International Journal Of Stroke[JOURNAL]
Sun
200 papers
The role of impaired autoregulation in cerebral small vessel disease and vascular cognitive impairment.
Webb AJS, Wong KCY, Llwyd O
Int J Stroke · 2026 May · PMID 42175678 · Publisher ↗
Cerebral autoregulation is the fundamental mechanism that regulates cerebral blood flow in the face of blood pressure variability. It is a dynamic process that depends on vascular smooth muscle cell contractile function,...
Cerebral autoregulation is the fundamental mechanism that regulates cerebral blood flow in the face of blood pressure variability. It is a dynamic process that depends on vascular smooth muscle cell contractile function, driven by myogenic, chemical, and autonomic mechanisms. Cerebral small vessel disease (cSVD) is associated with increased blood pressure variation due to systemic hemodynamic dysfunction, as well as dysfunction of the cerebral small vessels, characterized by endothelial dysfunction and vascular reactivity. As such, cerebral autoregulation may be impaired in cSVD, either as a manifestation of the disease or as a cause. This narrative review addresses current clinical evidence for involvement of autoregulatory dysfunction in cSVD. It discusses the mechanisms of autoregulation; how these overlap with vascular mechanisms involved in cSVD; methods of measurement of autoregulation in these patients; evidence for altered autoregulation in patients with either sporadic cSVD, previous stroke, or specific forms of cSVD; and effects of potential therapies for cSVD on autoregulation. This review thereby identifies the potential importance of autoregulation in cSVD, highlights current limitations in our understanding, and outlines future research avenues.
Incidence and associated risk factors of fecal incontinence in stroke patients: From a clinical observational study to meta-analysis.
Li J, Han X, Qiu W … +8 more , Bao Y, He Y, Zhang S, Sun Y, Yuan Y, Wu T, Ding D, Guo W
Int J Stroke · 2026 May · PMID 42129615 · Publisher ↗
BACKGROUND: Stroke patients are prone to gastrointestinal dysfunction, with a significantly higher risk of fecal incontinence (FI), which severely affects their quality of life. AIMS: We investigated the incidence and as...
BACKGROUND: Stroke patients are prone to gastrointestinal dysfunction, with a significantly higher risk of fecal incontinence (FI), which severely affects their quality of life. AIMS: We investigated the incidence and associated risk factors of FI in stroke patients. SUMMARY OF REVIEW: Stroke patients who met the inclusion and exclusion criteria were consecutively recruited at one university medical center from January 2022 to December 2024. FI occurred in 220 of 1359 stroke patients (16.19%). Logistic regression analysis revealed that age, gender, cognitive impairment, National Institutes of Health Stroke Scale (NIHSS) admission score, antibiotic use, and gavage feeding were closely associated with FI incidence in stroke patients. Subsequently, a systematic review and meta-analysis of observational studies followed the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Studies were included if they reported the incidence or risk factors of FI in stroke patients. Subgroup analyses were conducted according to the stage of stroke and survey site. The forest plot showed that the incidence of post-stroke FI was 24.42% (95% confidence interval (CI) = 15.11-33.72). On subgroup analysis, the incidence of FI was 25.73% (95% CI = 14.61-36.86) in the acute stage and 15.99% (95% CI = 9.32-22.67) in the rehabilitation stage. Meanwhile, the incidence of FI in the hospital-based stroke patients was 25.31% (95% CI = 11.37-39.26), which was higher than that in the community-dwelling stroke patients (15.14%, 95% CI = 2.26-28.02). CONCLUSION: The incidence of post-stroke FI is relatively high. Age, gender, cognitive impairment, NIHSS score, antibiotic use, and gavage feeding are closely associated with FI occurrence in stroke patients.
Dose-response effects of transcranial direct current stimulation on upper-limb recovery after stroke: A systematic review and meta-analysis.
Mei S, Dong B, Gao Y … +9 more , Zhou J, Yi H, Han Y, Zhuo W, Sun M, Li M, Wang H, Liu Y, Gong X
Int J Stroke · 2026 May · PMID 42129613 · Publisher ↗
BACKGROUND: Transcranial direct current stimulation (tDCS) is a noninvasive neuromodulation technique used to improve post-stroke motor deficits. However, previous trials and meta-analyses have reported inconsistent find...
BACKGROUND: Transcranial direct current stimulation (tDCS) is a noninvasive neuromodulation technique used to improve post-stroke motor deficits. However, previous trials and meta-analyses have reported inconsistent findings, and its dose-response effects on upper-limb recovery remain unclear. OBJECTIVE: To systematically evaluate the dose-response effects and safety of tDCS on post-stroke upper-limb recovery and assess potential effect modifiers. METHODS: PubMed, EMBASE, and seven other databases, as well as ClinicalTrials.gov and the Chinese Clinical Trial Registry, were searched from inception to August 12, 2025. Randomized controlled trials (RCTs) evaluating motor cortex-targeted tDCS (⩾5 sessions) with sham control were included if extractable FMA-UE data were available, regardless of whether FMA-UE was a primary or secondary outcome. Random-effects meta-analysis, subgroup, and meta-regression analyses explored dose-response patterns and effect modifiers. RESULTS: Forty-two RCTs involving 1523 patients were analyzed. tDCS significantly improved upper-limb function, with a small overall effect (SMD, 0.28; 95% confidence interval (CI), 0.12-0.43). Greater benefits were observed in severe impairment and chronic-phase stroke, and bihemispheric stimulation showed favorable pooled effects. Electrode size significantly influenced efficacy, and derived dose metrics, particularly current density and total charge density, appeared useful for characterizing dose-response patterns beyond conventional single-dose parameters. Common adverse events (AEs), including tingling, erythema, and headache, were mild and transient, and no excess risk of serious adverse events (SAEs) was detected. CONCLUSION: tDCS significantly improved post-stroke upper-limb recovery and showed no evidence of increased SAEs, although mild local AEs were more frequent. Treatment effects were not adequately explained by conventional single-dose parameters alone and appeared to be better characterized by electrode size and derived dose metrics, particularly current density and total charge density. These findings support multidimensional dose optimization and patient-stratified tDCS protocols in future trials. TRIAL REGISTRATION: PROSPERO CRD420251146501.
First World Health Organization resolution on stroke at the Seventy-ninth World Health Assembly: A turning point for global stroke prevention, care, and health-system readiness.
Agboyibor K, Ghamari SH, Tye SC … +7 more , Schiess N, Dua T, Pandian JD, Fredin Grupper M, Martins SO, Norrving B, Cieza A
Int J Stroke · 2026 Jul · PMID 42095627 · Publisher ↗
BACKGROUND: Stroke is the second leading cause of death and the third leading cause of disability worldwide, with global economic costs exceeding US $890 billion annually and a projected 50% rise in deaths between 2020 a...
BACKGROUND: Stroke is the second leading cause of death and the third leading cause of disability worldwide, with global economic costs exceeding US $890 billion annually and a projected 50% rise in deaths between 2020 and 2050. So far, stroke has been addressed within the World Health Organization (WHO) Global Noncommunicable Disease (NCD) Action Plan 2023-2030 and the Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders 2022-2031, but until now, no World Health Assembly resolution has been specifically dedicated to stroke. OBJECTIVES: To present the first WHO Resolution specifically dedicated to stroke (EB158/CONF./9), describe its content and significance, and analyze its implications for global public health. METHODS: This article presents and analyzes resolution EB158/CONF./9-"", as advanced by the WHO Executive Board at its 158th session on 3 February 2026 and adopted by the Member States in the Seventy-ninth World Health Assembly.Key content of the resolution:In February 2026, the 158th session of the WHO Executive Board advanced the first WHO resolution dedicated to stroke, proposed by Egypt and co-sponsored by Chile, Georgia, Palestine, Paraguay, and Tunisia, and adopted by Member States at the Seventy-ninth World Health Assembly. The resolution frames stroke as a continuum of care and sets out 16 operative actions for Member States (OP1), organized under three categories: (1) primary interventions across the prevention spectrum; (2) acute care and rehabilitation; and (3) surveillance and data; all underpinned by a health-system strengthening approach. A further eight requests to the Director-General (OP2) provide WHO's mandate to act, covering normative guidance, technical support, monitoring, research, medicine access, regional cooperation, and progress reporting.Public health implication:The resolution establishes a comprehensive stroke action plan across the full continuum of care. Its legacy will depend not on its adoption in Geneva but on whether political commitment is matched by sustained implementation, investment, robust monitoring, and accountability grounded in stroke-specific indicators.
Exercise and multidomain interventions for vascular cognitive impairment: A narrative review.
Yap KH, Yap RCW, Ong EHJ … +2 more , Venketasubramanian N, Chen CL
Int J Stroke · 2026 May · PMID 42068252 · Publisher ↗
BACKGROUND: Vascular cognitive impairment (VCI) encompasses cognitive impairment attributable to cerebrovascular disease, including post-stroke cognitive impairment (PSCI). Exercise and multidomain interventions have bee...
BACKGROUND: Vascular cognitive impairment (VCI) encompasses cognitive impairment attributable to cerebrovascular disease, including post-stroke cognitive impairment (PSCI). Exercise and multidomain interventions have been investigated in these populations; however, cognitive outcomes remain heterogeneous. AIMS: To synthesize randomized controlled trials on exercise-based and exercise-inclusive multidomain interventions in VCI (including PSCI) and examine how population definition, intervention delivery, and outcome selection influence cognitive outcomes. SUMMARY OF REVIEW: A narrative review identified randomized or controlled trials reporting cognitive outcomes following exercise-only or multidomain interventions. Studies were grouped into three populations: documented cerebrovascular brain injury, vascular or metabolic risk-enriched populations without cognitively defined inclusion criteria, and cognitively defined risk states. The latter two groups were included as contextual comparators and were not assumed to meet criteria for VCI. In populations with documented cerebrovascular brain injury ( = 20), longer-duration multidomain interventions focused on vascular risk-factor optimization and lifestyle advice improved vascular targets without consistent cognitive benefit. In contrast, structured and supervised exercise in chronic stroke and cerebral small-vessel disease more often reported domain-specific cognitive improvements, commonly in executive functioning and attention. In risk-enriched and cognitively defined populations, cognitive effects were more detectable when exercise was actively delivered and cognition was the primary outcome. CONCLUSIONS: Detectability of cognitive effects in exercise and multidomain interventions for VCI depends on population definition, outcome selection, and whether exercise is prescribed and delivered rather than simply advised.
Stroke Riskometer mobile phone application improves stroke knowledge in a randomized controlled trial.
Wake AD, Krishnamurthi R, Fraser BJ … +13 more , Chappell K, Feigin VL, Thrift AG, Kleinig T, Cadilhac DA, Bennett DA, Nelson MR, Purvis T, Jalili-Moghaddam S, Kitsos G, Horton E, Booth B, Gall SL
Int J Stroke · 2026 Apr · PMID 42057253 · Publisher ↗
BACKGROUND: Increasing knowledge about stroke may reduce its burden. We examined the effect of the Stroke Riskometer mobile phone application (the App) on stroke knowledge in a randomized controlled trial (RCT). METHODS:...
BACKGROUND: Increasing knowledge about stroke may reduce its burden. We examined the effect of the Stroke Riskometer mobile phone application (the App) on stroke knowledge in a randomized controlled trial (RCT). METHODS: This was a pre-specified secondary outcome analysis in a phase III, prospective, participant and outcome assessor-blinded, two-arm RCT in Australia and New Zealand. Participants were recruited between 2021 and 2023, aged 35-75 years, with ⩾2 stroke risk factors and no cardiovascular disease history. Participants were randomized after assessment of stroke risk factors and knowledge to the intervention group (IG-received risk factor assessment by email and links to the App), and the usual care group (UCG-received risk factor assessment with links to generic information by email). Stroke knowledge was measured at baseline, 3, 6, and 12 months using six validated questions (total score 0 (low knowledge) to 19 (high knowledge)). We used linear and logistic mixed-effects modeling to assess differences in the level of overall stroke knowledge and domains (description, warning signs, risk factors, management) between IG and UCG at each time point. Effect modification of the intervention with age, sex, level of education, ethnicity, socioeconomic status (SES), and country was assessed. RESULTS: There were 862 participants (mean age: 58.1 years (standard deviation (SD): 10.8), 63.0% female, 61.6% tertiary educated, 73.3% European, and 14.7% most disadvantaged area-level SES) randomized to IG (n = 429) and UCG (n = 433). Dropouts (IG/UCG) were as follows: 7.9%/4.8% at 3 months, 3.0%/1.8% at 6 months, and 13.5%/9.0% at 12 months. The time-IG interaction showed a statistically significantly increased overall stroke knowledge (β = 0.50, 95% confidence interval (CI) = 0.02, 0.97) compared with UCG at 6 months only. The intervention effect was stronger in tertiary educated, non-European, and non-Indigenous ethnic groups, and the least disadvantaged SES group. For domains, IG was more likely to correctly identify stroke risk factors (odds ratio (OR) = 1.92, 95% CI = 1.09, 3.39) at 3 months, compared with UCG. CONCLUSION: The Stroke Riskometer App modestly improved stroke knowledge compared with UCG at 6 months but lacks evidence for retaining knowledge at 12 months. As knowledge can drive behavior change, the App may be a tool to enhance primary stroke prevention. TRIAL REGISTRATION: ACTRN12621000211864.
Cardiac monitoring for detection of atrial fibrillation after TIA: An updated systematic review and meta-analysis.
Veltkamp AW, Korompoki E, D'Anna L … +4 more , Olma MC, Haeusler KG, Endres M, Veltkamp R
Int J Stroke · 2026 Apr · PMID 42056873 · Publisher ↗
BACKGROUND AND AIMS: The optimal monitoring strategy for atrial fibrillation (AF) detection after transient ischemic attacks (TIAs) is uncertain, as existing evidence is largely derived from ischemic stroke or mixed stro...
BACKGROUND AND AIMS: The optimal monitoring strategy for atrial fibrillation (AF) detection after transient ischemic attacks (TIAs) is uncertain, as existing evidence is largely derived from ischemic stroke or mixed stroke-TIA populations. This systematic review and meta-analysis aimed to determine the rate of newly diagnosed AF in TIA patients using different electrocardiographic monitoring modalities and durations. METHODS: A literature search from 1966 through 31 May 2025 was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using a protocol registered on PROSPERO (CRD420251075716). Prospective observational studies and randomized controlled trials including TIA patients who underwent at least 12 h of cardiac monitoring were eligible. The primary outcome was newly detected AF lasting at least 30 s, with subgroup analyses by monitoring duration and modality. RESULTS: Forty-two studies enrolling 3981 TIA patients were included. The pooled AF detection rate was 6.5% (95% confidence interval (CI): 4.5-9.3). AF detection rates increased with monitoring duration: 3.5% at 1 day, 6.3% at 7 days, 9.6% at 30 days, 13.1% at 90 days, and 19.1% at 12 months, respectively. Implantable cardiac monitors yielded statistically significantly higher AF detection rates than non-invasive cardiac monitoring (20.8% vs. 4.7%, < 0.0001). AF detection appeared higher in selected cohorts (based on older age, undetermined cause, and more extensive cardiovascular work-up) than in unselected cohorts (9.0% vs. 4.5%, = 0.031). However, stratified analysis of non-invasive monitoring showed no difference between selected and unselected TIA patients (5.0% (95% CI: 2.3-10.5) vs. 4.5% (95% CI: 3.1-6.5)). Substantial heterogeneity was observed among studies (² = 81.9%). CONCLUSION: This meta-analysis found high rates of newly detected AF in TIA patients undergoing prolonged cardiac monitoring, which are similar to rates previously reported after ischemic stroke. Studies using implantable cardiac monitors specifically in TIA patients are scarce. Randomized trials are needed for a face-to-face comparison of different monitoring strategies and to determine whether prolonged cardiac monitoring improves clinical outcomes in TIA patients.
Relative reductions in systolic blood pressure and functional outcomes in intracerebral hemorrhage: A pooled analysis of four INTERACT and ATACH-2 individual participant data.
Ren X, Li MBiostat Q, Chen X … +19 more , Ouyang M, Chen C, Delcourt C, Wang J, Robinson TG, Arima H, Ma L, Hu X, Yang J, Lin Y, Liu L, Muñoz-Venturelli P, Martins S, Chalmers J, Qureshi AI, Song L, Anderson CS, Wang X, INTERACT and ATACH-II Investigators
Int J Stroke · 2026 Apr · PMID 42037553 · Publisher ↗
BACKGROUND: Early intensive blood pressure (BP) lowering improves outcome after acute intracerebral hemorrhage (ICH), but the optimal degree of early systolic blood pressure (SBP) reduction remains uncertain. AIMS: We ai...
BACKGROUND: Early intensive blood pressure (BP) lowering improves outcome after acute intracerebral hemorrhage (ICH), but the optimal degree of early systolic blood pressure (SBP) reduction remains uncertain. AIMS: We aimed to identify relative SBP reduction thresholds associated with the most favorable functional outcome after ICH. METHODS: We performed an individual participant data meta-analysis of five randomized trials of acute BP lowering in ICH (INTERACT1-4 and ATACH-II). The relative reduction measurements in SBP were defined as the percentage decrease (a) from baseline SBP to the lowest SBP in 1 h (primary) and (b) from baseline SBP to the achieved mean of SBP between 1 and 24 h. Associations with functional outcome, assessed as an unfavorable shift in scores on the modified Rankin scale (mRS) at the end of follow-up (90 or 180 days), were examined in multivariable ordinal logistic regression models and tested for non-linearity using restricted cubic splines. Heterogeneity of associations between the 1-hrelative SBP reduction and functional outcome by age, sex, history of hypertension, history of diabetes, baseline SBP, and hematoma volume was further explored by including each interaction term into the models. RESULTS: Among 11,283 participants (mean age, 62.6 years; 36.0% female; mean baseline SBP, 176.9 mmHg), the association between 1-h relative SBP reduction and unfavorable functional outcome was U-shaped with an inflection nadir at around 20%. Associations differed by sex, baseline SBP, and history of diabetes (all for interaction <0.05). A similar U-shaped association was also observed in relation to the relative SBP reduction from baseline to the achieved level in 1-24 h, with the greatest apparent benefit at approximately 30%. CONCLUSION: In acute ICH, a first-hour relative SBP reduction of around 20% and a 24-h reduction target of 30%, individualized to the presenting SBP, were associated with the most favorable functional outcome. Larger reductions may attenuate the benefit and should be applied cautiously, particularly in patients with very high baseline SBP.
Biallelic loss-of-function variants in cause recurrent cervical internal carotid artery vasospasm.
Akagawa H, Onda H, Moteki Y … +10 more , Sorimachi T, Saito R, Nihira A, Hori T, Nakamura A, Terada M, Nagasaka T, Chida-Nagai A, Aoki T, Kubota Y
Int J Stroke · 2026 Apr · PMID 42033196 · Publisher ↗
BACKGROUND: Recurrent cervical internal carotid artery vasospasm (RCICAV) is a rare cause of ischemic stroke in young adults. However, its pathophysiology remains largely unknown. RCICAV is a life-threatening condition,...
BACKGROUND: Recurrent cervical internal carotid artery vasospasm (RCICAV) is a rare cause of ischemic stroke in young adults. However, its pathophysiology remains largely unknown. RCICAV is a life-threatening condition, sometimes accompanied by coronary spasmodic angina in addition to severe stroke, highlighting the need for further investigation of its etiology and therapeutic approaches. AIMS: This study aimed to identify the genetic basis of Japanese families harboring RCICAV. METHODS: Whole-exome and Sanger sequencing analyses were performed in five Japanese patients from four families (two affected siblings and three unrelated sporadic patients) and seven unaffected members from three families enrolled from October 2016 to May 2025. RCICAV was diagnosed using magnetic resonance angiography, which demonstrated vasospasm of the cervical portion of the internal carotid artery during the event and normalization during remission. and analyses of the detected variants were performed to verify functional deficiencies. RESULTS: RCICAV was found to be an autosomal recessive disorder caused by biallelic loss-of-function variants in the gene, which encodes the prostacyclin synthase. Three splice-site and nonsense variants, c. 1358 + 2T > C, p.W39X, and p. E314X, were identified in five patients from four families in either homozygous or compound heterozygous states. The c.1358 + 2T > C variant caused exon 9 skipping (p.V403Ifs*24), which was confirmed by a minigene assay and reverse transcription polymerase chain reaction using RNA extracted from peripheral blood leukocytes of a homozygous patient. Human carotid artery endothelial cells expressing these truncated variants exhibited markedly reduced protein and prostacyclin metabolite production. CONCLUSION: The results indicate that prostacyclin synthase deficiency is the core pathology of RCICAV. Given that prostacyclin is a potent vasodilator, impaired biosynthesis is consistent with the disease mechanism and may serve as a promising therapeutic target to prevent life-threatening events, including severe stroke and angina.
Changes in long-term survival after stroke between 2013 and 2020: A Nationwide cohort study from the Swedish Stroke Register.
Johnsson M, Sennfält S, Apostolaki-Hansson T … +5 more , Pihlsgård M, Wassélius J, Norrving B, Ullberg T, Hansen BM
Int J Stroke · 2026 Apr · PMID 42033194 · Publisher ↗
INTRODUCTION: Changes in long-term survival after stroke at the population level are incompletely characterized, particularly using recent data and stratified by stroke type. PATIENTS AND METHODS: This nationwide, regist...
INTRODUCTION: Changes in long-term survival after stroke at the population level are incompletely characterized, particularly using recent data and stratified by stroke type. PATIENTS AND METHODS: This nationwide, register-based cohort study used data from the Swedish Stroke Register (Riksstroke) and the Swedish Causes of Death Register. Adults (⩾18 years) hospitalized with ischemic stroke or intracerebral hemorrhage in Sweden during either 2013 or 2020 were included. Patients were followed for 3 years after the index stroke. The primary outcome was the difference in all-cause mortality within 3 years. Survival was assessed using Kaplan-Meier analyses and Cox proportional hazards regression, stratified by stroke type. RESULTS: The study included 42,926 patients. Among patients with ischemic stroke, 3-year survival increased from 63.8% in 2013 to 69.3% in 2020, corresponding to an absolute difference of 5.5 percentage points, with survival differences increasing progressively during follow-up. Ischemic stroke in 2020 was associated with a lower risk of 3-year mortality compared with 2013 in both unadjusted (hazard ratio (HR), 0.83; 95% CI, 0.80-0.86) and multivariable analyses (adjusted HR, 0.92; 95% CI, 0.89-0.96). Survival improvements after ischemic stroke were most pronounced among patients aged 75 years or older. In contrast, long-term survival after intracerebral hemorrhage did not change between cohorts (3-year survival, 50.9% in both years; adjusted HR, 0.97; 95% CI, 0.89-1.05). CONCLUSIONS: In this nationwide cohort study, 3-year survival after ischemic stroke improved between 2013 and 2020, particularly among patients aged 75 years or older, whereas long-term survival after intracerebral hemorrhage remained unchanged. These findings suggest a contemporary population-level improvement in long-term survival after ischemic stroke over a relatively short calendar period and indicate that survival differences between cohorts increased progressively over long-term follow-up.
Game-based rehabilitation improves upper limb movement capacity compared to task-based training in people post-stroke: Kinematic analyses from the EnteRtain randomized clinical trial.
Ali AS, Arumugam A, Häger CK … +7 more , N G, Nirmal P, Natarajan M, Solomon JM, Guddattu V, Pai AR, Kumaran D S
Int J Stroke · 2026 Apr · PMID 42033193 · Publisher ↗
BACKGROUND AND AIMS: Although many gaming systems for early stroke rehabilitation capture kinematic data, studies on upper limb (UL) movement capacity analysis after virtual reality (VR)-based gaming interventions remain...
BACKGROUND AND AIMS: Although many gaming systems for early stroke rehabilitation capture kinematic data, studies on upper limb (UL) movement capacity analysis after virtual reality (VR)-based gaming interventions remain limited. This study is a secondary analysis of the EnteRtain randomized clinical trial and aims to examine the effects of gamified rehabilitation using a low-cost arm rehabilitation system compared to task-based training on UL movement capacity in individuals with acute or subacute stroke. METHODS: This secondary analysis used data from a randomized, multicenter, single-blind clinical trial involving 120 participants (91 males) with unilateral stroke and an UL Brunnstrom motor recovery stage ⩾1 to ⩽5, recruited from four centers across India. Participants received either gamified training with the ArmAble device (experimental group; n = 64) or task-based training (control group; n = 56), alongside conventional therapy for 2 h/day, 6 days/week, over 2 weeks, followed by 4 weeks of home-based UL rehabilitation. Movement capacity outcomes (reach distance, time, and movement velocity) were assessed by blinded evaluators at 2 and 6 weeks and analyzed using a linear mixed-effects regression model. RESULTS: At 6 weeks, the experimental group demonstrated significantly greater improvements compared to control group in movement velocity for reaches to both near (mean difference (95% confidence interval (CI)): -2.8 (-5.0, -0.75); p = 0.008) and far targets (-2.7 (-4.9, -0.51); p = 0.016). No significant differences were, however, observed at 2 weeks. Changes in reach distance and movement time were not statistically significant between the groups at any time point. CONCLUSION: Gamified rehabilitation with the ArmAble device enhanced UL movement velocity at 6 weeks compared to task-based training in individuals recovering from acute/subacute stroke. These findings support the use of ArmAble both as an engaging therapeutic tool and as a quantitative assessment platform for evaluating UL function post-stroke. CLINICAL TRIALS REGISTRY NUMBER: CTRI/2020/09/027651.
Temporal trends in case fatality, long-term survival, and vascular events after stroke in young and middle-aged individuals: A systematic review and meta-analysis.
Nehme A, Li L
Int J Stroke · 2026 Apr · PMID 42026807 · Publisher ↗
BACKGROUND AND AIMS: In high-income countries, stroke incidence in the 21st century has increased or stagnated in young and middle-aged individuals. Assessing temporal trends in post-stroke outcomes is necessary to under...
BACKGROUND AND AIMS: In high-income countries, stroke incidence in the 21st century has increased or stagnated in young and middle-aged individuals. Assessing temporal trends in post-stroke outcomes is necessary to understand the impact of these changes in incidence. METHODS: Embase and MEDLINE were searched from 1 January 1970 to 30 October 2024. Studies were included if they reported case fatality, 1-year or 5-year mortality, or stroke recurrence in patients aged up to 65 years. For studies reporting outcomes across multiple time periods, risk ratios (RRs) were calculated comparing the earliest and latest periods and pooled using inverse-variance random-effects models. The annualized change in the RR for case fatality was estimated using meta-regression. RESULTS: Twenty-two studies reported case fatality across 28 populations after all strokes or ischemic stroke and intracerebral hemorrhage (14 population-based and 14 based on routinely collected data). The median (interquartile range (IQR)) duration between compared time points was 9 (7-13.3) years. Case fatality decreased over time (RR = 0.74, 95% confidence interval (CI) = 0.68-0.81), corresponding to a mean annual relative reduction of 3.2% (95% CI = 1.4-5.0). Results were consistent by age, sex, study design, geographical region, and stroke subtype (six studies; ischemic stroke: RR = 0.79, 95% CI = 0.75-0.83; intracerebral hemorrhage: RR = 0.77, 95% CI = 0.69-0.86). Trends were similar before and after 2000, with continued improvement after 2010 compared with 2000-2009 (six studies; RR = 0.70, 95% CI = 0.63-0.77). In addition, mortality decreased at 1 year (five studies; RR = 0.68, 95% CI = 0.52-0.87) and at 5 years after stroke (four studies; RR = 0.65, 95% CI = 0.45-0.95). In contrast, the 1-year cumulative incidence of recurrent stroke was unchanged after 2000 (three studies; RR = 1.04, 95% CI = 0.78-1.39). CONCLUSION: Early case fatality and long-term survival after stroke have progressively improved since the 1970s in high-income countries among young and middle-aged individuals, but stroke recurrence rates may have stagnated in the past two decades.
Antithrombotic strategies targeting the coagulation pathway and incident covert brain infarction: A systematic review and meta-analysis of randomized trials.
Yang F, Wang L, Wu X … +5 more , Li L, Jiao X, Zhang F, Ji X, Guo X
Int J Stroke · 2026 Apr · PMID 41999065 · Publisher ↗
BACKGROUND: Covert brain infarction is a common neuroimaging-defined manifestation of covert cerebrovascular disease and is associated with increased risks of future stroke and cognitive decline. Covert brain infarction...
BACKGROUND: Covert brain infarction is a common neuroimaging-defined manifestation of covert cerebrovascular disease and is associated with increased risks of future stroke and cognitive decline. Covert brain infarction has been included as an outcome in randomized trials evaluating coagulation-pathway-targeting strategies. However, whether these strategies consistently reduce incident covert brain infarction and whether treatment effects on covert brain infarction parallel those for acute ischemic stroke remain uncertain. METHODS: Following PRISMA 2020 guidelines, we searched PubMed, Ovid MEDLINE, Embase, and Web of Science through 10 November 2025, for randomized controlled trials and magnetic resonance imaging substudies enrolling patients without an established indication for anticoagulation. Eligible trials compared antithrombotic strategies targeting the coagulation pathway (oral anticoagulation or direct factor inhibition, with or without background antiplatelet therapy) with antiplatelet-based regimens and reported incident covert brain infarction on follow-up magnetic resonance imaging. Trial-level treatment effects for covert brain infarction, acute ischemic stroke, and their composite were compared. Exploratory cross-outcome comparisons were performed using the ratio of relative risks with prespecified interpretability bounds. RESULTS: Six randomized trials met the inclusion criteria, encompassing diverse clinical populations and varying antiplatelet regimens in the control arms. In stratified analyses according to treatment structure, coagulation-pathway strategies were not associated with a statistically significant reduction in incident covert brain infarction compared with antiplatelet therapy alone, with similar estimates across treatment strata and no evidence of interaction (P_interaction = 0.249). An exploratory pooled estimate was similar (risk ratio, 0.95; 95% confidence interval, 0.81-1.12). Findings were consistent across covert brain infarction subtypes, including lacunar and non-lacunar lesions. In trials reporting all three outcomes, these strategies were not associated with significant reductions in covert brain infarction, acute ischemic stroke (risk ratio, 0.85; 95% confidence interval, 0.65-1.11), or their composite endpoint (risk ratio, 0.97; 95% confidence interval, 0.84-1.11). The composite endpoint was predominantly driven by covert brain infarction (~70% of events). Exploratory cross-outcome comparisons yielded point estimates favoring acute ischemic stroke over covert brain infarction, although confidence intervals crossed unity. CONCLUSION: In clinical settings without a mandatory indication for anticoagulation, coagulation-pathway strategies were not associated with reduced incident covert brain infarction compared with antiplatelet therapy. Although effect estimates for covert brain infarction and acute ischemic stroke were broadly similar, uncertainty remains. Composite endpoints predominantly driven by covert brain infarction warrant cautious interpretation when inferring treatment effects on clinically manifest ischemic stroke.
Distinct perforator hemodynamic phenotypes differentiate mechanisms of single subcortical infarction: In vivo evidence from 7T phase-contrast MRI.
Wei N, Xu YY, Suo Y … +9 more , Zhang Z, Zhu W, Qu H, Gong X, Dong K, Li Z, Wang Y, Zhang Z, Jing J
Int J Stroke · 2026 Apr · PMID 41964451 · Publisher ↗
OBJECTIVE: Single subcortical infarction (SSI) arises from heterogeneous mechanisms, most commonly parent artery disease (PAD) or intrinsic small vessel pathology. However, whether these mechanisms produce distinct in vi...
OBJECTIVE: Single subcortical infarction (SSI) arises from heterogeneous mechanisms, most commonly parent artery disease (PAD) or intrinsic small vessel pathology. However, whether these mechanisms produce distinct in vivo hemodynamic signatures within perforating arteries remains unknown. We aimed to determine whether lenticulostriate artery (LSA) hemodynamics differ between SSI subtypes and whether such differences provide mechanistic insight into SSI pathophysiology. METHODS: Patients with recent SSI confined to the LSA territory were prospectively enrolled and underwent 7T magnetic resonance imaging. Based on intracranial vessel wall imaging, patients were classified as SSI + PAD (ipsilateral middle cerebral artery (MCA) plaque on T1-weighted vessel wall imaging defined by eccentric wall thickening) or SSI - PAD (no ipsilateral MCA plaque). LSA flow velocity was quantified at the arterial ostium and distal segment using phase-contrast magnetic resonance angiography (PC-MRA), and along-vessel velocity decline was calculated. LSA morphology was assessed with time-of-flight MRA. Linear mixed-effects models adjusted for age and sex were used for group comparisons. RESULTS: Forty-two patients (21 SSI + PAD and 21 SSI - PAD) were included. In SSI + PAD, ostial velocity in the symptomatic hemisphere was significantly lower than in the contralateral hemisphere (7.25 vs. 9.61 cm/s; p < 0.001) and the symptomatic side of SSI - PAD (8.95 cm/s, p = 0.001), indicating proximal inflow restriction. In contrast, SSI - PAD preserved ostial inflow (8.95 vs. 9.15 cm/s, p = 0.70) but exhibited a greater along-vessel velocity decline on both hemispheres compared with SSI + PAD, suggesting distal microvascular dysfunction. Morphologically, the symptomatic hemisphere showed fewer visible LSA branches and shorter LSA length than the contralateral hemisphere in both groups. In addition, LSA diameter tended to be smaller in SSI - PAD than in SSI + PAD. CONCLUSION: 7T PC-MRA revealed distinct hemodynamic patterns in SSI. SSI + PAD was characterized by proximal inflow limitation, whereas SSI - PAD reflected diffuse distal hypoperfusion characteristic of small vessel pathology. Quantitative perforator flow assessment may refine etiologic classification and guide secondary prevention in SSI.
Infarct growth rate and tenecteplase benefit in ischemic stroke at 4.5 to 24 h without thrombectomy-A secondary analysis of the TRACE-III randomized trial.
Wang L, Zhou L, Yin J … +19 more , Jin A, Campbell BCV, Fisher M, Schwamm LH, Parsons MW, Meng X, Duan C, Zong L, Ye W, Che F, Wang L, Dai H, Wang H, Wang Z, Hao M, Cao Z, Wu S, Wang Y, Xiong Y
Int J Stroke · 2026 Apr · PMID 41944559 · Publisher ↗
BACKGROUND: We aimed to explore whether the benefits of tenecteplase within 4.5 to 24 h would be modified by the infarct growth rate (IGR). METHODS: This study is a secondary analysis of the Tenecteplase Reperfusion Ther...
BACKGROUND: We aimed to explore whether the benefits of tenecteplase within 4.5 to 24 h would be modified by the infarct growth rate (IGR). METHODS: This study is a secondary analysis of the Tenecteplase Reperfusion Therapy in Acute Ischemic Cerebrovascular Events-III (TRACE-III) trial, a Phase 3, multicenter, prospective, open-label, randomized, blinded-outcome-assessment trial. In the TRACE-III trial, patients with large-vessel occlusion at 4.5 to 24 h without thrombectomy were enrolled at 58 centers in China and randomly assigned to receive 0.25 mg/kg tenecteplase or standard medical treatment. Of these, patients with witnessed stroke onset time were analyzed. The IGR was calculated as baseline ischemic core volume divided by time since onset. The primary outcome was the modified Rankin Scale (mRS) 0-1 at 90 days. The treatment effect of tenecteplase versus standard medical treatment was assessed in two groups based on the median IGR cut point. A multiplicative interaction term for IGR*treatment was used to test for effect modification. RESULTS: In 292 eligible patients, the median IGR was 1.4 ml/h. A total of 146 patients with IGR < 1.4 ml/h were classified as ultraslow IGR (Tenecteplase, 70; Standard medical treatment, 76), and 146 patients with IGR ⩾ 1.4 ml/h were classified as slow IGR (Tenecteplase, 73; Standard medical treatment, 73). The rate of no disability (mRS ⩽ 1) was significantly increased with tenecteplase in slow progressors (34.2% vs 15.1%; OR = 2.94, 95% CI 1.32 to 6.55; P = 0.009). The functional status was similar in ultraslow progressors (mRS 0-1: 37.1% vs 35.5%; OR = 1.07, 95% CI 0.55 to 2.11; P = 0.84). A P value for the interaction between IGR and treatment was 0.06. The incidence of sICH and mortality did not differ significantly between the two treatment regimens in the IGR groups. CONCLUSION: Patients with late-window ischemic stroke who are not eligible for endovascular thrombectomy may derive greater benefit from tenecteplase compared with standard medical treatment among those with relatively faster infarct growth, although this finding should be considered exploratory.
Global burden of cerebral small vessel disease determined from large MRI studies: A systematic review and meta-analysis.
Lam BYK, Cai Y, Zheng H … +24 more , Wei J, Akinyemi R, Biessels GJ, Brink HVD, Chen C, Duering M, Gustafson D, Hilal S, Ming Ho Hui V, Kalaria R, Kim S, Lam MLM, de Leeuw FE, Li ASM, Markus HS, Marseglia A, O'Brien J, Pantoni L, Sachdev PS, Smith EE, Wardlaw JM, Wong A, Ko H, Mok VCT
Int J Stroke · 2026 Apr · PMID 41934293 · Publisher ↗
BACKGROUND: Cerebral small vessel disease (SVD) is a major cause of ischemic stroke, intracerebral hemorrhage, and dementia. Despite its importance, there are few studies of its prevalence and how cerebral SVD varies acr...
BACKGROUND: Cerebral small vessel disease (SVD) is a major cause of ischemic stroke, intracerebral hemorrhage, and dementia. Despite its importance, there are few studies of its prevalence and how cerebral SVD varies across the world, different age ranges, sexes, and magnetic resonance imaging (MRI) parameters. SVD can be estimated using MRI neuroimaging markers, including white matter hyperintensities (WMHs), lacunes, cerebral microbleeds (CMBs), and perivascular spaces (PVS). AIMS: This study aimed to document the global prevalence of SVD based on population-based or large community-based MRI studies and to determine how SVD prevalence varies by region, mean age, and sex. With SVD neuroimaging markers being the standard to assess SVD prevalence, we aimed to investigate how different MRI acquisition parameters may influence its prevalence. SUMMARY OF REVIEW: In this systematic review and meta-analysis, articles were searched from the Ovid MEDLINE and EMBASE databases between 1 January 2000 and 31 March 2024, without language restrictions. Title and abstract screening, full-text review, and data extraction were performed by at least two independent reviewers. The prevalence of SVD, subject demographic information, and MRI acquisition parameters were extracted. The Risk of Bias for Non-randomized Studies tool was used. The protocol was registered on PROSPERO (CRD42022311133). Of 14,582 studies identified, 246 studies spanning 40 countries were included in the systematic review. In the meta-analysis, 85 studies (88 cohorts) from 17 regions (n = 1,562,765) were included. The quality of studies was high (mean score 7.67 out of 8, ranging between 5 and 8). The pooled prevalence of moderate-to-severe WMH was 18.9%, and the pooled mean of WMH volume was 4.4 mL. Pooled prevalences of lacunes, cerebral microbleeds (CMBs), and moderate-to-severe perivascular spaces (PVS) were 11.2%, 10.3%, and 22.6%, respectively. A lower lacune prevalence (7.3% vs 13.3%; adjusted OR (aOR) [95% confidence interval (CI)]: 0.45 [0.30-0.68]) but higher PVS prevalence (30.9% vs 19.6%; aOR [95% CI]: 12.15 [2.12-69.46]) was found in Europe compared with Asia. A higher mean age of the studies was associated with a higher prevalence of most SVD markers, except for PVS. There was an overall trend of more lacunes and CMBs in males. MRI field strength, sequence used, and slice thickness could potentially influence the reported SVD prevalence, especially for WMH volume and CMB count. There was high heterogeneity in the studies (>95%) that was not resolved by performing analyses stratified by Global Burden of Disease (GBD) regions, age groups, study design, or MRI parameters. CONCLUSION: This systematic review and meta-analysis based on large MRI studies demonstrated that SVD is a common health problem affecting about one-fifth of the adult population. SVD prevalence differs in regions separated by geographical regions. SVD prevalence is higher with increasing age. There is an overall trend of more lacunes and CMBs in males. WMH volume and CMB are SVD markers prone to the variability of MRI acquisition parameters, and a harmonised SVD scanning protocol should be used. More studies from middle- and low-income regions would benefit the estimation of a truly global prevalence of SVD.
The importance of advocacy in advancing stroke care: The global stroke action coalition.
Nelson M, Grupper M, van der Worp HB … +20 more , Brunelli N, Venketasubramanian N, Al-Mufti F, Asif K, Asperen R, Balguid A, Belson S, De Silva DA, Velazquez Garcia B, Haughton S, Jiang Y, Mason A, Martins S, Naidoo P, Pandian J, Schaub Jackson M, Setum K, Sperling C, Wang Y, Norrving B
Int J Stroke · 2026 Jun · PMID 41934286 · Full text
Stroke represents one of the most significant global health challenges of the 21st century, with 11.9 million people experiencing stroke annually and a disproportionate burden falling on low- and middle-income countries,...
Stroke represents one of the most significant global health challenges of the 21st century, with 11.9 million people experiencing stroke annually and a disproportionate burden falling on low- and middle-income countries, where 87% of stroke deaths and 89% of disability occur. Despite stroke being highly preventable-with 84% of the burden attributable to modifiable risk factors-and the availability of treatments that have proven to reduce the rate of death or disability, including stroke units, thrombolysis, and thrombectomy, these interventions remain inaccessible to most of the world's population. Advocacy-systematic efforts to influence policy, practice, and resource allocation through evidence-based engagement with decision-makers-has achieved notable successes such as establishing stroke units globally. However, individual advocacy efforts face structural limitations in addressing global stroke challenges. The Global Stroke Action Coalition (GSAC) was formed in 2024 as a coordinated, multi-sectoral initiative convened by the World Stroke Organization, uniting scientific, civil societies, and industry partners to transcend these limitations. The Coalition leverages established infrastructure and expertise to create a unified advocacy force capable of commanding attention from global health leaders. Centered around five strategic priorities-integrating stroke into national non-communicable disease (NCD) strategies, developing National Stroke Action Plans, securing funding commitments, implementing monitoring systems, and including survivors in policy development-the Coalition successfully utilized the 2025 UN High-Level Meeting on Non-Communicable Diseases to further elevate the position of stroke on the global agenda. Key achievements include securing ministerial commitments from 10 countries and launching the "Every Minute Counts" campaign. The Coalition's coordinated approach demonstrates that systematic, evidence-based advocacy can transform stroke care delivery globally, providing a framework for sustained collaboration across sectors and regions essential for meeting Sustainable Development Goal targets and reducing the devastating burden of stroke worldwide.
Early versus delayed anticoagulation in acute ischemic stroke with atrial fibrillation according to infarct volume and location: A prespecified subgroup analysis of the OPTIMAS randomized controlled trial.
Nash PS, Best JG, Lyon J … +37 more , Ruffle JK, Amornpojnimman T, Mendel R, Foulon C, Dehbi HM, Ahmed N, Arram L, Balogun M, Bennett K, Bordea E, Caverly E, Chau M, Cohen H, Cullen M, Doré CJ, Engelter ST, Fenner R, Ford GA, Gill A, Hunter R, James M, Jayanthi A, Lip GY, Massingham S, Murray ML, Mazurczak I, Ndoutoumou A, Norrving B, Philip J, Sims H, Sprigg N, Vanniyasingam T, Nachev P, Freemantle N, Doig D, Werring DJ, OPTIMAS Investigators
Int J Stroke · 2026 Mar · PMID 41906919 · Publisher ↗
BACKGROUND: Randomized trials have demonstrated that early anticoagulation after acute atrial fibrillation-associated ischemic stroke is safe and non-inferior to delayed initiation. Whether anticoagulation should be dela...
BACKGROUND: Randomized trials have demonstrated that early anticoagulation after acute atrial fibrillation-associated ischemic stroke is safe and non-inferior to delayed initiation. Whether anticoagulation should be delayed in people with larger infarcts is uncertain. AIMS: To investigate whether ischemic stroke infarct volume, measured precisely by segmentation, modifies the treatment effect of early anticoagulation with a direct oral anticoagulant (DOAC). METHODS: We did a prespecified secondary analysis of OPTIMAS (NCT: 03759938), a randomized, parallel-group, open-label trial with blinded outcome assessment which randomized people with acute ischemic stroke and atrial fibrillation to early initiation of any licensed DOAC, within 4 days of onset, or delayed initiation 7-14 days from onset. The primary outcome was a composite of recurrent ischemic stroke, symptomatic intracranial hemorrhage (ICH), and systemic arterial embolism within 90 days. A central neuroimaging laboratory determined infarct volume using diffusion-weighted magnetic resonance imaging (MRI) using a validated deep learning segmentation model; on computed tomography (CT), infarcts were segmented manually. We modeled infarct volume as a continuous variable using restricted cubic splines and tested for an interaction with treatment allocation in mixed effects logistic regression. RESULTS: We included 3572 participants (mean age = 78 ± 10 years, 45% female), 98.6% of the main trial population. The effect of early versus delayed anticoagulation did not vary with infarct volume (p = 0.18). Rates of the primary outcome were 17/568 (3.0%) and 12/599 (2.0%) for early versus delayed initiation with infarcts of 0-5 mL; 6/220 (2.7%) and 11/229 (4.8%) with infarcts of 5-10 mL; 13/258 (4.6%) and 10/283 (3.5%) with infarcts of 10-25 mL; 6/145 (4.1%) and 8/145 (5.5%) with infarcts of 25-50 mL; 1/93 (1.1%) and 7/94 (7.4%) with infarcts of >50 mL; and 14/481 (2.9%) and 10/430 (2.2%) in participants with no infarct visible on clinically acquired brain imaging. Corresponding odds ratios and 95% confidence intervals were 1.52 (0.71-3.20), 0.55 (0.20-1.51), 1.29 (0.55-3.00), 0.74 (0.25-2.21), 0.13 (0.02-1.11), and 1.25 (0.55-2.86), respectively. There were no increased rates of symptomatic ICH with respect to anticoagulation timing for those with large infarcts (>25 mL); there were 3/238 (1.3%) events in the early group and 5/239 (2.1%) in the delayed group. CONCLUSION: The treatment effect of early anticoagulation with a DOAC in acute ischemic stroke associated with atrial fibrillation was not modified by infarct volume. Adverse outcomes were not increased with early anticoagulation in people with larger infarcts. Our results provide no evidence that anticoagulation initiation should be delayed beyond 4 days on the basis of infarct size.
Hemorrhagic transformation after intracranial stenting for acute stroke: Clinical insights from the RESISTANT registry.
Olivé-Gadea M, Mujanovic A, Kaesmacher J … +73 more , Geyik S, Senadim S, Cervo A, Salcuni A, Piano M, Moreu M, López-Frías A, Hassan AE, Miller S, Diana F, Zapata-Arriaza E, de Albóniga-Chindurza A, Bergui M, Molinaro S, Sousa JA, Gomes F, Sargento-Freitas J, Alexandre A, Pedicelli A, Hofmeister J, Machi P, Giannakakis MP, Scarcia L, Kalsoum E, Amorim J, Meira T, Ortega-Gutierrez S, Cruz-Criollo L, Renieri L, Capasso F, Romano D, Bárcena-Ruiz E, Seoane D, Abdalkader M, Klein P, Nguyen TN, Perry da Câmara C, Fragata I, Yavagal D, Rodriguez-Calienes A, Charles J, Rodriguez Castro J, Vega P, Özcan Özdemir A, Uysal Kocabaş Z, Smajda S, Salman SA, Khalife J, Jovin TG, Biraschi F, Ricchetti F, Castro P, Pinheiro Albuquerque L, Siddiqui A, Jaikumar V, Navia P, Ntoulias N, Psychogios M, Velo M, Zamarro J, De Paco G, Ashouri Y, AlMajali M, Arenillas JF, Sierra A, Romoli M, Marto JP, Yaghi S, Gralla J, Fischer U, Ribo M, Tomasello A, Requena M
Int J Stroke · 2026 Mar · PMID 41889347 · Publisher ↗
BACKGROUND AND AIM: Acute intracranial stenting is increasingly used as a rescue strategy during endovascular treatment for large vessel occlusion strokes. Limited data exist regarding the risk, clinical relevance, and o...
BACKGROUND AND AIM: Acute intracranial stenting is increasingly used as a rescue strategy during endovascular treatment for large vessel occlusion strokes. Limited data exist regarding the risk, clinical relevance, and optimal management of hemorrhagic transformation (HT) in this context. We aimed to evaluate the incidence, predictors, outcomes, and post-interventional antiplatelet management of HT in an international multicentric registry. METHODS: We analyzed data from the RESISTANT registry, including patients who underwent emergent intracranial stenting for acute stroke between 2016 and 2023. Two complementary analyses were performed: (1) characterization of HT subtypes and associated outcomes (NIHSS at discharge, mortality, and mRS at discharge and 90 days) and (2) evaluation of antiplatelet management after Heidelberg class-1 HT detection and its impact on stent occlusion, hemorrhage progression, in-hospital mortality, and 90-day mRS. RESULTS: Among 809 patients included, 177 (22%) experienced HT, of which 63 (8%) were symptomatic intracranial hemorrhage. Parenchymal hematomas (PH-1 and PH-2) and HI-2 were associated with worse functional outcomes and higher mortality. In the post-HT management cohort (n = 117), use of a high-intensity antiplatelet regimen (dual oral antiplatelet or any intravenous agent) was associated with lower risk of stent occlusion (adjusted risk ratio (aOR) = 0.21 [0.05-0.86]) and in-hospital mortality (aOR = 0.08 [0.01-0.50]) without increased hemorrhagic progression (0.52 [0.09-3.07]). CONCLUSION: HT remains a relevant complication after emergent intracranial stenting, particularly in patients with parenchymal hematoma. High-intensity antiplatelet therapy appears safe in select HT subtypes and was linked to reduced occlusion and mortality.
Timing of insertable cardiac monitor implantation after embolic stroke of undetermined source and its impact on atrial fibrillation detection: A target trial emulation analysis.
D'Anna L, Maguidhir F, Simister R … +36 more , Chandratheva A, Desai G, Haneef M, Idian A, Favruzzo F, Pes A, Baracchini C, Rosin D, Valente M, Gigli GL, Zhang L, Leung Mres N, Sohal M, Sacco S, Ornello R, De Santis F, Coppola U, Prandin G, Edwards S, Safak C, Avila R, Cruz J, Laurie A, Romoli M, Tudisco V, Sepe FN, Guan J, Barnard A, Jeffrey L, Dagan J, Dolkar T, Hayton J, Banerjee S, Foschi M, Merlino G, Boon Lim P
Int J Stroke · 2026 Mar · PMID 41877402 · Publisher ↗
BACKGROUND: A substantial proportion of ischemic strokes remain classified as embolic stroke of undetermined source (ESUS) despite standard diagnostic evaluation. Prolonged cardiac monitoring with implantable cardiac mon...
BACKGROUND: A substantial proportion of ischemic strokes remain classified as embolic stroke of undetermined source (ESUS) despite standard diagnostic evaluation. Prolonged cardiac monitoring with implantable cardiac monitors (ICMs) increases atrial fibrillation (AF) detection, but the optimal timing of ICM implantation after ESUS remains uncertain. AIMS: To evaluate whether early versus delayed ICM implantation after ESUS influences AF detection and time to diagnosis. METHODS: We conducted a multicenter observational cohort study emulating a target trial. Consecutive ESUS patients undergoing ICM implantation were classified as ICM (⩽30 days) or ICM (31-365 days) implantation after the index event. Inverse probability weighting was applied to adjust for baseline confounding. Primary and secondary outcomes included AF detection within 30, 90, and 120 days after implantation, assessed using weighted logistic regression, Poisson models for detection rates per person-time, Cox proportional hazards models, and restricted mean survival time (RMST). Sensitivity analyses included center-level clustering and competing-risk models. RESULTS: Among 333 patients (90 ICM and 243 ICM), early implantation was associated with significantly higher AF detection within 30 days (7.8% vs 1.6%; odds ratio (OR) = 4.49, 95% confidence interval (CI) = 1.17-17.27; p = 0.028) and higher detection rates per person-time (incidence rate ratio (IRR) = 4.26, 95% CI = 1.16-15.60; p = 0.029). Consistent associations were observed at 90 and 120 days. Time-to-event analyses showed higher hazards of AF detection with early implantation (hazard ratio (HR) = 4.29 at 30 days; HR = 2.97 at 90 days; HR = 2.77 at 120 days; all p < 0.01). RMST analyses demonstrated progressively shorter time to AF diagnosis in the ICM group across multiple time horizons. Results were robust across sensitivity analyses. CONCLUSION: Early ICM implantation after ESUS is associated with higher and faster AF detection compared with delayed implantation. When ICM monitoring is indicated, avoiding unnecessary delays may substantially enhance diagnostic yield.
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