006, https://clinicaltrials.gov/study/NCT04205006).
Frailty and stroke: Global implications for assessment, research, and clinical care-A WSO scientific statement.
Evans NR, Pinho J, Beishon L … +8 more , Nguyen T, Ganesh A, Balasundaram B, Munthe-Kaas R, Hewitt J, Gandhi DBC, Quinn TJ, Lindley RI
Int J Stroke · 2025 Oct · PMID 40390672 · Full text
Frailty is common in stroke and has important disease- and treatment-modifying effects. The need to develop clinical practice and research for the impact of frailty on stroke is likely to increase in the coming decades a...
Frailty is common in stroke and has important disease- and treatment-modifying effects. The need to develop clinical practice and research for the impact of frailty on stroke is likely to increase in the coming decades as the global population ages, resulting in a higher burden of frailty that is likely to be borne disproportionately by lower- and middle-income countries.The global nature of frailty in stroke necessitates global action. This World Stroke Organization Scientific Statement synthesizes the current evidence relating to the prevalence and effects of frailty across the stroke pathway. Furthermore, it includes expert consensus on priority areas from a global panel: standardization of frailty assessments for research, explicit measurements of frailty (in addition to disability) in large clinical trials, dedicated studies investigating the treatment-modifying effects of frailty in acute stroke and secondary prevention, research investigating the impact of frailty on the different aspects of recovery and rehabilitation after stroke, and understanding the mechanisms underpinning the relationship between frailty and stroke for potential therapeutic exploitation.This scientific statement has been reviewed and approved by the World Stroke Organization Executive.
Argatroban plus dual antiplatelet therapy versus dual antiplatelet alone for acute atherothrombotic cerebral infarction.
Nakashima S, Kodama S, Aso S … +8 more , Jo T, Yasunaga H, Isogai T, Matsui H, Shirota Y, Fushimi K, Toda T, Hamada M
Int J Stroke · 2025 Oct · PMID 40375365 · Publisher ↗
BACKGROUND: Dual antiplatelet therapy (DAPT) is more effective than aspirin alone in preventing early recurrences of non-cardioembolic strokes. In Japan, DAPT is often combined with argatroban, a direct thrombin inhibito...
BACKGROUND: Dual antiplatelet therapy (DAPT) is more effective than aspirin alone in preventing early recurrences of non-cardioembolic strokes. In Japan, DAPT is often combined with argatroban, a direct thrombin inhibitor, for treating acute atherosclerotic stroke. However, the safety and effectiveness of this combination compared with those of DAPT alone remains unclear. METHODS: We identified patients with acute atherothrombotic stroke treated with DAPT between April 2016 and March 2022, using the Diagnostic Procedure Combination database, a large national inpatient database in Japan. Patients were divided into two groups: those receiving DAPT plus argatroban and those receiving DAPT alone. We compared 7-day mortality, hemorrhagic complications, and readmission for stroke recurrence within 90 days between the groups using propensity-score overlap weighting analyses. RESULTS: Of 59,983 eligible patients, 47,213 received DAPT plus argatroban, while 12,770 received DAPT alone. In the propensity-score overlap weighting analyses, no significant differences in 7-day mortality (0.2% vs 0.2%; adjusted risk ratio [aRR], 0.77; 95% confidence interval [CI], 0.49-1.21), the proportions of hemorrhagic complications (2.3% vs 2.1%; aRR, 1.12; 95% CI, 0.99-1.27), or 90-day readmission for stroke recurrence (1.2% vs 1.2%; aRR, 0.99; 95%CI, 0.84-1.17) were observed between the DAPT plus argatroban and DAPT alone groups. CONCLUSIONS: The outcomes did not differ significantly between DAPT alone and argatroban combined with DAPT for acute atherothrombotic stroke.
Cost-effectiveness of population-wide screening for intracranial aneurysms revisited in light of potential diagnostic developments.
Veldeman M, Schoeffski O, Hoellig A … +1 more , Rinkel GJE
Int J Stroke · 2025 Oct · PMID 40356019 · Full text
BACKGROUND: Preventive treatment of unruptured intracranial aneurysms (UIAs) has the potential to reduce aneurysmal subarachnoid hemorrhage (SAH) incidence. Population-wide screening (PWS) for UIAs has been disregarded,...
BACKGROUND: Preventive treatment of unruptured intracranial aneurysms (UIAs) has the potential to reduce aneurysmal subarachnoid hemorrhage (SAH) incidence. Population-wide screening (PWS) for UIAs has been disregarded, as it remains unclear how to manage low-risk UIAs. Higher cost for SAH treatment, along with improvements in UIA treatment decision-making, might improve the risk-benefit and cost-benefit ratios for PWS. Currently, blood-based screening tests for UIAs are under development and might be suitable for use in PWS. AIMS: This study sets out to identify what health economic criteria should be met by a hypothetical UIA screening test to justify PWS. METHODS: A Markov model was built to compare PWS versus standard of care. Model parameterization was done using real-world data derived from the population cared for by the RWTH Aachen University Hospital. Data in relation to SAH were derived from a prospective registry of consecutive SAH patients (n = 275). In addition, a database of newly diagnosed UIAs was retrospectively collected (n = 139). Incremental cost-effectiveness ratios (ICERs) were calculated to illustrate the annual cost per additional quality-adjusted life year (QALY). Sensitivity analyses were performed to determine at which price point the PWS strategy would become cost-effective based on different levels of willingness-to-pay (WTP). RESULTS: In a one-way sensitivity analysis, the price of a hypothetical screening test was varied between €1 and €811.3 (mean cost of magnetic resonance angiography). In case of a WTP of €50,000 per QALY gained, the cost per test may be €225.72 and remain cost-effective. If the same test could also be used for watchful-waiting in low-risk patients (i.e. assess the risk of aneurysm growth), the price may increase up to €294.19. There is no price point at which PWS would become dominant and yield negative ICERs. CONCLUSION: PWS for UIAs is unlikely to be cost-effective, even with new blood screening technologies. However, once patents expire, and price monopolies are broken, use of such technologies may become more attractive for health policymakers, depending on their WTP.
Intravenous thrombolysis versus endovascular thrombectomy in acute basilar artery occlusion-A multicenter cohort study.
Räty S, Strambo D, Gomez-Exposito A … +14 more , Marto JP, Ramos JN, Krebs S, Virtanen P, Ritvonen J, Abdalkader M, Klein P, Sairanen T, Sykora M, Lindsberg PJ, Poli S, Michel P, Nguyen TN, Strbian D
Int J Stroke · 2025 Oct · PMID 40356017 · Full text
BACKGROUND: Randomized controlled trials have demonstrated an improved outcome of basilar artery occlusion (BAO) with endovascular thrombectomy (EVT) compared to best medical treatment. However, a minority of the patient...
BACKGROUND: Randomized controlled trials have demonstrated an improved outcome of basilar artery occlusion (BAO) with endovascular thrombectomy (EVT) compared to best medical treatment. However, a minority of the patients recruited up to 12-24 h from onset in the positive trials received intravenous thrombolysis (IVT), and a trial with a higher IVT rate did not show superiority of EVT. Thus, the efficacy and safety of EVT compared to IVT for BAO remain less clear. AIMS: We aimed to compare outcomes after IVT alone to EVT with or without IVT for acute BAO. METHODS: This international, observational, retrospective study included patients who received recanalization therapy for BAO at six centers between January 2010 and March 2024. The primary outcome was 3-month modified Rankin Scale (mRS) score 0-3, and secondary outcomes comprised mRS 0-2, ordinal mRS, mortality, and symptomatic intracranial hemorrhage. Outcomes after IVT versus EVT ± IVT were compared using inverse probability-weighted regression adjustment models adjusting for known predictors of outcome in BAO and baseline variables differing between the treatment groups. Interaction of the treatment group with symptom severity and onset-to-treatment time was tested. RESULTS: Of 523 patients with BAO (median age 69, 35.2% women), 28.9% received IVT and 71.1% EVT ± IVT. The IVT-alone group had a lower baseline National Institutes of Health Stroke Scale score (median 11 vs 15) but equally extensive ischemic changes in baseline imaging. After inverse probability-weighted regression adjustment, the IVT-alone group had higher odds of mRS 0-3 (adjusted odds ratio (aOR) = 2.33 [95% confidence interval (CI) = 1.31-4.12]), mRS 0-2 (aOR = 1.93 [95% CI = 1.12-3.30]), lower median mRS (aOR = 1.81 [95% CI = 1.21-2.71]), and lower mortality (aOR = 0.53 [95% CI = 0.29-0.97]), but no difference in symptomatic intracranial hemorrhage (aOR = 0.81 [95% CI = 0.28-2.36]). No interactions for the primary outcome were found. CONCLUSION: In this study, patients with BAO had better outcome after IVT than EVT ± IVT independent of symptom severity and time from onset. Although the non-randomized design of the study warrants caution, the results encourage further trials comparing EVT and IVT to guide recanalization therapy in BAO patients.Data access statement:Anonymized data are available upon reasonable request to the corresponding author following the national legislation.
Nationwide analysis of routine clinical practices in the management of acute ischemic stroke patients in China.
Liu Y, Luo X, Xiang H … +11 more , Ma Y, Qin X, Yu J, Li H, Yao M, Huan J, Liu J, Mei F, Zou K, Li L, Sun X
Int J Stroke · 2025 Oct · PMID 40356015 · Publisher ↗
BACKGROUND AND PURPOSE: Despite stroke center advancements in China, real-world adherence to acute care protocols of ischemic stroke remains understudied. We aimed to systematically investigate the clinical characteristi...
BACKGROUND AND PURPOSE: Despite stroke center advancements in China, real-world adherence to acute care protocols of ischemic stroke remains understudied. We aimed to systematically investigate the clinical characteristics and in-hospital treatment of acute ischemic stroke (AIS) patients, and explore their association with prognosis. METHODS: We developed a nationwide cohort of AIS using data from the China National Electronic Disease Surveillance System. Patients were identified from the first discharge diagnosis. Comorbidities and prescription names were standardized by natural language processing and manual verification. Stepwise Cox regression models with fixed and time-dependent covariates explored the possible association between treatments and in-hospital mortality. RESULTS: This cohort included 14,046 patients with AIS from 111 hospitals between 2015 and 2020. Only a small proportion of patients received intravenous thrombolysis (2.76%) or endovascular interventional therapy (3.23%). Neuroprotective agents were used by 59.90% of patients, and dual antiplatelet therapy by 45.77%. Most patients (80.79%) received traditional Chinese medicine, including Chinese patent medicines (79.04%), Chinese herbal medicine slices (10.95%), and acupuncture (7.35%). Rehabilitation services were provided to 7.48% of patients. Cox regression analysis showed that neuroprotective agents (hazard ratio (HR) = 0.73, 95% confidence interval (CI) = 0.61-0.88), Chinese patent medicine (circulate blood and transform stasis: 0.49, 0.41-0.59; clear heat and remove toxins: 0.71, 0.52-0.98), Chinese herbal medicine slices (0.28, 0.17-0.44), acupuncture (0.58, 0.41-0.84), and rehabilitation therapies (0.95, 0.93-0.97) were potentially associated with reduced in-hospital mortality risk. CONCLUSIONS: Our findings showed relatively low utilization rates of thrombolytic (2.76%) and interventional therapies (3.23%) in China, highlighting the urgent need to improve access to these evidence-based reperfusion strategies. The use of neuroprotective agents, Chinese herbal medicine, acupuncture, and rehabilitation might be associated with reduced in-hospital mortality in AIS patients; however, future high-quality prospective studies are still warranted to confirm the clinical effects of these treatments.
International Care Bundle Evaluation in Cerebral Hemorrhage Research (I-CATCHER): Study protocol for a multicenter, batched, parallel, cluster-randomized trial with a baseline period.
Apostolaki-Hansson T, Ouyang M, Dowlatshahi D … +7 more , Caso V, Bufi A, Law ZK, Billot L, Norrving B, Anderson CS, Ullberg T
Int J Stroke · 2025 Aug · PMID 40356012 · Full text
RATIONALE: A care bundle approach to the management of spontaneous intracerebral hemorrhage (ICH) has been shown to benefit patients in low- and middle-income countries (LMIC), but uncertainty persists over the specific...
RATIONALE: A care bundle approach to the management of spontaneous intracerebral hemorrhage (ICH) has been shown to benefit patients in low- and middle-income countries (LMIC), but uncertainty persists over the specific components and its applicability in high-income countries (HICs). AIMS: An international collaborative initiative aimed at determining whether implementation of a care bundle improves functional outcome for patients with ICH in HIC. METHODS: An international, multicenter, batched, parallel, cluster-randomized clinical trial focused on implementation and quality improvement for adults with spontaneous ICH ⩽ 24 h of symptom onset. The care bundle includes time- and target-based interventions: early intensive blood pressure lowering, hyperglycemia and pyrexia management, anticoagulation reversal, avoidance of do-not-resuscitate orders, repeat imaging, and referral pathways for intensive care and neurosurgery. An embedded process evaluation will assess the effectiveness and implementation of the care bundle. SAMPLE SIZE: A total of 110 hospitals with 3500 ICH participants is estimated to provide 90% power (α = 0.05) to detect a plausible treatment effect of 0.20 improvement in utility-weighted modified Rankin scale (UW-mRS) scores. OUTCOMES: The primary outcome is UW-mRS at 6 months. Secondary outcomes include death, functional status, and health-related quality of life. Implementation outcomes include adoption, fidelity, acceptability, sustainability, and integration. DISCUSSION: We aim to provide reliable evidence to accelerate practice change for integration of a multifaceted ICH care bundle as a critical component of acute stroke care worldwide. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT06429332.
Effectiveness of external ventricular drainage versus lumbar drainage in aneurysmal subarachnoid hemorrhage: A propensity-matched multicenter study.
An X, Wang B, Ge X … +6 more , Guo Y, Yu H, Li T, Feng L, Zhao Y, Yang X
Int J Stroke · 2025 Oct · PMID 40355989 · Publisher ↗
BACKGROUND: There is no universally recognized optimal cerebrospinal fluid (CSF) drainage strategy. This study aimed to comprehensively compare the efficacy and safety of external ventricular drainage (EVD) and lumbar dr...
BACKGROUND: There is no universally recognized optimal cerebrospinal fluid (CSF) drainage strategy. This study aimed to comprehensively compare the efficacy and safety of external ventricular drainage (EVD) and lumbar drainage (LD) in the management of aneurysmal subarachnoid hemorrhage (aSAH). METHODS: We consecutively included aSAH patients who underwent surgical treatment with CSF drainage between January 2017 and December 2020 in the Chinese Multicenter Cerebral Aneurysm Database (CMAD). After 1:1 propensity score matching (PSM), intergroup outcomes and in-hospital complications were compared between the EVD and LD groups. The Generalized Estimating Equation (GEE) model was used to assess the relationship between the drainage method and intergroup outcomes. Kaplan-Meier curves were used to analyze survival, and Cox proportional hazard modeling was performed to identify risk factors for mortality. RESULTS: 952 aSAH patients were initially included. After PSM, 167 patients receiving EVD were matched with 167 patients receiving LD, resulting in a total of 334 patients for the matched analysis. Patients receiving EVD had higher 2-year mortality (27.1% vs 15.1%, = 0.011) and worse functional outcomes at discharge (45.5% vs 34.0%, adjusted OR: 0.567 95% CI: 0.324-0.991, = 0.046). However, functional outcomes at 2 years did not show significant differences (23.4% vs 22.0%, adjusted OR: 0.811 95% CI: 0.375-1.754, = 0.594). No differences were observed in in-hospital complication rates between the two groups. Multivariable Cox proportional hazard modeling identified WFNS Grade IV-V as a risk factor for mortality in the EVD group. In the LD group, mortality risk factors included age ⩾ 65 years, and diabetes. CONCLUSION: LD demonstrated significant advantages in short-term functional outcomes, and long-term survival outcomes, but did not demonstrate significant differences in long-term functional outcomes and in-hospital complications. Risk factors identified in the prognostic analysis may inform clinical decision-making.
Decade trends in risk factors, treatments, and prognosis of minor ischemic stroke and TIA in China.
Jiang Q, Wang M, Liu T … +12 more , Han C, Suo Y, Yang X, Meng X, Li Z, Zhao X, Wang Y, Jiang Y, Li H, Wang Y, Xie X, Jing J
Int J Stroke · 2025 Oct · PMID 40346973 · Publisher ↗
BACKGROUND: Real-world data on the long-term trends in risk factors, acute antithrombotic strategies, medication adherence, and their impact on the prognosis of minor ischemic stroke (MIS) or transient ischemic attack (T...
BACKGROUND: Real-world data on the long-term trends in risk factors, acute antithrombotic strategies, medication adherence, and their impact on the prognosis of minor ischemic stroke (MIS) or transient ischemic attack (TIA) are limited. METHODS: We analyzed cases of acute MIS (National Institutes of Health Stroke Scale score ⩽ 3) and TIA from the China National Stroke Registries (CNSRs), a series of multicenter, nationwide hospital-based registries in China. Stroke risk factors, acute antithrombotic strategies, and adherence to secondary prevention were compared between CNSR I (2007-2008) and CNSR III (2015-2018). The main outcomes were stroke recurrence, disability (modified Rankin Scale 3-5), and all-cause mortality at 3, 6, and 12 months of follow-up. RESULTS: In total, 15,352 patients with acute MIS or TIA were included, including 7,013 patients from CNSR I and 8,339 patients from CNSR III. Over the past decade, there has been a 10-fold increase in the acute use of dual antiplatelet therapy (3.15% in CNSR I vs 31.75% in CNSR III) and a seven-fold increase in statin adherence at the 12 month follow-up (10.56% in CNSR I vs 71.15% in CNSR III). It was also observed that the adjusted cumulative incidence of stroke recurrence (15.38% [15.29%-15.47%] vs 8.29% [8.27%-8.32%]), disability rates (11.29% [11.12%-11.46%] vs 4.38% [4.32%-4.44%]), and all-cause mortality (8.17% [8.04%-8.30%] vs 1.86% [1.83%-1.89%]) at the 12-month follow-up showed a marked decline over the decade. Risk factors such as age (per 10 years), diabetes, and prior stroke were linked to a higher risk of 12-month stroke recurrence in CNSR I (CNSR I: odds ratio (OR) and 95% confidence interval (CI), 1.25 [1.17-1.33] for age per 10 years; 1.40 [1.18-1.66] for diabetes; and 1.96 [1.68-2.27] for prior stroke), and these associations remained significant after 10 years (CNSR III: OR and 95% CI, 1.15 [1.08-1.24] for age per 10 years; 1.35 [1.13-1.61] for diabetes; and 1.54 [1.29-1.84] for prior stroke). CONCLUSION: The past decade has witnessed significant advancements in both acute antithrombotic strategies and medication adherence, accompanied by marked reductions in stroke recurrence, disability, and mortality. These improvements highlight a positive shift toward more effective evidence-based care for patients with MIS or TIA.
Timing of starting anticoagulation following decompressive surgery for cerebral vein and sinus thrombosis: An observational study.
Taveira MC, Aaron S, Ferreira JM … +19 more , Coutinho JM, Canhão P, Conforto A, Arauz A, Carvalho M, Masjuan J, Sharma VK, Putaala J, Uyttenboogaart M, Werring DJ, Bazan R, Mohindra S, Weber J, Coert BA, Kirubakaran P, Sanchez van Kammen M, Singh P, Aguiar de Sousa D, Ferro JM
Int J Stroke · 2025 Dec · PMID 40304408 · Full text
BACKGROUND: Anticoagulation is the mainstay acute therapy for cerebral venous thrombosis (CVT). Decompressive surgery is required in a small minority of patients with large parenchymal lesions and impending herniation, w...
BACKGROUND: Anticoagulation is the mainstay acute therapy for cerebral venous thrombosis (CVT). Decompressive surgery is required in a small minority of patients with large parenchymal lesions and impending herniation, which requires a temporary suspension of anticoagulation. AIM: The objective of this study was to identify the optimal timing for starting or resuming anticoagulation following decompressive surgery. METHODS: Data were collected from the Decompressive Surgery for CVT Study 2 (DECOMPRESS2), a prospective multinational cohort observational study of 118 patients with severe CVT treated by decompressive surgery. We assessed the frequency of new hemorrhagic and venous thrombotic events from admission to discharge in patients who started or resumed anticoagulation <24 h (early) and ⩾24 (late) following surgery, using propensity score matching and logistic regression. Death and disability were evaluated by the modified Rankin scale (mRS > 2) at discharge and at 1 year follow-up and compared between the two groups. RESULTS: Of the 90 patients available for analysis, 35 (39%) started or resumed anticoagulation within the first 24 h after surgery while 55 (61%) did so later than 24 h. Overall frequency of patients with new hemorrhagic or venous thrombotic events from admission to discharge was 26.7% (24 patients), without crude or adjusted for the propensity score statistically significant difference between the early and late anticoagulation groups (<24 h, 11 patients, 31%, vs ⩾24 h, 13 patients, 24%; odds ratio (OR): 0.86; 95% confidence interval (CI): 0.24 to 3.04; χ = 0.33, p = 0.57). The distribution of major hemorrhagic events was also comparable: 8 (23%) bleedings in the <24 h, and 9 (16%) in the ⩾24 h (χ = 0.24, p = 0.62). No CVT recurred. Two venous thrombotic events occurred in <24 h (6%) and 5 in the ⩾24 h (9%) group. There was no association between anticoagulation timing and death or dependence (mRS 3-6) at discharge (OR: 1.65. 95% CI: 0.30 to 9.01, p = 0.56), or at 1 year follow-up (OR: 2.19, 95% CI: 0.78 to 6.10, p = 0.14). CONCLUSIONS: The results of this cohort study suggest that the timing of anticoagulation therapy following decompressive surgery for CVT does not significantly influence the risk of new bleeding or venous thrombotic events or disability.
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