Intracranial hypertension (IH) from brain edema is a life-threatening complication of large vessel occlusion (LVO) stroke, yet clinical monitoring is often unreliable. Non-invasive methods for early IH prediction are needed. This study assessed whether sonographic measurement of the optic nerve sheath diameter (ONSD) could improve the prediction of IH after stroke. We prospectively measured the internal optic nerve sheath diameter (ONSDint) via transorbital ultrasound in 65 stroke patients and 30 controls. ONSD was also measured on the initial CT or MRI. The primary endpoint of IH was a composite of clinical and radiological signs of brain swelling. A predictive ONSD cut-off was determined from a multivariable logistic regression model, adjusted for age and infarct volume. Predictive performance was assessed using leave-one-out cross-validation. Seven of 65 stroke patients (11%) developed IH. The initial sonographic ONSDint was significantly increased in patients who developed IH. The multivariable model identified an optimal predictive cut-off of ⩾5.51 mm, which predicted IH with a sensitivity of 85.7% and a specificity of 94.8%. In comparison, ONSD derived from initial neuroimaging was also a strong predictor, with an optimal cut-off of 6.80 mm yielding a sensitivity of 100% and a specificity of 91.1%, and showed superior predictive accuracy in the cross-validation (AUC 0.905 vs 0.687). Our sonographic ONSDint cut-off of ≥5.51 mm aligns well with recent stroke literature that used similar standardized measurement techniques. Our findings also highlight the distinct roles of different imaging modalities. While the initial CT/MRI provides a static measurement with high predictive power, the unique advantage of sonography is its bedside applicability, allowing for the crucial, non-invasive serial monitoring of ONSD as a dynamic marker of intracranial pressure changes. Early ONSD assessment is a valuable predictor of IH after severe stroke. A sonographic ONSDint of ⩾5.51 mm identifies patients at high risk with excellent accuracy. While initial neuroimaging may offer superior predictive power, bedside sonography remains a crucial, repeatable tool for monitoring these critically ill patients.

Left atrial appendage (LAA) thrombus is associated with atrial fibrillation (AF) and can be a marker of atrial cardiomyopathy. We determined the association between computed tomography angiography (CTA) identified LAA thrombus in patients presenting with acute ischaemic stroke or transient ischaemic attack (TIA), and 3-month outcome. We undertook a dual-centre, retrospective cohort study from New Zealand and Australia. All consecutive patients presenting with acute ischaemic stroke or TIA during the inclusion period who underwent acute stroke imaging were included. We analysed the association with CTA-LAA thrombus and 3-month outcome on modified Rankin Scale using multivariable logistic regression models adjusted for known predictors of outcome. Of the 1435 patients included, 1304 (90.9%) had acute ischaemic stroke and 131 (9.1%) had TIA. 582 (41%) had confirmed intracranial medium or large vessel occlusion (MLVO), and 565 (40%) received reperfusion therapies. CTA-LAA thrombus was identified in 58 (4.0%) patients, and these patients were older (median age 85 (IQR 75-88) vs 73 (63-81), p < 0.01), more likely to be female (62% vs 40%, p < 0.01), had higher rates of AF (79% vs 29%, p < 0.01), heart failure (29% vs 9%, p < 0.01), MLVO (53% vs 40%, p = 0.05), and mortality at 3-months (28% vs 11%, p < 0.01). Adjusting for known predictors of poor outcome, LAA thrombus was independently associated with increased 3-month mRS score (OR: 2.02, 95% CI: 1.20-3.40, p < 0.01). CTA-LAA thrombus detected during the acute stroke imaging protocol in patients with ischemic stroke or TIA is a predictor of worse outcome.

Non-invasive convective head cooling is a promising putative neuroprotective therapy for ischemic stroke patients as it may portably, non-invasively, and selectively cool the ischemic penumbra. We aimed to investigate the feasibility of utilizing non-invasive convective head cooling in ischemic stroke patients before and during endovascular thrombectomy (EVT). We conducted a multi-center, prospective, non-randomized, open-label trial at two comprehensive stroke centers in ischemic stroke patients where EVT was planned. Patients were assessed for eligibility in the emergency department (ED) and had a cooling cap fitted that circulated coolant between -5°C and 0°C until EVT completion. The primary feasibility endpoint was adherence, defined as tolerating cooling for ⩾50% of the time from cooling cap application until EVT completion. Between July and November 2024, 40 EVT patients (19 (47.5%) female, mean ± SD age 71.6 ± 12.6 years) underwent a median (IQR) duration of convective head cooling of 86 (58-106) min. Thirty-nine (97.5%) participants met the primary feasibility endpoint. The enrollment rate was five participants per site per month. Median (IQR) time from comprehensive stroke center arrival to cooling start was 10 (5-51) min. Thirty-two (80%) patients received general anesthesia. eTICI 2b-3 reperfusion was achieved in 38 (95.0%) participants. Median (IQR) 24-h infarct volume was 14.3 (5.5-29.1) mL. Median (IQR) 3-month modified Rankin Scale score was 2 (1-5). Three-month mortality occurred in 8/38 (21.1%) participants. Nine serious adverse events occurred in 8 (20.0%) participants, none of which were attributed to head cooling. Convective head cooling is feasible in patients undergoing EVT and warrants further investigation in larger randomized controlled trials.

Cryptogenic stroke (CS) represents a heterogeneous group in terms of etiology. Atrial cardiopathy (AC) has emerged as a relevant underlying substrate for both stroke and atrial fibrillation (AF) in these patients. However, no reliable tools are currently available for the early and accurate identification of AC. We conducted a prospective study including consecutive patients with cardioembolic stroke due to AF (CES-AF), non-cardioembolic stroke (NCES) and cryptogenic stroke (CS). Left atrial strain (LAS) assessed by speckle-tracking echocardiography, and serum markers of AC were evaluated in CES-AF versus NCES patients using ROC curve analysis. Based on these results, we developed a logistic regression model to calculate the probability of AC in CS patients, aiming to discriminate between cardioembolic and non-cardioembolic etiology. Clinical characteristics were compared between CS patients with high (>0.5) and low (<0.5) predicted probability of AC. A total of 136 patients were included: 44 with CES-AF, 52 with NCES, and 40 with CS. The combination of N-terminal pro-brain natriuretic peptide (NT-proBNP) levels ⩾ 469 pg/mL and biplanar LAS during the contraction phase (LASct) ⩾ -10.2% demonstrated the best-performing AC biomarker combination among those evaluated for identifying cardioembolic etiology (AUC = 0.995). Based on this combination, 30% of CS patients had a predicted probability > 0.5 for AC. These patients were older (77.3 ± 8 vs 68.8 ± 10 years; p = 0.011), had more severe strokes (NIHSS score 10.1 ± 7.5 vs 4.6 ± 5.2; p = 0.024) and showed a higher incidence of AF during follow-up (6 vs 0 cases; p = 0.029). The combination of NT-proBNP levels and biplanar LASct provides highly sensitive and specific biomarkers of AC. This multiparametric model allows for individualized estimation of AC probability in CS patients, supporting its potential utility in discriminating cardioembolic from non-cardioembolic etiologies and guiding personalized clinical management.

Botulinum neurotoxin type A (BoNT-A) is a well-established treatment for post-stroke spasticity. However, its real-world use remains underexplored. This study evaluated BoNT-A use trends among stroke survivors in France from 2015 to 2023. A retrospective cohort study was conducted using data from the French National Hospital Discharge Database. We analyzed stroke hospitalizations and BoNT-A treatment rates by age and care pathway. Among patients presenting with stroke between 2017 and 2019 who survived beyond 6 months post-stroke, we estimated the prevalence of patients with coded post-stroke spasticity, BoNT-A use, and time from stroke onset to spasticity coding and the first BoNT-A injection. Between 2015 and 2023, 1,170,436 hospitalizations for stroke were recorded in France. BoNT-A treatment rates remained low, ranging from 1.4% in 2015 to 1.9% in 2022. BoNT-A treatment rates increased from 3.3% to 3.8% in stroke survivors aged 20-29 and from 1.0% to 1.6% in those aged 70-79 between 2015 and 2022. Patients who, during their care pathway, stayed in a neurovascular or neurorehabilitation unit were more likely to receive BoNT-A treatment-rising from 2.0% in 2015 to 2.6% in 2022 and 7.3% to 9.6%, respectively-than those managed in non-specialized units, where rates increased from 0.9% in 2015 to 1.1% in 2022. Among 287,370 patients presenting with stroke between 2017 and 2019, 37,692 (13.1%) were coded with post-stroke spasticity, 8056 (2.8%) received ⩾1 BoNT-A injection between 2017 and 2023, 4360 (1.5%) received ⩾3 injections, and 1003 (0.35%) received ⩾3 injections spaced ⩽6 months apart. The median time from stroke onset to spasticity coding was 96 days, and to the first BoNT-A injection 258 days. BoNT-A remains underutilized in the treatment of post-stroke spasticity in France. These results emphasize the need to enhance access to and adherence to BoNT-A therapy to optimize post-stroke spasticity management.

The role of CT angiography (CTA) and CT perfusion (CTP) in patient selection for thrombolysis <4.5 h after onset is unclear. Additional imaging may improve specificity of diagnosis by excluding stroke mimics or those without salvageable tissue, but may delay treatment. In a multicentre prospective randomised trial, thrombolysis-eligible patients <4.5 h from symptom onset were randomised 1:1 to non-contrast CT (NCCT) or multimodal CT (NCCT + CTA + CTP). The primary endpoint was the proportion receiving thrombolysis. Secondary end-points were times to decision-making and treatment delivery, early neurological recovery, functional recovery at 3 months and incidence of symptomatic intracerebral haemorrhage (SICH). Between March 2015 and May 2018, 271 patients were randomised, 134 to multimodal CT and 137 to NCCT. After initial NCCT, 114 had no contraindication to thrombolysis in the multimodal CT group and 108 in the NCCT group. Mean age was 67.5 years and median NIHSS score was 6 (interquartile range 3-12). Fewer patients assigned multimodal CT received thrombolysis (56/114, 49.1%) compared to NCCT (73/108, 67.6%, adjusted odds ratio (aOR) 0.46 (95% CI: 0.25-0.83), p = 0.0102). Times to treatment decision or thrombolytic administration, early neurological recovery and day 90 functional outcome did not differ significantly. SICH occurred in two patients, both assigned NCCT. Mortality was 6/114 (5.3%) in the multimodal CT group compared to 11/108 (10.2%; aOR 0.46 (95% CI: 0.16, 1.31), p = 0.147) in the NCCT group. Despite fewer patients receiving thrombolysis after multimodal imaging, treatment decision times and clinical outcomes did not differ significantly. Multimodal CT may identify patients who do not require thrombolysis such as stroke mimics and non-disabling strokes. Among acute stroke patients imaged <4.5 h from symptom onset, multimodal CT reduced use of thrombolysis. Treatment decision times and clinical outcomes did not differ between groups.

We aim to evaluate the association between door-to-needle time (DTN) and outcomes in a population of acute ischemic stroke (AIS) patients treated with intravenous thrombolysis (IVT) + mechanical thrombectomy (MT) in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS). Patients with AIS secondary to middle cerebral artery or intracranial internal carotid artery occlusion with known times of symptoms onset, directly presenting to an MT-capable center, were included in the analysis. According to pre-defined DTN cut-off values (⩽30, ⩽45, and ⩽60 min), we evaluated the association between DTN and outcomes by multivariate logistic regression analyses. Effectiveness outcomes were 3-month functional independence, 3-month excellent outcome and successful reperfusion. Safety outcomes were any intracranial hemorrhage (ICH), symptomatic intracerebral hemorrhage (sICH), and 3-month mortality. About 1602 patients were included in our analysis. After logistic regression analysis, a DTN ⩽ 60 min was significantly associated with 3-month functional independence (OR 1.36; 95% CI 1.02-1.82). DTNs ⩽ 30, ⩽45, and ⩽60 min were significantly associated with successful reperfusion (OR 2.66; 95% CI 1.6-4.43; OR 1.68; 95%CI 1.25-2.26; OR 1.57; 95% CI 1.21-2.05; respectively). A DTN ⩽ 60 min was also significantly associated with lower rate of any ICH (OR 0.61; 95% CI 0.43-0.86). DTNs ⩽ 30, ⩽45, and ⩽60 min were significantly associated with lower 3-month mortality (OR 0.24; 95% CI 0.08-0.67; OR 0.45; 95% CI 0.29-0.72; OR 0.58; 95% CI 0.39-0.84; respectively). In patients with AIS treated with IVT + MT, a shorter DTN is associated with better outcomes if IVT is initiated within 1 h of hospital admission.

Flow-diverting (FD) stents are increasingly used to treat small, unruptured intracranial aneurysms (UIA), but high-quality, unbiased data on initial complications and clinical outcomes were limited in previous literature reviews. We updated the literature review to assess quality, potential bias, complications and short-term outcomes in studies on FD-stents for UIAs. We systematically searched PubMed, Embase and Cochrane Library until January 9, 2025 for studies on FD-stents for UIAs. We assessed methodological quality using the methodological index for non-randomised studies (poor: 0-9, moderate: 10-13, good: 14-16), and financial conflicts of interest. The primary outcome was neurological outcome according to a validated outcome scale at 1-3 months after treatment. Secondary outcomes were clinical worsening and complications. We included 13 studies with 743 patients and 806 UIAs, of which 88.4% (95% CI: 85.7%-91.2%) were <10 mm. All studies were uncontrolled. The methodological quality was poor in six and moderate in seven studies. Financial conflicts of interest were reported in six studies. At 1-3 months after treatment, the proportion of patients were for mRS ⩾1 13.3% (95% CI: 10.0%-16.6%), mRS ⩾2 5.3% (95% CI: 3.2%-7.5%), mRS ⩾3 2.4% (95% CI: 0.1%-3.9%) and neurological worsening 3.1% (95% CI: 1.5%-4.6%). Complications within 3 months occurred in 12.7% (95% CI: 10.3%-15.0%). The literature on FD-stents is methodologically weak and potentially biased by financial interests but still shows relevant proportions of complications and post-treatment morbidity. Currently, there are no good data supporting the use of FD-stents for UIAs where standard treatment options are available. Randomised-controlled trials are needed to compare safety, efficacy and durability between FD-stents and coiling or clipping.