Prevalence and characteristics of known versus newly detected atrial fibrillation in ischemic stroke: a population-based study.

BACKGROUND: Atrial fibrillation (AF) is frequently diagnosed during the acute stage of ischemic (IS), and it may reflect undiagnosed AF before stroke, thus representing a missed opportunity for stroke prevention. This population-based study aimed to assess the prevalence of known AF (KAF) and AF diagnosed early after IS (AFDAS), and to compare clinical and brain/arterial imaging characteristics between patients. METHODS: Among patients with acute IS recorded in the population-based Dijon Stroke Registry, France (2013-2020), we identified those with KAF or AFDAS. AFDAS was considered when AF was diagnosed during the initial work-up based on electrocardiograms, in-hospital continuous electrocardiographic and/or Holter monitoring. Clinical and imaging characteristics on brain CT-scan or angio-CT-scan when available including old parenchymal lesions, arterial territory of the index IS, and aortic arch, cervical and intracranial arteries atheroma were compared between groups (KAF versus AFDAS). Regression logistic models were used to assess factors associated with AFDAS (compared to KAF). RESULTS: Among 1756 IS patients, 550 (31.3%) had AF (mean age: 83.6 ±10.3 years old, 60.5% women), of whom 367 (66.7%) presented with KAF and 183 (33.3%) had AFDAS. In multivariable model, hypertension (OR=0.37; 95% CI: 0.21-0.64, p<0.001), chronic heart failure (OR=0.34; 95% CI: 0.18-0.67, p=0.002), previous stroke (OR=0.42; 95% CI: 0.26-0.67, p<0.001), and preexisting dementia (OR=0.36; 95% CI: 0.21-0.63, p<0.001), were inversely associated with AFDAS, whereas NIHSS score was associated with AFDAS (OR=1.02; 95% CI: 1.00-1.05, p=0.012). CONCLUSIONS: Our findings indicate a more advanced stage of the atrial cardiomyopathy in KAF as compared with AFDAS patients, and may thus contribute to the fact that in these latter patients AF had not been diagnosed prior to stroke. This group of patients undeniably represents a missed opportunity for stroke prevention.

Value of HAVOC and Brown ESUS-AF scores for atrial fibrillation on implantable cardiac monitors after embolic stroke of undetermined source.

OBJECTIVES: Up to 20 % of ischemic strokes are associated with overt atrial fibrillation (AF). Furthermore, silent AF was detected by an implantable cardiac monitor (ICM) in 1 in 3 cryptogenic strokes in the CRYSTAL AF study. An ESC position paper has suggested a HAVOC score ≥ 4 or a Brown ESUS-AF score ≥ 2 as criteria for ICM implantation after cryptogenic stroke, but neither of these criteria has been developed or validated in ICM populations. We assessed the performance of HAVOC and Brown ESUS-AF scores in a cohort of ICM patients implanted after embolic stroke of undetermined source (ESUS). METHODS: All patients implanted with an ICM for ESUS between February 2016 and February 2022 at two French University Hospitals were retrospectively included. Demographic data, cardiovascular risk factors, and clinical and biological data were collected after a review of electronic medical records. HAVOC and Brown ESUS-AF scores were calculated for all patients. FINDINGS: Among the 384 patients included, 106 (27 %) developed AF during a mean follow-up of 33 months. The scores performances for predicting AF during follow-up were: HAVOC= AUC: 68.5 %, C-Index: 0.662, and Brown ESUS-AF=AUC: 72.9 %, C-index 0.712. Compared with the CHA2DS2-VASc score, only the Brown ESUS-AF score showed significant improvement in NRI/IDI. Furthermore, classifying patients according to the suggested HAVOC and Brown ESUS-AF thresholds, only 24 % and 31 % of the cohort, respectively, would have received an ICM, and 58 (55 %) and 47 (44 %) of the AF patients, respectively, would not have been implanted with an ICM. CONCLUSION: HAVOC and Brown ESUS-AF scores showed close and moderate performance in predicting AF on ICM after cryptogenic stroke, with a significant lack of sensitivity. Specific risk scores should be developed and validated in large ICM cohorts.

Long-Term Survival of Ischemic Stroke Patients according to Prior Cognitive Status: Dijon Stroke Registry.

INTRODUCTION: Understanding the influence of preexisting cognitive impairment on the poststroke outcome is a critical challenge in the context of current aging and growing population. This study aimed to assess long-term survival of patients with acute ischemic stroke (IS) according to their premorbid cognitive status and to identify contributing factors of death. METHODS: Patients with IS were prospectively identified among residents of Dijon, France, using a population-based registry (2013-2017). The association between case fatality at 5 years and prestroke cognitive status was assessed by multivariable Cox models adjusted for other clinical characteristics and preexisting brain damage on the initial CT scan including leukoaraiosis, old vascular brain lesions, and cortical and central brain atrophy, as well as major arterial occlusion. RESULTS: 1,049 patients were included (mean age ± SD: 76.3 ± 15.2 years old, 54% women). Case fatality rates at 5 years were 38.1% in patients without cognitive impairment, 65.9% in patients with prior mild cognitive impairment (MCI, n = 132, 12.6%), and 86.6% in patients with dementia (n = 164, 15.6%) (p < 0.001). MCI (HR = 1.39; 95% CI: 1.06-1.81, p = 0.016) and dementia (HR = 1.89; 95% CI: 1.45-2.46, p < 0.001) were both independently associated with higher case fatality after adjustment for clinical variables. The association remained significant after further adjustment for preexisting brain damage and major arterial occlusion (HR = 1.47; 95% CI: 1.10-1.98, p = 0.009, for MCI and HR = 1.90; 95% CI: 1.43-2.53, p < 0.001, for dementia) among patients with available data on the CT scan (n = 916). Factors associated with death were roughly similar across groups. CONCLUSION: This study highlighted a poor long-term survival of IS patients with preexisting cognitive impairment, independently of other contributing factors of death. It is critical to better understand the trajectory of IS patients with preexisting cognitive impairment and to identify prognostic markers to guide clinicians in their management strategies.

Pre-existing brain damage and association between severity and prior cognitive impairment in ischemic stroke patients.

BACKGROUND: We evaluated whether pre-existing brain damage may explain greater severity in cognitively-impaired patients with ischemic stroke (IS). METHODS: IS patients were retrieved from the population-based registry of Dijon, France. Pre-existing damage (leukoaraiosis, old vascular brain lesions, cortical and central brain atrophy) was assessed on initial CT-scan. Association between prestroke cognitive status defined as no impairment, mild cognitive impairment (MCI), or dementia, and clinical severity at IS onset assessed with the NIHSS score was evaluated using ordinal regression analysis. Mediation analysis was performed to assess pre-existing brain lesions as mediators of the relationship between cognitive status and severity. RESULTS: Among the 916 included patients (mean age 76.8 ± 15.0 years, 54.3% women), those with pre-existing MCI (n = 115, median NIHSS [IQR]: 6 [2-15]) or dementia (n = 147, median NIHSS: 6 [3-15]) had a greater severity than patients without (n = 654, median NIHSS: 3 [1-9]) in univariate analysis (OR=1.69; 95% CI: 1.18-2.42, p = 0.004, and OR=2.06; 95% CI: 1.49-2.84, p < 0.001, respectively). Old cortical lesion (OR=1.53, p = 0.002), central atrophy (OR=1.41, p = 0.005), cortical atrophy (OR=1.90, p < 0.001) and moderate (OR=1.41, p = 0.005) or severe (OR=1.84, p = 0.002) leukoaraiosis were also associated with greater severity. After adjustments, pre-existing MCI (OR=1.52; 95% CI: 1.03-2.26, p = 0.037) or dementia (OR=1.94; 95% CI: 1.32-2.86, p = 0.001) remained associated with higher severity at IS onset, independently of confounding factors including imaging variables. Association between cognitive impairment and severity was not mediated by pre-existing visible brain damages. CONCLUSION: Impaired brain ischemic tolerance in IS patients with prior cognitive impairment could involve other mechanisms than pre-existing visible brain damage.

Challenging the diagnosis of a posterior circulation dissecting aneurysm.

INTRODUCTION: I ntracranial vertebral dissections have polymorphs clinical presentations and can lead to haemorrhagic complications if they are intracranial. We here describe a case of a thrombosed dissecting aneurysm of postero-inferior cerebellar artery (PICA) revealed by a Wallenberg syndrome preceded by headaches. CASE: A 23-year-old patient, without neurological or vascular past medical history, was admitted for dizziness preceded by headache. The clinical examination on admission revealed an incomplete Wallenberg syndrome, associating hemiface sensitive deficit, Horner's syndrome, dysmetria and nystagmus. The brain MRI showed a latero-medullary infarct with a homolateral PICA thrombosed dissecting aneurysm. CONCLUSION: The diagnosis of intracranial dissecting aneurysms needs particular caution because aneurysm sac thrombosis can give false reassurance on angiographic MR sequences. Moreover, the anatomic features of intracranial artery walls make them prone to sub-adventitial dissection and subsequent subarachnoid haemorrhages. Therefore, antithrombotic therapy should be used with caution, due to the risk of bleeding in these intracranial dissections.

Ischemic Stroke With Atrial Fibrillation: Characteristics and Time Trends 2006 to 2017 in the Dijon Stroke Registry.

Background and Purpose: Because of the aging population, an increase in the prevalence of atrial fibrillation (AF) is currently observed, thus leading to a rise in AF-related ischemic stroke (IS). We analyzed the current prevalence of AF among patients with IS, their characteristics, and temporal trends from 2006 to 2017 in the population-based Dijon Stroke Registry. Methods: We used data from the Dijon Stroke Registry, an ongoing population-based study that records all cases of acute stroke among residents of the city of Dijon. All patients with IS between 2006 and 2017 were included. Previous AF was defined if it was mentioned in the medical file before stroke and newly diagnosed AF if it was diagnosed during the diagnostic workup of patients with acute stroke. Results: During the period 2014 to 2017, among the 796 patients with IS recorded in the Dijon Stroke Registry, 239 (30.0%) had AF, of whom 79 (9.9% of total patients with IS) had newly diagnosed AF, and 98 (12.3%) had previous AF treated with oral anticoagulants. Patients with IS with AF had more disabilities and a higher initial severity according to the National Institutes of Health Stroke Scale compared with those without AF. The age-adjusted prevalence of AF in patients with IS increased between 2006 and 2017 (+9% per time period), with an important increase in men aged 65 to 74 years (+81%) and women aged ≥85 years (+24%), and a significant decrease in women aged 65 to 74 years (−39%). The use of oral anticoagulant treatment in previous AF patients increased between 2006 and 2009 and 2014 and 2017 (29.3% to 61.3%, P<0.0001). However, 37.5% of patients with previous AF and CHADS2 score ≥2 were not treated with OAC. Conclusions: The increase in AF prevalence in patients with IS could be related to a better diagnosis of this condition. The underuse of oral anticoagulation treatment was still observed.

Temporal Trends in the Incidence of Ischemic Stroke in Young Adults: Dijon Stroke Registry.

INTRODUCTION: Stroke is associated with major consequences in terms of socioeconomic impact and lost disability-adjusted life in young victims, thus justifying a careful surveillance of epidemiological trends. This study aimed to assess changes in the incidence of ischemic stroke in young adults over a long period. METHODS: All cases of first-ever ischemic stroke that occurred among adults aged 18-55 years were prospectively recorded using the population-based Dijon Stroke Registry, from 1985 to 2017. Sex-specific annual incidence rates were calculated and were presented according to 6 time periods. Incidence rate ratios (IRRs) were determined to assess sex differences in stroke incidence. RESULTS: Over the whole study period, 4,451 patients suffered a first-ever ischemic stroke. Among these patients, 469 (10.5%) were young adults (median age: 46 years, IQR: 39-50; 53.9% men). Incidence rates rose from the study period 2003 to 2007 compared with previous periods and remained stable thereafter, both in men and women. Hence, incidence per 100,000 per year was globally 11.0 (95% CI: 9.4-12.7) before 2003 and 22.9 (20.3-25.6) thereafter. In individuals aged 18-45 years, incidence rates were 5.4 (4.3-6.9) overall, 4.1 (2.7-6.0) in men, and 6.7 (4.9-9.0) in women, before 2003. After 2003, incidence rates rose to 12.8 (10.7-15.1) overall, 12.0 (9.2-15.4) in men, and 13.6 (10.6-17.0) in women. In this age group, the men/women IRR was 0.78 (95% CI: 0.62-1.26, p = 0.08), although sex differences decreased over time (IRR = 0.62; 95% CI: 0.36-1.02, p = 0.046 before 2003, vs. IRR = 0.88; 95% CI: 0.62-1.26, p = 0.48 after 2003). In individuals aged 45-55 years, incidence rates before 2003 were 47 (37-61) in men and 25 (17-35) in women (IRR = 1.90; 95% CI: 1.24-2.97, p < 0.001), and they increased to 82 (67-100) in men and 46 (35-59) in women (IRR = 1.79; 95% CI: 1.29-2.49, p < 0.001) after 2003. CONCLUSIONS: The incidence of ischemic stroke in young adults increased during the early 2000s and remained stable thereafter. These results highlight the priority need for dedicated prevention strategies for the young to reduce the burden of stroke.

Current characteristics and early functional outcome of older stroke patients: a population-based study (Dijon Stroke Registry).

BACKGROUND: the ongoing growing and ageing population is associated with an increase in older patients suffering a stroke. We aimed to assess the current profile of these patients in a population-based setting. METHODS: all patients with acute stroke were prospectively identified among residents of Dijon, France, between 2013 and 2017, using a population-based registry. Characteristics and early outcome of patients were compared according to age groups. RESULTS: 1,288 stroke cases were recorded (median age: 81.1 years, interquartile range: 66.1-86.7, 54% women). Patients aged 75-85 years and those >85 years accounted for 27.6 and 33.9% of overall cases. Increasing age was associated with a greater prevalence of vascular risk factors, pre-existing cognitive impairment and handicap, higher initial severity, more frequent cardioembolic ischemic stroke, post-stroke pulmonary infection and delirium. Only 41% of patients aged 75-85 years and 18% of those aged >85 years had a good early recovery. Compared with patients aged <75 years, patients aged 75-85 years [adjusted odds ratio (OR) = 2.61; 95% confidence interval (CI): 1.74-3.93, P < 0.001] and those aged >85 years (adjusted OR = 7.18; 95% CI: 4.58-11.3, P < 0.001) had an increased risk of poor post-stroke functional outcome. Among survivors, the proportion of patients discharged to home was 60% in age group <75 years, compared with 49% in patients aged 75-85 years and 29% in those aged >85 years. Thirty per cent of patients >85 years old required a long-term care institution. CONCLUSION: the increasing burden of stroke in older people has major implications for future treatment strategies and need for dedicated care facilities.

Influence of Preexisting Cognitive Impairment on Clinical Severity of Ischemic Stroke: The Dijon Stroke Registry.

Background and Purpose- The ongoing ageing population is associated with an increasing number of patients with stroke who have preexisting cognitive impairment. This study aimed to evaluate clinical severity in patients with ischemic stroke according to prestroke cognitive status. Methods- Patients with ischemic stroke were prospectively identified among residents of Dijon, France using a population-based registry (2013-2017). Prestroke cognitive status (no impairment, mild cognitive impairment [MCI], or dementia) was recorded, and severity at stroke onset was measured using the National Institutes of Health Stroke Scale (NIHSS) score. Association between prestroke cognitive status and severity was evaluated using ordinal regression analysis models in which the NIHSS score was considered as a categorical variable. Results- Among the 1048 patients (mean age, 76.3±15.2 years; 54.0% women), a greater severity was observed in those with MCI (n=132; median NIHSS: 6; interquartile range, 2-15), and those with dementia (n=164; median NIHSS: 7; interquartile range, 3-16), than in patients without cognitive impairment (n=752; median NIHSS: 3; interquartile range, 1-9). MCI (odds ratio [OR], 1.70 [95% CI, 1.21-2.38]; P=0.002) and dementia (OR, 2.24 [95% CI, 1.65-3.04]; P<0.001) were both associated with a greater severity at onset. The association was still observed after adjustment for clinical variables and proximal arterial occlusion (OR, 1.52 [95% CI, 1.02-2.28]; P=0.04 for MCI; OR, 2.16 [95% CI, 1.45-3.22]; P<0.001 dementia). Further adjustment for prestroke handicap slightly reduced the magnitude of the association (OR, 1.49 [95% CI, 0.98-2.25]; P=0.06 for MCI, and OR, 1.98 [95% CI, 1.26-3.12]; P=0.02 for dementia). The greater severity in patients with prestroke cognitive impairment was not specifically driven by a more severe impairment of either motor or language function. Conclusions- Patients with preexisting cognitive impairment suffered more severe ischemic stroke. This result could reflect a lower brain tolerance of acute ischemia. Further studies are needed to explore the underlying mechanisms that could be targeted from therapeutic perspectives focusing on neuroprotection.

Incidence of Acute Ischemic Stroke With Visible Arterial Occlusion: A Population-Based Study (Dijon Stroke Registry).

BACKGROUND AND PURPOSE: Because of several methodological limitations, previous studies focusing on the prevalence of large vessel occlusion in ischemic stroke (IS) patients provided conflicting results. We evaluated the incidence of IS with a visible arterial occlusion using a comprehensive population-based registry. METHODS: Patients with acute IS were prospectively identified among residents of Dijon, France, using a population-based registry (2013-2017). All arterial imaging exams were reviewed to assess arterial occlusion. Annual incidence rates of IS (first-ever and recurrent events) and IS with a visible occlusion were calculated. RESULTS: One thousand sixty cases of IS were recorded (mean age: 76.0±15.8 years, 53.9% women). Information about arterial imaging was available in 971 (91.6%) of them, and only preexisting dementia was independently associated with having missing information (odds ratio=0.34 [95% CI, 0.18-0.65], P=0.001). Among these patients, 284 (29.2%) had a visible arterial occlusion. Occlusion site was the anterior circulation in 226 patients (23.3% of overall patients with available data) and the posterior circulation in 58 patients (6.0%). A proximal occlusion of the anterior circulation was observed in 167 patients (17.2%). The crude annual incidence rate of total IS per 100 000 was 138 (95% CI, 129-146). Corresponding standardized rates were 66 (95% CI, 50-82) to the World Health Organization and 141 (95% CI, 118-164) to the 2013 European populations. The crude annual incidence rate of IS with a visible arterial occlusion per 100 000 was 37 (95% CI, 33-41) and that of IS with a proximal occlusion of the anterior circulation was 22 (95% CI, 18-25). Corresponding standardized rates were 18 (95% CI, 10-26) and 10 (95% CI, 8-13) to the World Health Organization population, and 38 (95% CI, 26-50) and 23 (95% CI, 19-26) to the 2013 European population, respectively. CONCLUSIONS: These results will be helpful to plan the need for thrombectomy-capable stroke center resources.

Long-Term Relative Survival after Stroke: The Dijon Stroke Registry.

OBJECTIVE: The aim of this study was to assess long-term survival after stroke and to compare survival profiles of patients according to stroke subtypes, age, and sex, using relative survival (RS) method. METHODS: All patients with a first-ever stroke were prospectively recorded in the population-based Dijon Stroke Registry from 1987 to 2016. RS is the survival that would be observed if stroke was the only cause of death. Ten-year RS was estimated using a flexible parametric model of the cumulative excess mortality rate, which was obtained by matching the observed all-cause mortality in the stroke cohort to the expected mortality in the general population. A separate model was fitted for each stroke subtypes, first fitted for each age and sex separately, and then adjusted for age and sex. RESULTS: In total, 5,259 patients (mean age 74.9 ± 14.3 years, 53% women) were recorded including 4,469 ischemic strokes (IS), 655 intracerebral hemorrhages (ICH), and 135 undetermined strokes. In IS patients, unadjusted RS was 82% at 1 year and decreased to 62% at 10 years. Adjusted RS showed a lower survival in older age groups (p < 0.001), but no difference between men and women (p = 0.119). In ICH patients, unadjusted RS was 56 and 42% at 1 and 10 years, respectively, with a lower adjusted survival in older age groups (p < 0.001), but no sex differences (p = 0.184). CONCLUSION: This study showed that RS after stroke is lower in older than in younger patients but without significant sex differences, and survival profiles differ according to stroke subtypes. Since RS allows a better estimation of stroke-related death than observed survival does, especially in old patients, such a method is adapted to provide reliable information when considering long-term outcome.

Atrial fibrillation and preexisting cognitive impairment in ischemic stroke patients: Dijon Stroke Registry.

BACKGROUND: Atrial Fibrillation (AF) is a common cause of ischemic stroke (IS), and is associated with cognitive impairment in the general population. We aimed to compare the prevalence of preexisting cognitive impairment between IS patients with and without AF, and to assess whether prior brain damage could contribute to the observed differences. METHODS: Patients with acute IS were prospectively identified from the population-based Dijon Stroke Registry, France. Patients who had a CT-scan as brain imaging modality were included in this analysis to assess the presence of preexisting leukoaraiosis, old vascular brain lesions, and cerebral atrophy. Characteristics of patients including prior-to-stroke cognitive status (normal cognition, mild cognitive impairment (MCI), or dementia) were compared between those with and without AF. RESULTS: Among 916 IS patients, 288 (31.4 %) had AF, of whom 88 had newly diagnosed AF. AF patients had more frequent prior MCI (17.8 % versus 10.2 %) or dementia (22.4 % versus 13.1 %) (p = 0.001), vascular risk factors, and preexisting brain damage. In unadjusted model, preexisting cognitive impairment was associated with AF (OR=2.24; 95 % CI: 1.49-3.37, p < 0.001 for MCI; OR=2.20; 95 % CI: 1.52-3.18, p < 0.001 for dementia). After adjustment for clinical and imaging variables, preexisting mild cognitive impairment (OR=1.87; 95 % CI: 1.06-3.32, p = 0.032) and dementia (OR=1.98; 95 % CI: 1.15-3.40, p = 0.013) were independently associated with AF. CONCLUSION: AF is a common condition in IS patients and is associated with preexisting cognitive impairment. Brain lesions visible on imaging did not seem to fully account for this association that may involve other mechanisms yet to be elucidated.

Is COVID-19 Infection a Multiorganic Disease? Focus on Extrapulmonary Involvement of SARS-CoV-2.

First described in December 2019 in Wuhan (China), COVID-19 disease rapidly spread worldwide, constituting the biggest pandemic in the last 100 years. Even if SARS-CoV-2, the agent responsible for COVID-19, is mainly associated with pulmonary injury, evidence is growing that this virus can affect many organs, including the heart and vascular endothelial cells, and cause haemostasis, CNS, and kidney and gastrointestinal tract abnormalities that can impact in the disease course and prognosis. In fact, COVID-19 may affect almost all the organs. Hence, SARS-CoV-2 is essentially a systemic infection that can present a large number of clinical manifestations, and it is variable in distribution and severity, which means it is potentially life-threatening. The goal of this comprehensive review paper in the series is to give an overview of non-pulmonary involvement in COVID-19, with a special focus on underlying pathophysiological mechanisms and clinical presentation.

Prevalence of major embolic findings and incidental findings on early cardiac CT in patients with suspected ischemic stroke.

PURPOSE: The purpose of this study was to assess the type and prevalence of stroke and non-stroke-related findings diagnosed on early cardiac computed tomography (CT) in patients with suspected stroke. The secondary objective was to assess the clinical consequences on the management of patients with non-stroke-related conditions identified by early cardiac CT. MATERIALS AND METHODS: This single-center, retrospective, observational study included 1111 consecutive patients with suspected ischemic stroke between November 2018 and March 2020 who underwent cardiac CT examination in addition to the usual brain CT protocol (i.e., non-enhanced brain CT, perfusion brain CT when needed, aortic arch and supra-aortic CT angiography, and post contrast brain CT). There were 562 women and 549 men with a median age of 74 years (range: 60-85 years). Of these, 415 (415/1111; 37.4%) patients had ischemic stroke and 692 (692/1111; 62.3%) had no stroke. Cardiac CT examinations were retrospectively reviewed for cardiac CT findings at high embolic risk and clinically significant extracardiac incidental findings. RESULTS: Among 1111 included patients, 89 (89/1111; 8.0%) had a stroke-related condition identified on early cardiac CT. This was significantly more frequent in patients with ischemic stroke (66/415; 15.9%) by comparison with those without ischemic stroke (23/696; 3.3%) (P < 0.001), with 41 patients (41/415; 9.9%) diagnosed with left atrial thrombus. Cardiac CT revealed a clinically significant non-stroke-related finding in 173 patients (173/1111; 15.6%), including 17 pulmonary embolisms (1.5%), seven suspicious pulmonary lesions (0.6%), and three breast lesions suspected to be malignant (0.3%). Twenty out of 173 patients (20/173; 11.5%) with incidental findings on early cardiac CT had a change in their management. CONCLUSION: This study shows that adding early cardiac CT to brain CT during the acute phase of an ischemic stroke leads to a higher rate of etiological diagnoses and highlights the major interest of looking at the bigger picture.

Nationwide projections of ischemic stroke with large vessel occlusion of the anterior circulation by 2050: Dijon Stroke Registry.

Introduction: Data on the epidemiology of ischemic stroke (IS) with large vessel occlusion (LVO) are scarce although there is a need to better assess future demands for dedicated facilities in an aging population. This study aimed to estimate the number of expected cases of IS with LVO of the anterior circulation in the French population by 2050. Methods: IS were retrieved from the population-based registry of Dijon, France (2013-2017). Patients with LVO were identified and age-and sex-standardized incidence rates were calculated to estimate the number of expected cases in the whole French population by 2050 according three scenarios: stable incidence; a decrease in incidence rates of 0.5%/year in people >65 years old; a decrease in incidence rates of 0.5%/year in overall population. Results: 1,067 cases of IS with LVO were recorded in Dijon over the study period, corresponding to crude incidence rate of 22/100,000/year (95% CI: 18-25). By 2050, the number of cases is expected to increase by 51 to 81% according to the various scenarios, to reach between 22,457 cases (95% CI: 10,839 - 43,639) and 26,763 cases (95% CI: 12,918 - 52,008) annually. This increase will be mainly driven by patients >80 years old, with a rise of cases between +103% and +42% in this age group. The proportion of patients >80 years old among overall IS with LVO will increase from 43 to 57% approximately. Conclusion: The expected massive increase in IS with LVO highlights the need for a rapid action to cover stroke care requirements.

Symptomatic Intracranial Hemorrhage after Ischemic Stroke Treated with Bridging Revascularization Therapy.

(1) Background: bridging revascularization therapy is now the standard of care in patients with ischemic stroke due to large vessel occlusion. This study aimed to determine the frequency of symptomatic intracranial hemorrhage (sICH) related to this treatment, and to assess contributing factors and patients' outcomes. (2) Methods: consecutive ischemic stroke patients treated with bridging therapy were prospectively enrolled. sICH (intracranial hemorrhage with an increase in NIHSS score of ≥4 points) was assessed on imaging at 24 h. The functional status of patients was measured at 6 months using the mRS score; (3) Results: 176 patients were included (mean age 68.7 ± 1.2 years, 52.3% women), among whom 15 (8.5%) had sICH. Patients with sICH had more frequent alcohol abuse (30.1% versus 9.7%, p = 0.023), prestroke use of dual antiplatelet therapy (14.3% versus 1.3%, p = 0.002), higher NIHSS scores at admission (median score 20.5 versus 15, p = 0.01), greater systolic blood pressure upon admission, more frequent vascular intracranial calcifications (p = 0.004), leukoaraiosis (p = 0.001), and intracranial atheroma (p = 0.02), and higher neutrophil-to-lymphocyte ratios (p = 0.02) and neutrophil-to-platelet ratios (p = 0.04). At 6-month follow-up, 9 (60%) patients with sICH died, versus 18% of patients without sICH (p < 0.001). Only 1 (7%) patient with sICH had a good functional outcome, defined as an mRS score of 0 to 2, versus 51% of patients without sICH. (4) Conclusions: one in twelve ischemic stroke patients treated with bridging therapy suffered sICH. Given the observed poor outcomes after sICH, further studies are required to better identify patients at risk to help clinicians in guiding therapeutic strategies.

Functional outcomes of ischemic stroke patients aged over 80 years treated with acute revascularization therapy according to pre-morbid disability: a PARADISE study.

Introduction: Aging population leads to changes in the profile of patients with acute ischemic stroke (IS), and older adults were largely excluded from randomized clinical trials of acute revascularization therapy. This study aimed to assess functional outcomes of treated IS patients > 80 years old according to prior disability and identify associated factors. Methods: Consecutively older patients with acute IS treated with either IV thrombolysis and/or mechanical thrombectomy were enrolled between 2016 and 2019. Pre-morbid disability was assessed using the modified Rankin Scale (mRS) score, and patients were classified as being independent (mRS score, 0-2) or having pre-existing disability (mRS score, 3-5). A multivariable logistic regression analysis was performed to assess factors associated with a poor functional outcome (mRS score > 3) at 3 and 12 months in each group of patients. Results: Among 300 included patients (mean age: 86.3 ± 4.6 years, 63% women, median NIHSS score: 14, IQR: 8-19), 100 had a pre-existing disability. In patients with a pre-morbid mRS score of 0-2, 51% had mRS >3 including 33% of deaths at 3 months. At 12 months, 50% had a poor outcome including 39% of deaths. In patients with a pre-morbid mRS score of 3-5, 71% had a poor outcome at 3 months including 43% of deaths, and at 12 months, 76% had mRS >3 including 52% of deaths. In multivariable models, the NIHSS score at 24 h was independently associated with poor outcomes at 3 and 12 months in both patients with (OR = 1.32; 95% CI: 1.16-1.51, p < 0.001 for 12 months outcome) or without (OR = 1.31; 95% CI: 1.19-1.44, p < 0.001 for 12 months outcome) pre-morbid disability. Conclusion: Although a large proportion of older patients with a pre-existing disability had a poor functional outcome, they did not differ from their non-impaired counterparts regarding prognostic factors. This means that there were no factors in our study that would help clinicians identify patients at risk of poor functional outcomes after revascularization therapy among those with prior disability. Further studies are needed to better understand the post-stroke trajectory of older IS patients with a pre-morbid disability.

Plasma growth differentiation factor - 8 / Myostatin level as prognostic biomarker of patients with ischemic stroke and acute revascularization therapy. PARADISE study.

BACKGROUND: Identifying biological markers of ischemic stroke (IS) is an important research approach to develop innovative therapeutic strategies. This study aimed to assess the association between plasma Growth Differentiation Factor-8 (GDF-8)/Myostatin levels and outcome of IS patients. METHODS: Consecutive patients with acute IS treated with either intravenous thrombolysis and/or mechanical thrombectomy at Dijon University Hospital, France were prospectively included. Clinical variables were recorded, and plasma GDF-8 was collected just after the revascularization procedure. Primary endpoint was functional outcome at 3 months assessed by the modified Rankin Scale (mRS) score. Secondary endpoints included mRS scores at 6 and 12 months, and overall mortality over 1-year of follow-up. RESULTS: Among the 173 included patients (median age: 76 years, Interquartile range (IQR): 66-85; 49% women), median plasma GDF-8 levels at admission were significantly lower in those with a poor outcome at 3 months defined as a mRS score > 2 (2073 (IQR: 1564-2757) pg/mL versus 1471 (1192-2241) pg/mL, p < 0.001). Lower GDF-8 levels at admission were associated with higher 3-months mRS score in multivariable ordinal logistic regression analysis (OR = 0.9995; 95% CI: 0.9991-0.9999, p = 0.011). The association was also observed with 6- and 12-month mRS scores. Although mortality was higher in patients with lower GDF-8 levels, the association was not significant in multivariable Cox analysis. CONCLUSION: Lower plasma GDF-8 levels were associated with a poorer functional outcome in IS patients treated with acute revascularization therapy. Underlying pathophysiological mechanisms involving GDF-8 in post-stroke outcome remain to be elucidated.

Comparison of Stroke Recurrence, Cardiovascular Events, and Death Among Patients With Pregnancy-Associated vs Non-Pregnancy-Associated Stroke.

Importance: Women with pregnancy-associated stroke might have different risks of stroke recurrence, including during subsequent pregnancies, and other cardiovascular events due to pregnancy-specific stroke risk factors, such as gestational hypertension, preeclampsia, or gestational diabetes. Objective: To estimate the rate of stroke recurrence, cardiovascular hospitalization, and death in women with pregnancy-associated stroke compared with women with non-pregnancy-associated stroke. Design, Setting, and Participants: This cohort study included all women aged 15 to 49 years in France who were affiliated with the general scheme of French health care insurance (94% of women) and had a first hospitalization for stroke between January 1, 2010, and December 31, 2018. Women were followed up until December 31, 2020, with the registration of stroke recurrence, hospitalization for cardiovascular conditions, and death. Data were from the French health care database Système National des Données de Santé. Statistical analyses were conducted between December 2021 and September 2022. Exposure: Pregnancy status at the time of stroke. Main Outcomes and Measures: Poisson regressions were used to estimate incidence rates of these events with 95% CIs. We used Cox proportional hazards regression models to estimate the hazard ratios (HRs) of each event during the follow-up for women with a pregnancy-associated stroke vs women with a non-pregnancy-associated stroke. Results: Among women aged between 15 and 49 years between 2010 and 2018 and living in France, 1204 had a pregnancy-associated stroke at a mean (SD) age of 31.5 (5.8) years, and 31 697 had a non-pregnancy-associated stroke at a mean age of 39.6 (8.2) years. Among the 1204 women with a pregnancy-associated stroke, the incidence rate was 11.4 (95% CI, 9.0-14.3) per 1000 person-years, with 2 recurrent events during a subsequent pregnancy. Compared with women with non-pregnancy-associated stroke, women with pregnancy-associated stroke had lower risks of ischemic stroke (adjusted HR, 0.53; 95% CI, 0.36-0.77), cardiovascular events (adjusted HR, 0.58; 95% CI, 0.49-0.69), and death (adjusted HR, 0.42; 95% CI, 0.22-0.79). In contrast, the risk of recurrent intracerebral hemorrhage and cerebral venous thrombosis did not differ significantly, whereas the risks of venous thromboembolism (HR, 2.02; 95% CI, 1.14-3.58) and acute coronary syndrome with ST-segment elevation (HR, 3.93; 95% CI, 1.10-14.0) were increased. Conclusions and Relevance: In this cohort study, although the risks of ischemic stroke, overall cardiovascular events, and mortality were lower after a pregnancy-associated stroke than after a non-pregnancy-associated stroke, the risks of venous thromboembolism and acute coronary syndrome with ST-segment elevation were higher. Recurrent stroke during a subsequent pregnancy remained rare.