Bo Song

Background Trials failed to demonstrate superiority of intravenous thrombolysis (IVT) versus best medical therapy (BMT) in minor stroke; however, modest sample sizes raised concerns. This study aimed to compare the efficacy and safety of IVT with BMT in minor stroke based on pooled cohorts from clinical trials.Methods This was a pooled analysis using individual participant data from two randomised controlled trials. Patients with acute minor ischaemic stroke presented within 4.5 hours of symptom onset in the full analysis set were included and classified into IVT and BMT groups. In IVT group, patients received intravenous alteplase or urokinase. In BMT group, patients received standard care based on current guidelines. Primary outcome was excellent functional outcome at 90 days, defined as modified Rankin Scale scoring 0 or 1. Safety outcome was symptomatic intracranial haemorrhage within 36 hours.Results A total of 1417 patients were included (median age, 64 years; male, 915 (64.6%)) and assigned into IVT group (707 patients) and BMT (710 patients). The proportion of 90-day excellent functional outcome was similar between groups (89.4% vs 89.4%, adjusted OR, 1.054 (95% CI 0.741 to 1.500), p=0.770). Compared with BMT, symptomatic intracranial haemorrhage was numerically higher in the IVT but not statistically significant (0.7% vs 0.3%, adjusted OR, 2.125 (95% CI 0.506 to 11.929), p=0.310).Conclusions Among patients with acute minor ischaemic stroke presented within 4.5 hours of symptom onset, no statistically significant difference was observed between IVT and BMT regarding excellent functional outcome at 90 days.Trial registration number ClinicalTrials.gov Identifier: NCT03661411 and NCT04420351.

Background: The blood urea nitrogen-to-serum albumin ratio (BAR) is a novel composite biomarker. This study investigated whether BAR could reliably predict poor functional outcomes in patients with cerebral venous sinus thrombosis (CVST). Methods: All patients with CVST enrolled in this observational study between January 2011 and December 2025 were identified. The study population was randomly divided into a derivation cohort comprising 70% of the patients and a validation cohort comprising the remaining 30%. Logistic regression analysis was performed to identify independent predictors of poor functional outcomes. A prognostic nomogram was developed using data from the derivation cohort, and its predictive performance was assessed in the validation cohort. Results: A total of 803 patients were included in this study. In the derivation cohort, coma, older age, intracerebral hemorrhage, straight sinus thrombosis, and higher BAR were independently associated with poor functional outcomes and were incorporated into the nomogram. Straight sinus thrombosis was independently associated with higher odds of poor functional outcome (odds ratio [OR], 4.525; 95% confidence interval [CI], 2.267–9.031), whereas each one-unit increase in BAR was associated with an OR of 1.411 (95% CI, 1.226–1.625). In the derivation cohort, the area under the receiver operating characteristic curve was 0.900, compared with 0.893 in the validation cohort. Conclusion: Higher admission BAR was independently associated with poor functional outcomes in patients with CVST. The nomogram incorporating BAR and radiologically confirmed straight sinus thrombosis may facilitate early individualized risk stratification.

Background: The aim of the current study was to investigate the predictive values of computed tomographic angiography–derived radiomics features (RFs) for stroke recurrence in symptomatic intracranial atherosclerotic stenosis. Methods: This was a substudy of a cohort study recruiting patients with ischemic stroke or transient ischemic attack with symptomatic intracranial atherosclerotic stenosis (50%–99% stenosis) confirmed by computed tomographic angiography from 2 centers. Baseline clinical variables were collected. RFs were extracted from computed tomographic angiography source images from the plaque region alone and the plaque and lumen region, respectively. All patients received guideline‐recommended medical treatment. The primary outcome was same‐territory ischemic stroke recurrence within 1 year. Four machine learning algorithms were used to develop and test predictive models for the primary outcome. Results: Overall, 203 patients (median age, 60 years) were randomly split into training (n=121, 60%) and testing (n=82, 40%) sets. No significant difference was observed in clinical variables between patients with and without primary outcome. Of 1046 RFs extracted, 4 from the plaque region and 5 from the plaque and lumen region were selected. Among all machine learning algorithms, models based on the plaque and lumen region exhibited better discrimination of the primary outcome than plaque region RFs‐based model in the training (area under the curve 0.86–0.87 versus 0.79–0.80) and testing set (area under the curve 0.74–0.81 versus 0.58–0.62), consistent with internal validation result with repeated cross‐validation. A similar trend was observed in performance metrics, calibration analysis, and reclassification indices. Conclusions: In patients with symptomatic intracranial atherosclerotic stenosis, computed tomographic angiography–derived RFs of the plaque and lumen region had better predictive value for stroke recurrence than RFs of the plaque region alone, offering a promising tool for stroke risk stratification.

Introduction: Early prediction of neurological deterioration (ND) in acute ischemic stroke (AIS) remains challenging. We aimed to develop a diffusion-weighted imaging (DWI)-based radiomic model that integrates intra- and peri-infarction radiomic signatures with clinical characteristics to improve ND prediction. Methods: This retrospective study included 767 patients with anterior circulation AIS (training, n = 537; test, n = 230) who underwent DWI within 3 days of onset. Infarct cores were manually segmented, and peri-infarction regions (1–3 mm annular expansions) were generated. Radiomics features were extracted from all regions. Significant clinical predictors and radiomics features were selected to construct four models: clinical, intra-infarction radiomics, peri-infarction radiomics (1–3 mm), and a combined model. Performance was assessed using area under the curve (AUC), sensitivity, specificity, calibration, and decision curve analysis (DCA). Results: In total, 767 patients were included in the analysis. In multivariate analysis, glucose level was an independent clinical predictor of ND [odds ratio (OR) = 1.003; 95% confidence interval (95% CI), 1.001–1.006; p < 0.05]. Overall, 1,561 radiomic features were extracted from the intra-infarction region. Ten radiomics features were deemed valuable for dimensionality reduction and selection. Similarly, 1,561 radiomic features were extracted from the Peri2mm region, and 16 radiomics features were included. Among the intra-infarction radiomics models, the XGBoost model showed the best predictive efficiency, with AUCs of 0.911 and 0.898 for the training and test cohorts, respectively. The 2 mm peri-infarction model performed best among all peri-infarction models (AUCs: 0.854 for training, 0.850 for test). The combined model (intra-infarction + 2 mm peri-infarction + clinical feature) achieved the highest AUC values of 0.922 (training) and 0.911 (test), accompanied by favorable calibration and stable clinical net benefit. Although the combined model yielded a perfect sensitivity of 1.000 in the test cohort (95% Wilson CI: 0.867–1.000), this finding should be interpreted cautiously due to the small number of ND events ( n = 25). Further pairwise comparison revealed that the combined model possessed significantly better discriminative ability than the clinical model and the 1 mm peri-infarction model in the test cohort ( p < 0.05). However, the improvement over intra-infarction radiomics alone did not reach statistical significance in the test cohort (DeLong p = 0.179), and no significant superiority was observed versus the Peri2mm and Peri3mm models either. Discussion: Integrating DWI-derived intra-infarction radiomics, 2 mm peri-infarction signatures and clinical indicator achieves optimal AUC discrimination within the training cohort, though its statistical advantage over isolated intra-infarction radiomics could not be validated in the independent test set. This multimodal nomogram provides a non-invasive imaging tool to assist ND risk stratification for acute ischemic stroke patients, while larger multi-center cohorts are required to confirm its universal incremental predictive value and stable detection performance.

Background: Neutrophil extracellular traps contribute to thrombolytic resistance and the no‐reflow phenomenon after acute ischemic stroke, thereby impairing microvascular reperfusion and leading to unfavorable clinical outcomes. This study investigated the association between prethrombolytic circulating neutrophil extracellular trap biomarkers, CitH3 (citrullinated histone 3) and MPO (myeloperoxidase)‐DNA complexes, and early neurological deterioration (END) in patients with acute ischemic stroke treated with intravenous thrombolysis alone. Methods: We prospectively enrolled patients with acute ischemic stroke who received standard‐dose alteplase within 4.5 hours of symptom onset (January 2019–April 2023). Venous blood was drawn before intravenous thrombolysis to measure serum CitH3 and MPO‐DNA. The primary outcome was END, defined as an increase of ≥4 points in NIHSS score at 24 hours versus baseline. Logistic regression with restricted cubic splines assessed associations between neutrophil extracellular trap biomarkers and END. Results: Among 287 patients (mean age 61.69±12.41 years, 70.4% male), 45 (15.7%) developed END. Serum CitH3 >17.67 ng/mL (odds ratio [OR], 3.81 [95% CI, 1.75–8.29]) and MPO‐DNA >79.72 ng/mL (OR, 5.58 [95% CI, 2.36–13.21]) were independently associated with END. The associations remained significant when treated as continuous variables. Restricted cubic splines confirmed a linear dose–response relationship between higher CitH3 levels and END risk ( P for nonlinearity=0.475). Subgroup analyses revealed stronger associations for CitH3 in patients with coronary artery disease or stroke history ( P for interaction=0.018) and D‐dimer P for interaction=0.013). A significant interaction of smoking was found between MPO‐DNA and END ( P for interaction=0.026). Conclusions: Serum neutrophil extracellular traps may serve as promising biomarkers associated with END after intravenous thrombolysis in patients with acute ischemic stroke.

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, p = 0.034) and the incidence of MACE (HR = 0.53, 95% CI: 0.29–0.97, p = 0.041) during the 1-year follow-up, consistent with the IPTW-based cohort (HR = 0.35, 95% CI: 0.16–0.76, p = 0.008; HR = 0.43, 95% CI: 0.22–0.83, p = 0.012). The win-ratio analysis of MACE favored DPI therapy (win ratio = 2.34, 95% CI: 1.41–3.90, p = 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.

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.