International Journal Of Stroke[JOURNAL]
Sun
200 papers
Contrasting patterns of leptomeningeal and parenchymal gadolinium extravasation in cerebral amyloid angiopathy: An MRI-based evaluation.
Voigt S, de Jong J, Voorter P … +13 more , Koemans EA, Schipper MR, van der Plas MC, Kaushik K, van der Zwet R, van Dort R, van den Brink H, van Veluw SJ, van Osch M, van Walderveen M, Backes WH, Wermer M, Freeze WM
Int J Stroke · 2026 Feb · PMID 41641789 · Publisher ↗
BACKGROUND: Previous studies suggest that blood-brain barrier (BBB) disruption may play a role in the pathophysiology of vessel rupture in cerebral amyloid angiopathy (CAA). Here, in a cross-sectional cohort study, we ap...
BACKGROUND: Previous studies suggest that blood-brain barrier (BBB) disruption may play a role in the pathophysiology of vessel rupture in cerebral amyloid angiopathy (CAA). Here, in a cross-sectional cohort study, we apply contrast-enhanced 3 Tesla magnetic resonance imaging (MRI) to test the hypothesis that the BBB is damaged in patients with CAA and to determine whether BBB leakage is associated with hemorrhagic brain injury in CAA. METHODS: Parenchymal BBB leakage rate (K) was assessed in the cortex and white matter with dynamic contrast-enhanced (DCE)-MRI and quantified with pharmacokinetic modeling. Leptomeningeal BBB leakage was assessed visually on post-contrast heavily T2-weighted fluid attenuation inversion recovery (FLAIR) images. Cortical cerebral microbleeds (CMBs) and cortical superficial siderosis (cSS) were assessed on susceptibility-weighted images. Analyses included descriptive statistics, group comparisons using the Mann-Whitney U test and Spearman's rank correlation for associations with imaging markers. RESULTS: In total, 25 patients with a clinical diagnosis of probable CAA without prior intracerebral hemorrhage and 19 age- and sex-matched controls were included. In patients with CAA, BBB leakage rates were lower in the cortex (4.2 × 10 min vs 5.6 × 10 min; p = 0.004) and in the white matter (1.2 × 10 min vs 2.1 × 10 min; p < 0.001) compared with controls. The presence of leptomeningeal enhancement was higher in patients with CAA (68%) compared with controls (47%) (p = 0.007). Within the group with CAA, we did not find a correlation between the number of cortical leakage and cortical CMBs (Spearman's ρ = 0.06, p = 0.79) or the number of foci of leptomeningeal enhancement and cSS hemisphere score (Spearman's ρ = 0.30, p = 0.15). DISCUSSION: Our results suggest that global parenchymal gadolinium extravasation across the BBB is lower in patients with CAA compared with controls. This observation can be explained in terms of limited capillary blood perfusion and/or raising the possibility that vascular amyloid-β deposition impairing molecular transport across the BBB. In contrast, focal leptomeningeal enhancement was higher in CAA, reflecting vessel wall infiltration.
Low-dose rivaroxaban plus antiplatelet therapy for symptomatic intracranial atherosclerotic stenosis: A prospective cohort study.
Zhang D, Zhao Z, Qian Y … +19 more , Pei L, Liu K, Cao Y, Rong W, Hou H, Zhang Y, Zhang W, Zong C, Zhou Y, Wang J, Lan C, Han X, Wang D, Pan Y, Ning M, Buonanno FS, Leng X, Xu Y, Song B
Int J Stroke · 2026 Feb · PMID 41641760 · Publisher ↗
BACKGROUND: The antithrombotic strategies for symptomatic intracranial atherosclerotic stenosis (sICAS) remains challenging. Dual pathway inhibition (DPI) has demonstrated clinical benefit in coronary and peripheral arte...
BACKGROUND: The antithrombotic strategies for symptomatic intracranial atherosclerotic stenosis (sICAS) remains challenging. Dual pathway inhibition (DPI) has demonstrated clinical benefit in coronary and peripheral artery disease. AIMS: This study aimed to evaluate the efficacy of DPI with low-dose rivaroxaban plus antiplatelet therapy (APT) compared with APT alone on recurrent stroke with sICAS. METHODS: This prospective cohort study included patients with sICAS identified from the Ischemic Cerebrovascular Disease Database of the First Affiliated Hospital of Zhengzhou University between January 2019 to August 2023. Low-dose rivaroxaban was prescribed off-label to patients in the DPI group. The outcomes were ischemic stroke, transient ischemic attack (TIA), acute coronary syndrome (ACS), all-cause death and cardio-cerebrovascular death within 1 year of discharge. Cox regression with inverse probability of treatment weighting (IPTW) was applied to compare outcomes between the DPI and APT groups. The win-ratio method was used to assess the major adverse cardiovascular events (MACE), prioritized in the order of all-cause death, recurrent ischemic stroke or TIA, and ACS. RESULTS: Among the 1217 patients with sICAS, 131 (10.8%) received DPI therapy. The recurrence rate of ischemic stroke was lower in the DPI group compared to the APT group (8/131 [6.1%] vs 136/1086 [12.5%]). DPI significantly reduced the risk of ischemic stroke recurrence (HR = 0.46, 95% CI: 0.23-0.94, = 0.034) and the incidence of MACE (HR = 0.53, 95% CI: 0.29-0.97, = 0.041) during the 1-year follow-up, consistent with the IPTW-based cohort (HR = 0.35, 95% CI: 0.16-0.76, = 0.008; HR = 0.43, 95% CI: 0.22-0.83, = 0.012). The win-ratio analysis of MACE favored DPI therapy (win ratio = 2.34, 95% CI: 1.41-3.90, = 0.001). Symptomatic intracranial hemorrhage, fatal bleeding, and hospitalization for gastrointestinal bleeding were infrequent in this cohort. CONCLUSIONS: DPI therapy may be associated with a lower risk of recurrent stroke compared with antiplatelet therapy alone in patients with sICAS. These findings warrant further investigation through large-scale randomized controlled trials.
The concordance and correlation of Global Burden of Disease stroke incidence rates with stroke incidence rates from population-based stroke registers.
Youkee D, Wolfe CD
Int J Stroke · 2026 Feb · PMID 41631666 · Publisher ↗
BACKGROUND: The Global Burden of Disease (GBD) 2021 study and population-based stroke registers are principal sources of stroke incidence estimates. This study aims to assess the concordance and correlation between GBD s...
BACKGROUND: The Global Burden of Disease (GBD) 2021 study and population-based stroke registers are principal sources of stroke incidence estimates. This study aims to assess the concordance and correlation between GBD stroke incidence rates and stroke incidence rates from population-based stroke registers. METHODS: Crude and age-standardized stroke incidence rates were sourced from high-quality population-based stroke registers and compared to GBD estimates matched by year and location, using GBD subnational data where available. Studies were categorized by country income group status using the World Bank country classifications: high-income countries (HICs); upper middle-income countries (UMICs), and lower middle-income countries (LMICs). Studies were categorized as to whether they were reported as informing the GBD 2021 model, using the online GBD 2021 sources tool. Concordance and correlation were assessed using Lin's concordance correlation coefficient and Pearson's correlation coefficient, respectively. Bland-Altman plots were created to display 95% limits of agreement. FINDINGS: Fifty crude matched incidence rates and 31 matched age-standardized rates were compared. Concordance and correlation for crude stroke incidence were 0.67 and 0.68 overall, 0.66 and 0.68 for HICs, 0.59 and 0.77 for UMICs and 0.03 and 0.97 for LMICs respectively. Overall, 11 (22.0%) GBD estimates, accounting for UIs, matched population-based stroke register crude incidence rates. 95% limits of agreement were -110.2/100,00 to 134.1/100,000 overall. Concordance and correlation for age-standardized incidence rates were 0.56 and 0.59 overall, 0.59 and 0.63 for HICs, 0.12 and 0.17 for UMICs, and 0.25 and 0.42 for LMICs. 95% limits of agreement were from -94.6 to 84.1/100,000. Subgroup analysis including only studies where more specific subnational geographical GBD estimates were available marginally improved crude incidence (n = 18) concordance (0.67 to 0.71) but not age-standardized incidence (n = 13) concordance (0.53 to 0.49). Subgroup analysis limited to population-based stroke registers included as GBD 2021 sources, did not significantly improve correlation or concordance. INTERPRETATION: Our findings demonstrate limited concordance and correlation in crude and age-standardized stroke incidence rates between population-based stroke registers and the GBD 2021 model, with lower concordance for UMICs and LMICs, compared to HICs. The wide 95% limits of agreement demonstrated should provide caution in the use of GBD stroke incidence estimates to guide policy or assess progress in the primary prevention of stroke.
Comparison of pragmatic post-thrombectomy prognostic scores not based on advanced imaging in a large national stroke registry.
Ciacciarelli A, Pensato U, Pracucci G … +73 more , Saia V, Nicolini E, De Michele M, Fasolino CA, Fainardi E, Casetta I, Marcheselli S, Laiso A, Nencini P, Vallone S, Bigliardi G, Da Ros V, Maestrini I, Bergui M, Bosco G, Ruggiero M, Longoni M, Bracco S, Tassi R, Simonetti L, Zini A, Del Sette B, Benzi Markushi T, Tessitore A, Ferraù L, Menozzi R, Pezzini A, Saletti A, De Vito A, Boghi A, Naldi A, Lazzarotti GA, Giannini N, Milazzo N, Persico A, Plebani M, Cappellari M, Comai A, Franchini E, Burdi N, Boero G, Allegretti L, Tassinari T, Zimatore DS, Petruzzellis M, Cavasin N, Critelli A, Lozupone E, Caggiula M, Gallesio I, Ferrandi D, Puglielli E, Casalena A, Perri M, De Santis F, Besana M, Giossi A, Galvano G, Saracco E, Carità G, Russo M, Allegritti M, Caproni S, Alberti M, Invernizzi P, Filizzolo M, Mannino M, Pelle G, Alessiani M, Konda D, Sallustio F, Mangiafico S, Toni D
Int J Stroke · 2026 Jan · PMID 41605880 · Publisher ↗
BACKGROUND: Nearly half of the patients who received endovascular thrombectomy (EVT) for large vessel occlusion experience poor functional outcomes. Reliable tools for early post-procedural prognostication are needed. We...
BACKGROUND: Nearly half of the patients who received endovascular thrombectomy (EVT) for large vessel occlusion experience poor functional outcomes. Reliable tools for early post-procedural prognostication are needed. We aimed to assess and compare the performance of existing, pragmatic post-EVT prognostic scores in a large national multicenter cohort. METHODS: We conducted a systematic literature search to identify pragmatic post-thrombectomy prognostic scores predicting 90-day functional outcomes. Models relying on advanced imaging, small derivation samples, or machine learning were excluded. We analyzed data from the IRETAS registry-a prospective, multicenter Italian cohort of stroke patients treated with EVT. Inclusion criteria were pre-stroke modified Rankin Scale (mRS) ⩽ 2 and available 90-day mRS. The primary outcome was good functional outcome (mRS ⩽ 2). Prognostic performance was assessed using c-statistics in the samples where each individual score was measurable. Scores were compared using DeLong tests in the subset of patients for whom all scores were measurable. RESULTS: Three scores were identified: HERMES-24, BET, and SNARL. Among 22,768 patients in the registry, 18,408 (89.1%) had a measurable HERMES-24 score, 13,593 (59.7%) had a measurable BET score, and 19,007 (83.5%) had a measurable SNARL score. Median age was 75 years (IQR 65-82), and 11,528 (50.6%) were female. In the subset in which each test was measurable, HERMES-24 showed the best performance for predicting mRS ⩽ 2 (c-statistic = 0.889), followed by BET (c-statistic = 0.794) and SNARL (c-statistic = 0.762) ( < 0.001). In the subset of 12,233 patients for whom all three prognostic scores were calculable, a head-to-head comparison confirmed the superior performance of the HERMES-24 model: HERMES-24 score versus BET score (c-statistic difference = 0.098 [95% CI = 0.092-0.105]; < 0.001) and HERMES-24 score versus SNARL score (c-statistic difference = 0.124 [95% CI = 0.116-0.132]; < 0.001). CONCLUSIONS: In this large, multicenter, national cohort, the post-EVT HERMES-24 score-which accounts only for age and 24-h NIHSS-demonstrated the highest prognostic performance among existing, pragmatic post-EVT scores. Its simplicity and robust performance support its routine adoption in clinical practice.
Rates and risk factors for major adverse cardiovascular and cerebrovascular events after stroke due to intracerebral hemorrhage: Systematic review and study-level meta-analysis.
Putri VP, Samarasekera N, Moullaali TJ … +26 more , Jampana S, Aked J, Åsberg S, Schulman S, Tsivgoulis G, Pikilidou M, Tsai HH, Tsai LK, Myint PK, Pana TA, Cordonnier C, Casolla B, Gaist D, Pezzini A, Camps-Renom P, Klijn CJM, Romoli M, Tveiten A, Liu M, Xu M, Wu B, Werring D, Nash PS, Banerjee G, Li L, Al-Shahi Salman R
Int J Stroke · 2026 Jul · PMID 41605872 · Full text
BACKGROUND: Intracerebral hemorrhage (ICH) survivors are at increased risk of major adverse cardiovascular and cerebrovascular events (MACE) compared with population controls; however, little is known about the annual ra...
BACKGROUND: Intracerebral hemorrhage (ICH) survivors are at increased risk of major adverse cardiovascular and cerebrovascular events (MACE) compared with population controls; however, little is known about the annual rates and risk factors for MACE. METHODS: We searched Medline, Embase, and trial registries systematically in April 2024 for studies of adults with ICH, reporting either a MACE composite outcome or both ischemic and hemorrhagic outcomes, with at least one year of follow-up. We excluded studies limited to secondary ICH or isolated non-ICH intracranial hemorrhages. We used the QUIPS tool to assess studies' risk of bias. The primary outcome was the rate of MACE. We used a random-effects meta-analysis to estimate the annual event rate (per 100 person-years, expressed as %) for each outcome. We conducted subgroup analyses and meta-regression to explore heterogeneity. RESULTS: We included 26 studies, involving 198,289 ICH survivors. Individual studies' reported annual rate of MACE ranged 4.2-14.6%. The pooled annual rate of recurrent ICH was 2.1% (95% confidence interval (CI) = 1.7-2.6; 26 studies; I = 94%) and of ischemic stroke was 2.0% (95% CI = 1.5-2.7; 24 studies; I = 95%). Meta-regression analyses identified one statistically significant association between a higher prevalence of atrial fibrillation and an increased risk of ischemic stroke. DISCUSSION: The rates of recurrent ICH and ischemic stroke were comparable among ICH survivors, but evidence about other MACE outcomes remains limited. An individual participant data meta-analysis is needed to investigate the predictors of MACE outcomes, which may help inform risk stratification and prognosis among ICH survivors.
Rates and determinants of incident lacunes: A systematic review and meta-analysis.
Han F, Zhang DD, Wardlaw JM
Int J Stroke · 2026 Jan · PMID 41605866 · Publisher ↗
BACKGROUND: Lacunes of presumed vascular origin are a key imaging marker of cerebral small-vessel disease (cSVD), predicting stroke and dementia risk. Their incidence and determinants have not been systematically quantif...
BACKGROUND: Lacunes of presumed vascular origin are a key imaging marker of cerebral small-vessel disease (cSVD), predicting stroke and dementia risk. Their incidence and determinants have not been systematically quantified across different populations, and implications for clinical research remain unclear. AIMS: This study aims to estimate the annualized incidence of new lacunes across diverse populations, identify study-level factors contributing to heterogeneity, summarize patient-level risk factors for incident lacunes, and provide empirical data to inform sample size estimation for studies using incident lacunes as an imaging outcome. SUMMARY OF REVIEW: Thirty-one studies comprising 12,646 participants and 56,073 person-years were included. The pooled overall incidence was 3.27 per 100 person-years (95% CI, 2.12-4.42), ranging from 1.50 to 8.03 across populations. Rates were highest in cSVD patients (8.03; 95% CI, 3.8-12.27), intermediate in stroke and memory-clinic patients, and lower in community-based, hypertensive, and non-specific artery disease cohorts. Meta-regression showed that baseline lacune prevalence was positively associated with incidence (β = 0.057; 95% CI, 0.006-0.108; = 0.031). At the individual level, male sex, baseline lacunes, hypertension, and diabetes were associated with higher risk. In cSVD populations, detecting a 30% relative risk reduction required 563, 867, and 1782 participants per arm for 3-, 2-, and 1-year follow-up, respectively. CONCLUSION: Incident lacune rates vary substantially across populations and are strongly influenced by baseline lacune burden and vascular risk factors. These findings provide context for population selection and sample size considerations in studies using incident lacunes as an imaging outcome.
Vascular dementia, and advances in acute stroke care.
Markus HS
Int J Stroke · 2026 Feb · PMID 41593867 · Publisher ↗
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Sex differences in mortality and functional outcomes across stroke subtype: A nationwide cohort study.
Kim TJ, Lee JS, Kim JY … +21 more , Kim DY, Kim YS, Kang DW, Kang J, Kim BJ, Kim SE, Park JM, Lee K, Lee JY, Cho YJ, Jeong HY, Jeong HG, Ban B, Oh MS, Lee SJ, Lee J, Kwon YU, Lee YR, Lim YJ, Gorelick PB, Bae HJ
Int J Stroke · 2026 Jan · PMID 41568781 · Publisher ↗
BACKGROUND: Sex disparities in stroke outcomes are well-recognized, but it remains unclear whether these disparities vary across stroke subtypes and how they relate to differences in acute care delivery. AIM: The aim of...
BACKGROUND: Sex disparities in stroke outcomes are well-recognized, but it remains unclear whether these disparities vary across stroke subtypes and how they relate to differences in acute care delivery. AIM: The aim of the study was to examine sex differences in long-term mortality, functional outcomes, and acute stroke management across stroke subtypes using a nationwide population-based cohort. METHODS: This retrospective cohort study analyzed linked clinical audit and claims data from 58,429 patients with acute stroke admitted to 269 hospitals in South Korea between 2018 and 2021. Clinical data were derived from the national Acute Stroke Quality Assessment Program and linked to claims. The primary outcome was all-cause mortality. The secondary outcome was poor functional outcome at discharge. Multivariable Cox and logistic regression models were used to assess associations between sex and outcomes, stratified by stroke subtype and adjusted for age, stroke severity, and comorbidities. Differences in acute stroke care were also analyzed. RESULTS: Of 58,429 patients (mean [SD] age, 68.6 [13.8] years; 43.9% female), 76.1% had ischemic stroke (IS), 15.7% intracerebral hemorrhage (ICH), and 8.2% subarachnoid hemorrhage (SAH). Females were older than males across all subtypes and had different comorbidity profiles. After adjustment, females had significantly lower mortality in all subtypes (adjusted hazard ratios [95% CI]: IS, 0.77 [0.74-0.80]; ICH, 0.60 [0.56-0.64]; SAH, 0.60 [0.54-0.67]; all P < 0.001). Functional outcomes varied: females had worse outcomes in IS, better in ICH, and no difference in SAH. Males were more likely to receive reperfusion and surgical therapies; females were more likely to receive rehabilitation services. These care differences did not fully explain the observed disparities in outcomes. CONCLUSION: In this national cohort, sex disparities in stroke outcomes differed by subtype. Despite lower adjusted mortality in females, functional outcomes were not uniformly better. These findings underscore the importance of adopting sex- and subtype-specific approaches to stroke care, secondary prevention, and rehabilitation.
Decompressive hemicraniectomy for large hemispheric infarction after endovascular therapy.
Nie X, Lu Q, Liu J … +10 more , Yan H, Wei Y, Wang M, Yang J, Liu Y, Huo X, Pan Y, Miao Z, Yan B, Liu L
Int J Stroke · 2026 Jan · PMID 41568777 · Publisher ↗
BACKGROUND: Although endovascular therapy (EVT) improves functional outcomes in acute ischemic stroke patients, some with large hemispheric infarction (LHI) post-EVT may still require decompressive hemicraniectomy (DHC)....
BACKGROUND: Although endovascular therapy (EVT) improves functional outcomes in acute ischemic stroke patients, some with large hemispheric infarction (LHI) post-EVT may still require decompressive hemicraniectomy (DHC). This study aimed to explore whether DHC benefits all patients with post-EVT LHI and to identify which patients are more likely to benefit from DHC. METHODS: This pooled analysis of the RESCUE-RE study and the ANGEL-ASPECT trial enrolled patients with LHI and severe neurological deficits after EVT. According to the treatment received, patients were categorized into DHC and conservative therapy groups. The primary outcome was 90-day mortality. Propensity score matching (PSM) analysis was used to control for differences between groups. RESULTS: In total, 136 of 2036 EVT-treated patients (6.7%) in the RESCUE-RE study and 59 of 230 (25.6%) in the ANGEL-ASPECT trial met inclusion criteria. Among the 195 patients included, 50 (25.6%) underwent DHC (41 after PSM), while 145 (74.4%) received conservative therapy (41 after PSM). Patients undergoing DHC after EVT had significantly lower 90-day mortality rates compared with those receiving conservative therapy (odds ratio (OR) = 0.26; 95% confidence interval (CI), 0.10-0.66; = 0.005), but no significant improvement was observed in 90-day modified Rankin Scale (mRS) distribution (common OR = 0.47; 95% CI = 0.21-1.05; = 0.06). Patients within an overlapping range of post-EVT midline shift (approximately 10-17 mm) or infarct volume (approximately 250-330 mL), where both 90-day mortality and ordinal mRS distribution models favored DHC, appeared more likely to derive a comprehensive clinical benefit. Baseline infarct-core volume was not associated with the treatment effect of DHC. CONCLUSION: In patients with LHI after EVT, DHC was associated with reduced mortality when performed in accordance with current guidelines. Moreover, patients within a higher, but not the most extreme, range of injury severity after EVT might be more likely to benefit from DHC.
Chinese guidelines for diagnosis and treatment of intracranial atherosclerotic stenosis.
Leng X, Sui B, Liu C … +13 more , Wang T, Li M, Tian X, Liu Y, Song B, Sun Q, Wang H, Yang Y, Leung TW, Gu Y, Liu L, Jiao L, Xu W
Int J Stroke · 2026 Jan · PMID 41568775 · Publisher ↗
Intracranial atherosclerotic stenosis (ICAS) is an important cause of ischemic stroke and transient ischemic attack (TIA), which is also associated with increased risks of cognitive impairment and dementia. The prevalenc...
Intracranial atherosclerotic stenosis (ICAS) is an important cause of ischemic stroke and transient ischemic attack (TIA), which is also associated with increased risks of cognitive impairment and dementia. The prevalence of both asymptomatic and symptomatic ICAS (asICAS and sICAS) is significantly higher in Asian populations than in Western populations. In recent years, substantial new evidence has emerged regarding the epidemiology, diagnosis, assessment, prognosis, and treatment of asICAS and sICAS. The China ICAS Research Group has developed this guideline based on published research and relevant domestic and international guidelines or expert consensus, to further clarify the definition, epidemiology, and prognosis of ICAS and the profiles of high-risk ICAS patients and provide evidence-based recommendations on screening, diagnosis, assessment, and treatment strategies of asICAS and sICAS. For imaging exams, noninvasive and contrast-independent modalities are generally suitable for screening and assessment of ICAS in stroke-free individuals with multiple risk factors as well as for routine exams of stroke patients, while contrast-dependent or invasive imaging methods may be employed for further assessment or guiding treatment decision-making in sICAS patients. In addition, vessel wall imaging is valuable for distinguishing the etiology of intracranial stenosis, particularly in young stroke patients. Multiple imaging modalities or methods are available for the assessment of cerebral perfusion, hemodynamics, and collateral circulation that may meet different needs. Regarding interventions, lifestyle modifications (healthy diet, safe exercise, smoking cessation) are recommended for both asICAS and sICAS patients. For stroke-free individuals with asICAS, controlling vascular risk factor is the primary strategy, while routine aspirin or endovascular treatment for primary stroke prevention is not recommended. For sICAS patients, the cornerstone is intensive medical management, including short-term dual antiplatelet therapy in high-risk patients (such as those with severe luminal stenosis, minor stroke, or high-risk TIA) followed by lifelong monotherapy, aggressive lipid control (targeting low-density lipoprotein cholesterol < 1.8 mmol/L), blood pressure control (<140/90 mmHg), and glycemic control (targeting HbA1c < 7.0%), with structured follow-up to enhance treatment adherence. Endovascular treatment is not recommended for sICAS with mild to moderate luminal stenosis (<70%) but may be considered for carefully selected patients with severe (70-99%), medically refractory sICAS, particularly those with hypoperfusion, with a preference to delay the intervention for more than 21 days after stroke to enhance safety.
Does illicit drug use increase stroke risk? A systematic review, meta-analyses, and Mendelian randomization analysis.
Ritson M, Markus HS, Harshfield EL
Int J Stroke · 2026 Jul · PMID 41566428 · Full text
BACKGROUND: Epidemiological evidence suggests associations between substance use disorders and risk of stroke, but whether these are due to confounding or are true causal relationships remains uncertain. AIMS: To meta-an...
BACKGROUND: Epidemiological evidence suggests associations between substance use disorders and risk of stroke, but whether these are due to confounding or are true causal relationships remains uncertain. AIMS: To meta-analyze the observational evidence on illicit substance use and stroke risk and apply Mendelian randomization (MR) to evaluate potential causal effects of substance dependence on stroke subtypes. METHODS: We conducted a systematic review and meta-analysis of studies reporting associations between illicit drug use and stroke (PROSPERO registration-CRD420251053702). The meta-analysis included 32 studies comprising more than 100 million total participants across administrative, hospital-based, and population-based datasets. Pooled odds ratios (ORs) were estimated using multivariate random-effects models for ischemic and hemorrhagic subtypes. We then performed two-sample MR using genome-wide association study summary statistics to examine associations between seven drug exposures and all stroke, ischemic and hemorrhagic stroke, and ischemic stroke subtypes. RESULTS: Meta-analysis demonstrated significant associations of cannabis (OR = 1.37, 95% confidence interval (95% CI) = 1.14-1.65), cocaine (OR = 1.96; 95% CI = 1.27-3.01), and amphetamines (OR = 2.22, 95% CI = 1.40-3.53) with increased stroke risk, while no significant association was observed for opioids. Findings for cannabis showed some heterogeneity and small-study effects. MR analyses revealed that cannabis use disorder was associated with any stroke (OR = 1.11 [1.01-1.51]) and large artery stroke (OR = 1.35, 95% CI = 1.01-1.80), and cocaine dependence was associated with cardioembolic stroke (OR = 1.08, 95% CI = 1.02-1.14) and intracerebral hemorrhage (OR = 1.38, 95% CI = 1.15-1.65). Genetically predicted substance use disorder overall was associated with any stroke (OR = 1.33, 95% CI = 1.02-1.72) and intracerebral hemorrhage (OR = 7.79, 95% CI = 3.46-17.54). Problematic and dependent alcohol use was linked to large artery and cardioembolic stroke, whereas nicotine dependence showed no significant associations. CONCLUSION: Our findings provide consistent observational and genetic evidence that several forms of substance misuse increase stroke risk, particularly cocaine, amphetamines, and cannabis. These findings suggest important public health implications for prevention strategies targeting substance use disorders to mitigate stroke risk.
Dyslipidemia management in stroke prevention: An individualized approach.
Stefanou MI, Panagiotopoulos E, Liberopoulos E … +9 more , Milionis H, Theodorou A, Katan M, Aguiar de Sousa D, Palaiodimou L, Vlachopoulos C, Siasos G, Giannopoulos S, Tsivgoulis G
Int J Stroke · 2026 Jul · PMID 41532416 · Publisher ↗
Dyslipidemia remains a major, modifiable determinant of global stroke burden, accounting for more than one-fifth of ischemic strokes (IS) worldwide. Recent evidence has shifted emphasis from conventional lipid fractions...
Dyslipidemia remains a major, modifiable determinant of global stroke burden, accounting for more than one-fifth of ischemic strokes (IS) worldwide. Recent evidence has shifted emphasis from conventional lipid fractions to apolipoprotein B (ApoB)-containing lipoproteins, including lipoprotein(a) [Lp(a)], which more accurately reflect atherogenic particle burden than low-density lipoprotein cholesterol (LDL-C) alone and are increasingly used for stroke risk stratification. While the principle "the faster and the lower, the better" underpins dyslipidemia management, evidence-based, subtype-specific lipid strategies in stroke remain limited. Intensive LDL-C reduction significantly lowers recurrent IS risk; however, uniform lipid targets are often applied without accounting for stroke etiology. High-intensity statins remain first-line therapy, with pleiotropic benefits extending beyond LDL-C reduction. For statin intolerance or suboptimal response, ezetimibe and PCSK9 inhibitors provide potent, bleeding-neutral LDL-C lowering. Inclisiran and bempedoic acid broaden therapeutic options, although stroke-specific efficacy data are still pending. Lp(a)-lowering agents, including pelacarsen, olpasiran, and lepodisiran, are under active evaluation and may address residual cardiovascular risk. For triglyceride lowering, recent randomized evidence supports icosapent ethyl for reducing IS risk. In intracerebral hemorrhage (ICH), the optimal intensity and thresholds of lipid lowering remain uncertain, warranting individualized weighting of ischemic against hemorrhagic risk, particularly in patients with lobar ICH or suspected cerebral amyloid angiopathy (CAA). In such cases, hydrophilic statins, ezetimibe, or PCSK9 inhibitors may represent reasonable options. This review synthesizes current evidence and proposes a phenotype-guided, individualized framework for dyslipidemia management across stroke subtypes. Moving beyond uniform targets toward etiologic and genetically informed lipid modulation may improve post-stroke outcomes and refine individualized stroke prevention.
Association of cognitive reserve with stroke outcome: A systematic review and meta-analysis.
Gallucci L, Heldner MR, Sperber C … +1 more , Umarova RM
Int J Stroke · 2026 Jan · PMID 41532407 · Publisher ↗
BACKGROUND: For neurodegenerative diseases, the inter-individual variability in the functional response to pathology is explained by the construct of cognitive reserve (CR). We aimed to evaluate the association of CR wit...
BACKGROUND: For neurodegenerative diseases, the inter-individual variability in the functional response to pathology is explained by the construct of cognitive reserve (CR). We aimed to evaluate the association of CR with stroke outcome to improve the understanding of its inter-individual variability and prediction. METHODS: The peer-reviewed protocol was preregistered on PROSPERO (CRD42021256175). The systematic review and meta-analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Meta-analysis of Observational Studies in Epidemiology (MOOSE), and CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies (CHARMS) reporting guidelines. Original studies reporting the association between CR-proxies (e.g. level or years of education, occupational attainment) and measures of non-cognitive stroke outcome (e.g. National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale, Barthel Index, Functional Independence Measure) were selected. Risk of bias was assessed using Quality In Prognosis Studies (QUIPS). Estimates were pooled using a random-effects model. RESULTS: Of 4129 studies identified, 17 were included in the systematic review. Based on the quality check, 10 of them involving 19,308 patients were included in the meta-analysis, whereby only five studies directly addressed the association of CR-proxies with stroke outcome. Pooled standardized mean differences (SMDs) showed evidence for the association of low CR with poor stroke outcome (SMD = 0.23; 95% confidence interval (CI) = 0.04 to 0.42 corresponding to odds ratio (OR) = 1.52; 95% CI = 1.08 to 2.14). Subgroup analysis showed a greater association of level of education (SMD = 0.37; 95% CI = 0.12 to 0.62) and occupational attainment (SMD = 0.34; 95% CI = 0.10 to 0.57) with stroke outcome, as compared to years of education (SMD = 0.01; 95% CI = -0.06 to 0.08). The effect of CR was greater in the acute-subacute stroke phase (⩽3 months post-stroke, SMD = 0.28; 95% CI = 0.04 to 0.52) than in the chronic phase (SMD = 0.01; 95% CI = -0.06 to 0.08). CONCLUSION: We found evidence that CR explains inter-individual variability in stroke outcome and thus may improve its prediction. Low CR increases the risk of poor stroke outcome, and its proxies should be considered in both clinical and research settings. However, we observed high heterogeneity across studies, and further research with specific focus on this topic and CR-proxies extending beyond educational and occupational attainment is needed.
Risk of ischemic stroke during pregnancy and postpartum period in women with a prior history of ischemic stroke.
Qureshi AI, Chen KY, Qayyum M … +2 more , Raza H, Shyu CR
Int J Stroke · 2026 Jan · PMID 41532406 · Publisher ↗
BACKGROUND: The risk of recurrent ischemic stroke during pregnancy or postpartum period in women with a history of ischemic stroke is unclear. AIMS: To determine the risk of incident ischemic stroke during pregnancy or e...
BACKGROUND: The risk of recurrent ischemic stroke during pregnancy or postpartum period in women with a history of ischemic stroke is unclear. AIMS: To determine the risk of incident ischemic stroke during pregnancy or early postpartum period (within 6 weeks) among women with and without a prior history of ischemic stroke. METHODS: We conducted a retrospective cohort study using Oracle Health Real-World Data (January 2015-February 2025). We identified 220,479 completed pregnancies; prior ischemic stroke by the (ICD-10-CM) I69.3x/Z86.73; and incident ischemic stroke by I63 during pregnancy or ⩽ 42 days postpartum. Odds ratios (ORs) with 95% CIs were estimated using multivariable logistic regression after 1:10 propensity-score matching based on demographics and comorbidities. RESULTS: The incident ischemic stroke rates were 415 out of 1192 pregnancies (34.82%, 95% confidence interval [CI] = 32.16%-37.56%) among pregnant women with a prior history of ischemic stroke and 737 out of 219,287 pregnancies (0.34%, 95% CI = 0.31%-0.36%) among pregnant women without a history of ischemic stroke. In the multivariate analysis, the risk of ischemic stroke during pregnancy or early postpartum period was significantly higher among pregnancies in women with a prior history of ischemic stroke compared with those in women without a history of ischemic stroke (OR = 2.37, 95% CI = 1.97-2.87, p < 0.0001). Previous myocardial infarction (OR = 1.82, 95% CI = 1.38-2.39, p < 0.0001) and obesity (OR = 1.25, 95% CI = 1.07-1.47, p < 0.01) were also associated with recurrent ischemic stroke during pregnancy or early postpartum period. The odds of experiencing an incident ischemic stroke among women with a prior history of ischemic stroke was significantly higher in women during pregnancy or early postpartum period compared with those with neither of the two conditions (OR = 3.35, 95% CI = 2.67-4.22, p < 0.0001). CONCLUSION: Women with a prior history of ischemic stroke had two times higher odds of having another ischemic stroke during pregnancy or postpartum period. Our findings have implications for counseling, surveillance, and enhanced recurrent stroke prevention in this high-risk group.
Stroke patterns, risk factors, management, and outcomes from hospital-based stroke registries in India.
Mathur P, Huliyappa D, Pv P … +5 more , Urs V, Koli RR, N S, Seenappa K, National Stroke Registry Programme (NSRP) Investigators
Int J Stroke · 2026 Jul · PMID 41502107 · Full text
BACKGROUND: India is facing a growing burden of stroke due to population aging, lifestyle changes, and increased exposure to risk factors. However, longitudinal data on stroke patterns and outcomes in India are limited....
BACKGROUND: India is facing a growing burden of stroke due to population aging, lifestyle changes, and increased exposure to risk factors. However, longitudinal data on stroke patterns and outcomes in India are limited. OBJECTIVES: This study assessed stroke patterns, risk factors, management practices, and outcomes using data from the Hospital-Based Stroke Registries (HBSRs) in India. METHODS: This prospective hospital-based registry included 34,792 stroke cases from 30 centers across India, recorded between 2020 and 2022. Data on demographics, clinical features, risk factors, diagnostics, treatments, and outcomes were collected, with follow-up at 28 days and 3 months. Functional outcome was assessed using the modified Rankin Scale (mRS), along with data on recurrence. RESULTS: The mean age was 59.4 years; 13.8% were aged under 45, 63.4% were male, and 72.1% were from rural areas. Hypertension (74.5%) was the most common risk factor, followed by smokeless tobacco use (28.5%) and diabetes mellitus (27.3%). Ischemic stroke accounted for 60% of cases. Only 20.1% were presented within 4.5 h of symptom onset, while 37.8% of cases presented after 24 h. Motor impairment (74.8%) followed by speech disturbance (51.2%) were the commonest symptoms at onset. Thrombolysis was given in 4.6%, and thrombectomy in 0.7%, of ischemic strokes. At 3 months, 27.8% had died, 29.7% had significant disability (mRS 3-5), and 1.1% had a recurrent stroke. CONCLUSION: In this study, one in 7 stroke were in the young, 2 in 5 patients arrived after 24 h of symptom onset, and thrombolysis and mechanical thrombectomy were underutilized. Over half had poor 3-month outcomes, highlighting the need for improving comprehensive stroke care across India.
Corrigendum to: Baseline NIH Stroke Scale is an Inferior Predictor of Functional Outcome in the Era of Acute Stroke Intervention.
Int J Stroke · 2026 Jan · PMID 41496695 · Publisher ↗
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Young stroke: An update on epidemiology, emerging risk factors, and future research directions.
Rasing A, Hilkens NA, Leeuw FE
Int J Stroke · 2026 Jan · PMID 41482721 · Full text
The incidence of ischemic stroke among young adults (aged 18-49 years) has risen over recent decades, particularly in high-income countries, contrasting with the decline seen in older populations. This trend represents a...
The incidence of ischemic stroke among young adults (aged 18-49 years) has risen over recent decades, particularly in high-income countries, contrasting with the decline seen in older populations. This trend represents a growing public health concern, as stroke at young age often leads to long-term psychosocial consequences and loss of productive life years. The increasing incidence may partly reflect a higher prevalence of traditional vascular risk factors, as well as the identification of non-traditional risk and trigger factors such as air pollution, sleep apnea, long working hours, vigorous exercise, and illicit drug use. Diagnostic evaluation in this young population is typically more extensive than in older patients, given the broad spectrum of potential underlying causes. A structured, multidisciplinary approach integrating vascular, hematologic, and cardiac assessment is essential for accurate etiological classification. Although functional outcomes are generally favorable, many young stroke survivors experience persistent psychosocial sequelae, including cognitive impairment, depression, anxiety, and fatigue, which significantly affect quality of life. Recurrence risk varies according to stroke etiology, with the lowest rates observed in patients with a cryptogenic stroke. These findings highlight the importance of more tailored secondary prevention strategies, as antiplatelet therapy is not without risks. Further research is needed to identify novel risk and trigger factors, refine prognostic tools, optimize secondary prevention, and develop interventions addressing the psychosocial recovery of young stroke survivors.
Artificial intelligence in stroke in 2026.
Markus HS
Int J Stroke · 2026 Jan · PMID 41482720 · Publisher ↗
Abstract loading — click title to view on PubMed.
Vascular dementia: World Stroke Organization fact sheet 2026.
Cai Y, Mok VCT, Markus HS
Int J Stroke · 2026 Feb · PMID 41479247 · Full text
There were 56.9 million people worldwide living with dementia in 2021, according to the Global Burden of Disease study, and this number is projected to exceed 137 million by 2050. Vascular dementia (VaD) is the second le...
There were 56.9 million people worldwide living with dementia in 2021, according to the Global Burden of Disease study, and this number is projected to exceed 137 million by 2050. Vascular dementia (VaD) is the second leading cause of dementia. While high-quality global epidemiological data on VaD remain limited, population-based studies with autopsy confirmation allow an approximate estimation. These show that pure VaD represents approximately 15% of all dementia cases, with mixed vascular and degenerative dementia accounting for an additional 16%. According to these estimates, approximately 8.5 million people worldwide suffer from pure VaD, and 9.1 million from mixed dementia. Under the assumption that existing proportional rates remain constant, the global burden of total VaD (i.e. pure VaD and mixed dementia) will reach 42.7 million cases by 2050. However, the impact of cerebrovascular disease is likely to be even greater. Increasing evidence demonstrates that vascular pathology commonly coexists with Alzheimer's and other neurodegenerative pathologies, increasing the risk that these neurodegenerative pathologies cause clinical dementia. Despite the importance of VaD, it remains underrecognized and underresearched compared to other forms of dementia. This fact sheet highlights the urgent need for improved recognition, standardized diagnostic approaches, and enhanced preventive strategies for this highly prevalent yet underrecognized cause of dementia. The factsheet has been reviewed and approved by the World Stroke Organization (WSO) executive.
Cognitive impairment after cerebral venous thrombosis: A systematic review and meta-analysis.
Medeiros Visentini L, Nascimento de Medeiros G, D'lucas Alves E Gomes A … +9 more , Rodrigues Silva W, Alcântara Nascimento Aguiar F, de Lima Loiola J, Ueda GN, Marinheiro G, Barroso Cunha G, Clares de Andrade JB, Aguiar de Sousa D, Pardini Fagundes T
Int J Stroke · 2025 Dec · PMID 41416684 · Publisher ↗
BACKGROUND: Cerebral venous thrombosis (CVT) is a less common type of stroke that predominantly affects young adults, particularly women. Although CVT is generally associated with more favorable functional outcomes than...
BACKGROUND: Cerebral venous thrombosis (CVT) is a less common type of stroke that predominantly affects young adults, particularly women. Although CVT is generally associated with more favorable functional outcomes than other stroke subtypes, its cognitive consequences remain poorly understood. AIMS: We aimed to perform a systematic review and meta-analysis evaluating the prevalence and characteristics of cognitive impairment in patients after CVT. SUMMARY OF REVIEW: A systematic review was conducted in accordance with PRISMA guidelines. We searched PubMed, Embase, and Cochrane databases up to May 2025 for studies assessing cognitive impairment in patients with cerebral venous thrombosis (CVT), with a minimum follow-up of 6 months. Data extraction was performed independently by two reviewers. Pooled prevalence estimates were calculated using random-effects generalized linear mixed models with logit transformation as the primary approach, with Freeman-Tukey (double arcsine) transformation applied only in analyses with zero events or extreme proportions. Heterogeneity was evaluated using the I² statistic. All statistical analyses were conducted in R (version 4.5.2). Eleven observational studies and one randomized clinical trial involving 801 post-CVT patients were included. The pooled prevalence of cognitive impairment after CVT ranged from 19.25% (95% CI: 7.15-42.47%) among studies at low risk of bias to 29.20% (95% CI: 14.91-49.27%) in the overall analysis. Memory loss and affected executive function and visuospatial domains occurred in 39.21% (95% CI: 18.70-64.40%) and 35.94% (95% CI: 21.86-52.94%) of patients, respectively. Among functionally independent patients, cognitive impairment was observed in 28.6% (95% CI: 21.0-37.6%) of those with mRS 0, 36.3% (95% CI: 26.5-47.5%) with mRS 1, and 32.7% (95% CI: 15.5-56.3%) with mRS 2. CONCLUSIONS: Cognitive impairment affects roughly one-fifth to one-third of CVT survivors (19-29%), including those with minimal or no functional disability. These findings highlight the need to move beyond the mRS when assessing recovery and planning follow-up care.
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