Francisco Bernardo

BACKGROUND: Contrast-associated acute kidney injury (CA-AKI) after endovascular thrombectomy (EVT) worsens outcomes in acute ischemic stroke, but threshold-based definitions do not capture prognostic information from subthreshold changes. We tested whether early creatinine change within 48 hours of EVT conveys graded prognostic information beyond dichotomous CA-AKI. METHODS: We performed a secondary analysis of the CAN-REST registry (Contrast-Associated Nephropathy After Endovascular Stroke Treatment), a retrospective multicenter observational cohort study of 6638 EVT-treated adults with acute ischemic stroke enrolled at 73 centers in 16 countries between January 1 and December 31, 2023. Early creatinine change was quantified as the natural logarithm ratio of 48-hour creatinine to baseline creatinine (ln[48-hour/baseline creatinine]), with CA-AKI defined per Kidney Disease: Improving Global Outcomes criteria (≥0.3 mg/dL or ≥1.5× baseline rise within 48 hours). Multivariable logistic regression adjusted for prespecified baseline and periprocedural covariates examined associations with 90-day modified Rankin Scale shift and in-hospital mortality; linear versus restricted cubic spline specification was selected by likelihood ratio testing, and contrasts were estimated at ±10%, ±25%, and ±50%. RESULTS: Greater creatinine worsening within 48 hours of EVT was independently associated with an unfavorable 90-day modified Rankin Scale shift (adjusted common odds ratio per 1-unit log-ratio increase, 1.48 [95% CI, 1.07–2.04]; linear) and in-hospital mortality (nonlinear dose-response, of larger magnitude). A 10% increase in creatinine at 48 hours—well below Kidney Disease: Improving Global Outcomes threshold—was associated with worse functional outcome (adjusted common odds ratio, 1.04 [95% CI, 1.01–1.07]) and death (adjusted odds ratio, 1.22 [95% CI, 1.13–1.32]); a 10% decrease in creatinine at 48 hours was associated with lower odds of both outcomes (adjusted common odds ratio, 0.96 [95% CI, 0.93–0.99]; adjusted odds ratio, 0.74 [95% CI, 0.65–0.86]). The functional-outcome association concentrated at upper modified Rankin Scale cut-points (severe disability, death); effect modification by baseline renal function was not significant. CONCLUSIONS: Early creatinine change after EVT conveys graded, outcome-specific prognostic information extending below formal CA-AKI thresholds, with a dose-response detectable at changes as modest as ±10%, complementing binary CA-AKI as a framework for post-EVT renal risk assessment. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT06596603.

Background Persistent headache attributed to past stroke (PHAPS) is a controversial entity, recently included in the third edition of the International Classification of Headache Disorders (ICHD-3) despite being described only in retrospective studies. Objective To determine the frequency and characteristics of PHAPS in patients admitted with acute stroke. Methods We selected all patients with headache associated with acute stroke (HAAS) from a prospective, single-center registry of patients with acute stroke admitted to a Neurology ward between November 2018 and December 2019. We analyzed demographic, clinical, and neuroimaging data. We assessed the follow-up with a phone call questionnaire at 6 to 12 months. Results Among 121 patients with acute stroke, only 29 (24.0%) had HAAS. From these, 6 (5.0%) were lost to follow-up. In total, 23 (20.0%) patients answered the 6- to 12-month follow-up questionnaire and were included in this study. The median age of the sample was 53 years (interquartile range [IQR]: 38–78 years), and there was no sex predominance. Of the 10 patients (8,3%) that had persistent headache, 8 (6.6%) suffered from previous chronic headaches; however, they all mentioned a different kind of headache, and 1 (0,8%) probably had headache secondary to medication. Conclusions In the present study, only 10 out of 121 stroke patients (8.3%) referred persistent headache at the 6- to 12-month follow-up, but the majority already suffered from previous chronic headache, which raises the question that the actual prevalence of PHAPS may be lower than previously reported.

Introduction Pediatric cerebral sinus venous thrombosis (CSVT) is a rare entity. Risk factors differ from the adults, and treatment is not consensual. With this work, we aimed to characterize a pediatric cohort from two Portuguese tertiary centers. Methods All patients under 18 years old with confirmed CSVT admitted between 2006 and 2019 were retrospectively included. Demographics, clinical presentation, workup, and follow-up were evaluated. Results Fifty-three patients were included, 29 were male (54.7%). Median age was 5 years (IQR 11.08, range 0–17 years old). Headache, seizures and impairment of consciousness were the most frequent manifestations. A risk factor was identified in 90.6% (n = 48), mostly infections (43.8%; n = 21). CNS complications were comprised of hemorrhage, venous infarction, hydrocephalus and edema. Treatment included anticoagulation in 36 patients (67.9%), and there were no recurrences on follow-up. Prognosis was favorable, with most patients presenting no or only slight disability comparing to same age and sex children, on the follow-up. Discussion In this cohort, impairment of consciousness was the most frequent clinical presentation and infections were the most frequent risk factors. The outcome was mainly favorable, with most patients presenting none or mild disability and without recurrences on follow-up. Studies are needed to define the criteria for anticoagulation and its recommended duration in children.

Efficacy and safety of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) due to intracranial artery dissection (IAD) are currently not established. We aimed to present a single-center experience on IAD-related AIS treated by IVT. We selected all consecutive patients with IAD-related AIS treated by IVT from a prospectively constructed single-center acute stroke registry from 2003 to 2017. We reviewed demographical, clinical and neuroimaging data and recorded hemorrhagic complications, mortality within 7 days and modified Rankin Scale at 3-months. Out of 181 AISs related to cervicocephalic dissections, 10 (5.5%) were due to IAD and five of these patients received IVT. Among these five patients, median age was 62 years; hypertension and dyslipidemia were the most frequent vascular risk factors. IAD locations were distal internal carotid artery, middle cerebral artery (M1), anterior cerebral artery (A2), and, in two cases, the basilar artery. All anterior circulation IADs were occlusive or subocclusive, while the two basilar artery IADs caused arterial stenosis. After IVT, there were no subarachnoid or symptomatic intracranial hemorrhages. One patient had an asymptomatic hemorrhagic infarct type 1. Two patients died within 7 days from ischemic mass effect. The other three patients had favorable clinical outcomes at 3-months. In this small single-center case series of IAD-related AIS, thrombolysis seemed relatively safe. However, IVT efficacy and the likelihood of arterial recanalization are still uncertain in this context. Further studies are needed to assess the safety and efficacy of IVT in these patients.

Background: Limited observational data are available on endovascular treatment in acute ischemic stroke due to cervical artery dissection. Three studies comparing endovascular treatment with standard medical therapy or intravenous thrombolysis in cervical artery dissection-related acute ischemic stroke did not demonstrate superiority of endovascular treatment. Efficacy and the choice of endovascular treatment technique in this setting remain to be established. Aims: To assess the potential efficacy and safety of endovascular treatment compared to intravenous thrombolysis alone or to no revascularization treatment in our center. Methods: We selected all consecutive patients with cervical artery dissection-related acute ischemic stroke and intracranial occlusion from the Acute STroke Registry and Analysis of Lausanne between 2003 and 2017. We compared clinical and neuroimaging data of patients treated by endovascular treatment versus patients receiving intravenous thrombolysis or patients without revascularization treatment. Safety analysis included symptomatic intracranial hemorrhage, major radiological hemorrhages (parenchymal hematoma 1, parenchymal hematoma 2, and subarachnoid hemorrhage) and mortality within seven days. We assessed favorable clinical outcome (modified Rankin Scale 0-2) at three months using a binary logistic regression model. Results: Of the 109 patients included, 24 had endovascular treatment, 38 received intravenous thrombolysis alone, and 47 had no revascularization treatment. Endovascular treatment patients had a higher rate of recanalization at 24 h. Major radiological hemorrhages occurred more often in endovascular treatment patients (all with bridging therapy) than in patients without revascularization treatment (p = 0.026), with no differences in symptomatic intracranial hemorrhage or mortality within seven days. Favorable clinical outcome at three months did not differ between groups (endovascular treatment versus intravenous thrombolysis p = 0.407; endovascular treatment versus no revascularization treatment p = 0.580). Conclusions: In this single-center cohort of cervical artery dissection-related acute ischemic stroke with intracranial occlusion, endovascular treatment with prior intravenous thrombolysis may increase the risk of major radiological but not symptomatic intracranial hemorrhage. Despite the lack of clear superiority in our cohort, endovascular treatment should currently not be withheld in these patients.