Meng Lee

Aims: Cardiac autonomic neuropathy (CAN) is a frequent but under‐recognised complication of diabetes that may exacerbate cardiovascular risk after stroke. This study aimed to characterise circadian patterns of heart rate (HR) and HR variability (HRV) in patients with acute ischaemic stroke, comparing those with and without type 2 diabetes. Methods: We conducted a retrospective case‐control study of 157 patients with acute ischaemic stroke who underwent 7‐day continuous electrocardiographic (ECG) monitoring (80 with type 2 diabetes, 77 without diabetes). Patients with paroxysmal atrial fibrillation, insufficient ECG data ( 7% [53 mmol/mol]) was associated with higher HR and lower HRV, particularly during nocturnal hours, supporting a dose–response relationship. Conclusions: Type 2 diabetes is associated with attenuated circadian autonomic regulation after ischaemic stroke, characterised by elevated HR and reduced HRV, most evident during sleep and early morning periods. Continuous ECG monitoring may facilitate early detection of nocturnal autonomic dysfunction, and interventions that enhance parasympathetic tone—such as improved glycaemic control and potentially cholinergic modulation—warrant further investigation to mitigate post‐stroke cardiovascular risk.

Background The impact of renal function on patients receiving endovascular thrombectomy (EVT) remains uncertain due to inconsistent results from previous studies. We investigated the effects of estimated glomerular filtration rate (eGFR) at admission on outcomes. Methods This cohort study analyzed data from the Taiwan Registry of EVT for Acute Ischemic Stroke (2019–24). Patients were categorized based on admission eGFR (mL/min/1.73 m²): renal hyperfiltration (≥120), normal renal function (60–119), mild renal impairment (30–59), moderate renal impairment (15–29), and end stage renal disease (ESRD Results Among 2561 patients, the distribution was: 3.2% renal hyperfiltration, 69.6% normal renal function, 24.1% mild/moderate renal impairment, and 3.1% ESRD. Functional independence at 90 days declined with worsening renal function (43.2% to 11.3%), while mortality increased (18.5% to 43.8%). After multivariable adjustment, both renal hyperfiltration (adjusted OR (aOR) 0.35; 95% CI 0.18 to 0.67) and ESRD (aOR 0.35; 95% CI 0.15 to 0.78) were independently associated with reduced 90 day functional independence. Renal impairment was associated with increased 90 day mortality. The beneficial effect of successful recanalization on survival diminished in patients with renal impairment. Post-EVT intracerebral hemorrhage risk remained similar across all eGFR groups. These results were consistent across predefined subgroups. Conclusions Both renal hyperfiltration and impairment predicted worse outcomes after EVT, but did not increase the risk of hemorrhage. The results indicate that EVT remains appropriate for all eligible patients, regardless of renal function.

Background: Endovascular thrombectomy (EVT) is the standard treatment for acute ischemic stroke due to internal carotid artery (ICA) or middle cerebral artery (MCA) M1 occlusion with a small ischemic core. However, the effect of EVT on acute stroke with a large ischemic core remains unclear. This study aimed to evaluate the association of EVT plus medical care versus medical care alone with outcomes in patients with acute stroke and a large ischemic core due to ICA or MCA M1 occlusion. Methods and findings: PubMed, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched from January 1, 2000 to September 25, 2024. There were no language restrictions. Randomized controlled trials (RCTs) of patients with acute stroke and a large ischemic core that compared EVT plus medical care versus medical care alone were evaluated. We computed the random-effects estimate based on the inverse variance method. Risk ratio (RR) with 95% confidence interval (CI) was used to measure outcomes of EVT plus medical care versus medical care alone. The primary outcome was functional independence, defined as modified Rankin Scale (mRS) of 0–2 at 90 days post-stroke; and the lead secondary outcome was reduced disability, defined as ordinal shift of mRS. Safety outcomes were requiring constant care or death (mRS 5–6), death, and early symptomatic intracranial hemorrhage (sICH). Grading of Recommendations Assessment, Development and Evaluations (GRADE) was used to evaluate summaries of evidence for the outcomes. We included six RCTs comprising 1870 patients (826 females [44.2%]) with acute stroke and a larger moderate or large ischemic core due to ICA or MCA M1 occlusion. All patients were nondisabled before stroke. Pooled results showed that at 90 days post-stroke, EVT plus medical care, compared with medical care alone, was associated with greater functional independence (RR 2.53, 95% CI [1.95, 3.29]; p < 0.001; number needed to treat [NNT], 9, 95% CI [6,15]) and reduced disability (common odds ratio 1.63, 95% CI [1.38, 1.93]; p < 0.001; NNT, 4 [minimum possible NNT, 2; maximum possible NNT, 6]). EVT plus medical care, compared with medical care alone, was associated with a lower risk of requiring constant care or death (RR 0.74, 95% CI [0.66, 0.84]; p < 0.001; NNT, 7, 95% CI [6,11]). EVT plus medical care, compared with medical care alone, was associated with a nonsignificantly higher proportion of patients with early symptomatic intracranial hemorrhage (RR 1.65, 95% CI [1.00, 2.70]; p = 0.05). The rates of death were not significantly different between the EVT plus medical care and medical care alone groups (RR 0.86, 95% CI [0.72, 1.02]; p = 0.08). Main limitations include variability in imaging definitions of large core and inclusion of both larger moderate and large cores in the analysis. Conclusions: Among patients with acute stroke and a larger moderate or large ischemic core due to ICA or MCA M1 occlusion who were nondisabled before stroke, EVT plus medical care, compared with medical care alone, may be associated with improved functional independence, reduced disability, and reduced rates of severe disability or death at 90 days post-stroke. PROSPERO registration number: CRD42024514605

INPLASY2024100122 Comparison of neuroprotective adjuvant treatments in patients with acute ischemic stroke after reperfusion therapy: A systematic review and network meta-analysis Keywords: acute i…

Background: Endovascular thrombectomy (EVT) is standard treatment for an acute ischemic stroke due to large-vessel occlusions (AIS-LVO) with a small ischemic core, but the effect of EVT on AIS-LVO with a large ischemic core remains unclear. The objective was to assess the benefit and safety of EVT for AIS-LVO with large ischemic cores. Methods and Finding: PubMed, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched from January 1 2000 to September 25 2025. Randomized clinical trials (RCTs) of patients with AIS-LVO and large ischemic cores that compared EVT plus medical care vs. medical care alone were evaluated. Risk ratio (RR) with 95% CI was used to measure outcomes of EVT vs. medical care alone. Primary outcome was functional independence, defined as modified Rankin Scale (mRS) of 0 to 2 at 90 days; and lead secondary outcome was reduced disability, defined as ordinal shift of mRS. Safety outcomes were requiring constant care or death (mRS 5 to 6), death, and early symptomatic intracranial hemorrhage (sICH). We included 6 RCTs comprising 1870 patients (women 826 [44.2%]) with AIS-LVO. Pooled results showed that at 90 days, EVT vs. medical care alone was associated with greater functional independence (RR 2.53, 95% CI, 1.95-3.29; number needed to treat [NNT], 9) and reduced disability (common odds ratio 1.63, 95% CI 1.38-1.93; NNT, 4). EVT vs. medical care alone was associated with a lower risk of requring constant care or death (RR 0.74, 95% CI 0.66 to 0.84; NNT, 7). The rates of death and early sICH were not significantly different between the EVT and medical care alone groups. Conclusions: EVT combined with medical care compared with medical care alone may be associated with improved functional outcomes and reduced severe disability or death at 90 days for acute stroke with large ischemic cores. PROSPERO registration number: CRD42024514605

Background: Stroke risks associated with rapid climate change remain controversial due to a paucity of evidence. Aims: To examine the risk of subarachnoid hemorrhage (SAH), intracranial hemorrhage (ICH), and ischemic stroke (IS) associated with meteorological parameters. Methods: In this time-stratified case-crossover study, adult patients hospitalized for their first stroke between 2011 and 2020 from the insurance claims data in Taiwan were identified. The hospitalization day was designated as the case period, and three or four control periods were matched by the same day of the week and month of each case period. Daily mean and 24-h variations in ambient temperature, relative humidity, air pressure, and apparent temperature were measured. Conditional logistic regression models were applied to assess the risk of stroke associated with exposure to weather variables, using the third quintile as a reference, controlling for air pollutant levels. Results: There were 7161 patients with SAH, 40,426 patients with ICH, and 107,550 patients with IS. There was an inverse linear relationship between mean daily temperature and apparent temperature with ICH. Elevated mean daily atmospheric pressure was associated with an increased risk of ICH. A greater decrease in apparent temperature over a 24-h period was associated with increased risk of ICH but decreased risk of IS (odds ratio (95% confidence interval) for the first vs. third quintile of changes in apparent temperature, 1.141 (1.053–1.237) and 0.946 (0.899–0.996), respectively). Conclusions: There were considerable differences in short-term associations between meteorological parameters and three main pathological types of strokes. Data access statement: The authors have no permission to share the data.

Purpose Optimal imaging modalities to select patients for endovascular thrombectomy (EVT) in the late window of acute ischemic stroke due to large vessel occlusions (AIS-LVO) are not known. We conducted a systematic review comparing outcomes of patients selected by non-contrast computed tomography (NCCT)/CT angiography (CTA) vs. those selected by CT perfusion (CTP) or magnetic resonance imaging (MRI) for EVT in these patients. Methods We searched PUBMED, EMBASE, and the Cochrane Library from January 1, 2000, to July 15, 2023, to identify studies comparing outcomes of patients selected for EVT by NCCT/CTA vs. CTP or MRI in the late time window for AIS-LVO. Primary outcome was independence (mRS 0–2) at 90 days or discharge. Secondary outcomes were symptomatic intracranial hemorrhage (sICH) and mortality. We pooled data across studies based on an inverse variance method. Results Six cohort studies with 4208 patients were included. Pooled results showed no significant difference in the rate of independence at 90 days or discharge (RR 0.96, 95% CI 0.88–1.03) and sICH (RR 1.26, 0.85–1.86) between patients selected by NCCT/CTA vs. CTP or MRI for EVT in the late window of AIS-LVO. However, patients selected by NCCT/CTA vs. CTP or MRI for EVT were associated with a higher risk of mortality (RR 1.21, 1.06–1.39). Conclusion For AIS-LVO in the late window, patients selected by NCCT/CTA compared with those selected by CTP or MRI for EVT might have a comparable rate of functional independence and sICH. Baseline NCCT/CTA may triage AIS-LVO in the late window.

Hypertension is a major risk factor for recurrent stroke in patients with ischemic and hemorrhagic stroke or transient ischemic attack (TIA), and blood pressure lowering is therefore a guideline-recommended strategy to prevent recurrent stroke. Indeed, recurrent stroke has declined substantially over decades, with improved blood pressure control as a leading cause.¹

Background: Long-term mortality prediction can guide feasible discharge care plans and coordinate appropriate rehabilitation services. We aimed to develop and validate a prediction model to identify patients at risk of mortality after acute ischemic stroke (AIS). Methods: The primary outcome was all-cause mortality, and the secondary outcome was cardiovascular death. This study included 21,463 patients with AIS. Three risk prediction models were developed and evaluated: a penalized Cox model, a random survival forest model, and a DeepSurv model. A simplified risk scoring system, called the C-HAND (history of Cancer before admission, Heart rate, Age, eNIHSS, and Dyslipidemia) score, was created based on regression coefficients in the multivariate Cox model for both study outcomes. Results: All experimental models achieved a concordance index of 0.8, with no significant difference in predicting poststroke long-term mortality. The C-HAND score exhibited reasonable discriminative ability for both study outcomes, with concordance indices of 0.775 and 0.798. Conclusions: Reliable prediction models for long-term poststroke mortality were developed using information routinely available to clinicians during hospitalization.